Thursday, June 22, 2017

Follow the Money: Non-Profit Hospital CEOs Quietly Collect Their Millions While US Health Care Reform Battle Rages

In Washington, DC the health care policy wars continue, with a few Republican senators working behind closed doors on a bill to "repeal and replace" Obamacare, aka the Affordable Care Act, and Democrats decrying their secrecy.  Just as during the era in which Obamacare was enacted, there is constant discusison of how US health care costs continually rise, driving up insurance premiums, and how access to health insurance is continually in peril.

However, while the current Republican process to write new legislation seems strikingly opaque, in neither era has there been a frank discussion of why US health care costs are so amazingly high, and disproportionate to our mediocre health care outcomes. In particular, there has hardly been any discussion of just who benefits from the rising costs, and how their growing wealth may impede any real cost-cutting measures.

Extreme Compensation for Top Managers of Non-Profit Hospitals

An obvious example is the gravity defying pay given to top health care managers, particularly the top managers of non-profit hospital systems.

Such systems provide much of the hospital care to Americans, and most have declared their missions to be providing the best possible care to all patients, or words to that effect.  Many explicitly include care of the poor, unfortunate and vulnerable as a major part of their missions.  As non-profit organizations, their devotion of mission provides some rationale to their freedom from responsibility for federal taxes.

As we last discussed in detail in May, 2016, we have suggested that the ability of top managers to command ever increasing pay uncorrelated with their organizations' contributions to patients' or the public's health, and often despite major organizational shortcomings indicates fundamental structural problems with US health, and provides perverse incentives for these managers to defend the current system, no matter how bad its dysfunction.

In particular, we have written a series of posts about the lack of logical justification for huge executive  compensation by non-profit hospitals and hospital systems.  When journalists inquire why the pay of a particular leader is so high, the leader, his or her public relations spokespeople, or hospital trustees can be relied on to cite the same now hackneyed talking points.

As I wrote in 2015,  and in May, 2016,

It seems nearly every attempt made to defend the outsize compensation given hospital and health system executives involves the same arguments, thus suggesting they are talking points, possibly crafted as a public relations ploy. We first listed the talking points here, and then provided additional examples of their use. here, here here, here, here, and here, here and here

They are:
- We have to pay competitive rates
- We have to pay enough to retain at least competent executives, given how hard it is to be an executive
- Our executives are not merely competitive, but brilliant (and have to be to do such a difficult job).

Yet as we discussed recently, these talking points are easily debunked.  Additionally, rarely do those who mouth the talking points in support of a particular leader provide any evidence to support their applicability to that leader.

But since May, 2016, we have steadily accumulated more stories about million-dollar plus pay for CEOs and other top managers of non-profit hospitals and hospital systems.  The reports may be shorter than they used to be, as journalism comes under economic and other attack, and as more journalistic resources go to cover the current president.  Here are some examples, in chronologic order per the date of the published article, rather telegraphically.

Examples of High Executive Pay

Boston, Massachusetts area, August, 2016 (Per the Boston Business Journal)

Brigham and Women's Hospital CEO Dr Elizabeth Nabel, total compensation $5.5 million in 2014, 20% higher than 2013.  Talking points =  brilliant: "committed to retaining a team of top professionals," per Edward Lawrence, Chair, Partners Board of Trustees

Tufts Medical CEO Dr Michael Wagner, $1.1 million, 82% increase.

UMass Memorial Medical Center CEO Dr Eric Dickson, $1.6 million, 74% increase, Patrick Muldoon, President UMass Memorial Center's biggest hospital, $1.2 million, 67% increase

West New York State, August, 2016 (Per the Buffalo News)

Catholic Health System CEO Joseph D McDonald, $1.4 million.

Roswell Park Cancer Institute CEO Candace S Johnson, $1 million

Kaleida Health CEO Jody L Lomeo, $1 million:

Talking points = brilliant "few executives have the required skill set and experience to fill these posts"

New Jersey, September, 2016 (Per NJ Advance Media)

Top 10 hospital CEOs received total compensation from $1.94 million to $4.7 million

New Orleans, Lousisiana, September, 2016 (Per the Times-Picayune)

Ochsner Health System former CEO and board chair Dr Patrick Quinlan, $3.3 million in 2014, current CEO and board member Warner Thomas, $1.49 million.  Talking points = competitive rates and brilliant: "we must compete nationally to recruit top talent"

Touro Infirmary CEO James Montgomery, $1.3 million

Children's Hospital Inc Chief Medical Officer Alan Robson, $1.26 million

General talking points = competitive rates: "you're looking to attract hospital executives from Californai or New York where they're paid a lot of money"

Gastonia, North Carolina, February, 2017 (Per the Gaston Gazette)

CaroMont CEO Doug Luckett, $1.03 million in 2015.  Talking points = retain and brilliant "paying what it takes to ensure they attract and retain top-level talent that can help provide premiums health care"

Dayton, Ohio, March, 2017 (Per the Dayton Daily News)

Kettering Health System CEO Fred Manchur, $1.65 million in 2015, former president Terri Day, $1.23 million, current president Roy Chew, $1.07 million

Premier Health former CEO James Pancoast, $1.42 milllion (excluding retirement payments) in 2015. Talking points = brilliant "you've got one person at the top who's trying to provide oversight, direction, and strategy.  At the same time, health care continues to grow in scope, complexity, regulation, and compliance."

York County, Pennsylvania, April, 2017 (Per the York Daily Record)

WellSpan Health president Kevin Mosser, $1.6 million in 2014.  Talking points = competitive rates Forrest Brisco, associate professor, Penn State Smeal College of Business, "nonprofit hospitals are competing with for-profit hospitals"; brilliant: "If you are at the top of a health care organization, you're going to have pay that's higher than many members of the organization. The the skill and knowledge to understand and interact with surgeons and physicians can command a high salary" [ed note: which often seems higher than those of some surgeons and physicians, though]; also brilliant: Robert Batory, senior vice-president and chief human resources officer, Wellspan, "Kevin has 24/7 responsibility for Wellspan."

Ephrata Community Hospital (WellSpan subsidiary) CEO  and WellSpan Medical Group (WellSpan subisidiary) CEO  "more than $1 million"

Winston-Salem, North Carolina, May, 2017 (Per the Winston-Salem Journal)

Novant Health Inc CEO Carl Armato, $1.31 million in 2015.  Talking points = retain and brilliant "high compensation levels are necessary to recruit and retain executive to run a 'very complex organization'"

Tri-Cities region, Tennessee and Virginia, June, 2017 (Per WJHL)

Wellmont Health System CEO Bart Hove, $1.4 million in 2015.  Talking points = competitive rates: Wellmont board of trustees chair Roger Leonard, "we have to compete on a national level and we're competing not just with other non-profits, but we're competing with other for-profits"

Mountain States Health Alliance CEO Alan Levine, $1.3 million in 2015. Talking points = competitive rates: HSHA board of trustees chair Barbara Allen, "make sure CEO pay is comparable to similarly sized facilities across the country with similar complexities"; retain and brilliant, "we want to attract the best talent ... and be able to retain him."

Connecticut, June, 2017 (Per the Connecticut Post)

Yale New Haven Health System CEO Marna Borgstrom, $3.8 million in 2015.  Nine other employees paid over $1 million, including Bridgeport Hospital CEO William Jennings, $1.5 million, Greenwich Hospital CEO Norman Roth, $1.3 million.  Talking points = brilliant: Yale senior vice president of public affairs, "Yale New Haven Health is the largest and most complex health system in the state."

Also, a total of 39 people, including the above, received over $1 million in 2016.

General talking points = brilliant: "there are a limited number of executives experienced enough to guide a state-of-the-art hospital and growing healthcare system in an increasingly competitive and complex industry"; competitive rates: "pay and benefits for such executives need to be comparable to what they could receive at another leading national hospital system or another industry"  
Summary and Conclusions

The current inflamed discussion of "Obamacare" and Republican attempts to "repeal and replace" it focuses on the costs of care and how they affect individual patients.  Examples include concerns about health insurance premiums that are or could be unaffordable for the typical person; insurance that fails to cover many costs, and thus may leave patients at risk of bankruptcy due to severe illness; poor people unable to or who might become unable to obtain any insurance, and perhaps any health care.  Yet there is little discussion of what really drives high and ever increasing health care costs (while quality of health care remains mediocre).

That may be because those who are benefiting the most from the status quo want to prevent discussion of their role.  There are many such people, but top management of non-profit hospitals provide a ready example.  Their institutions' mission is to provide care to sick patients.  Many such hospitals specifically pledge to provide care to the poor, vulnerable, and disadvantaged.  Non-profit hospitals have no owners or stockholders to whom they owe revenue.

Yet these days the top executives of non-profit hospitals receive enough money to become rich.

See the examples above. 

The justification for such compensation is pretty thin.  Consider the talking points above.  Apparently hospitals are extremely concerned about paying top management enough to recruit and retain them.  Yet there is much less evident concern about paying a lot of money to recruit and retain the health care professionals who actually take care of patients to fulfil the hospitals' mission.  Hospital CEOs are frequently proclaimed to be brilliant, visionaries, or at least incredibly hard workers with very complex jobs.  I wonder if those who make such proclamations have any idea what it takes to be a good physician or a good nurse.  Yet such health care professionals' hard work, long training, devotion to duty, and ability to deal with trying situations and make hard decisions rarely inspire hospitals to shower them with money.

Furthermore, hospital CEO compensation is almost never justified in terms of their ability to uphold and advance the fundamental hospital mission, taking care of sick people.  The articles above do not contain any justifications of generous CEO compensation based on hospitals' clinical performance or health care outcomes.  At best, hospital executive pay seems to be justified by the hospitals' financial, not clinical performance.

So why do non-profit hospital CEOs get paid enough to become rich?  Apparently, because they can.

As we discussed here, there is a strong argument that huge executive compensation is more a function of executives' political influence within the organization than their brilliance or the likelihood they are likely to be fickle and jump ship for even bigger pay.  This influence is partially generated by their control over their institutions' marketers, public relations flacks, and lawyers.  It is partially generated by their control over the make up of the boards of trustees who are supposed to exert governance, especially when these boards are subject to conflicts of interest and  are stacked with hired managers of other organizations.

Furthermore, such pay may provide perverse incentives to grow hospital systems to achieve market domination, raise charges, and increase administrative bloat.  As an op-ed in US News and World Report put it about executive pay in general,

But the executive pay decisions made inside corporate boardrooms have an enormous impact in the outside world. Outrageous pay gives top executives an incentive to behave outrageously. To hit the pay jackpot, they'll do most anything. They'll outsource and downsize and make all sorts of reckless decisions that pump up the short-term corporate bottom line at the expense of long-term prosperity and stability.

So I get to recycle my conclusions from many previous posts....

We will not make any progress reducing current health care dysfunction if we cannot have an honest conversation about what causes it and who profits from it.  In a democracy, we depend on journalists and the news media to provide the information needed to inform such a discussion.  When the news media becomes an outlet for  propaganda in support of the status quo, the anechoic effect is magnified, honest discussion is inhibited, and out democracy is further damaged.

True health care reform requires publicizing who benefits most from the current dysfunction, and how and why.  But it is painfully obvious that the people who have gotten so rich from the current status quo will use every tool at their disposal, paying for them with the money they have extracted from patients and taxpayers, to defend their position.  It will take grit, persistence, and courage to persevere in the cause of better health for patients and the public. 

And for our musical interlude, the beginning of "For the Love of Money," sung by the O'Jays, used in the official intro of season 2 of guess what show?

Wednesday, June 14, 2017

Health Care Corruption No Longer a Taboo Topic?

We have been going on about the ruinous effects of health care corruption, the role of impunity in enabling worsening corruption, our lack of good ways to challenge these problems, and our ongoing inability to even discuss what amounts to taboo topics (which we dubbed the "anechoic effect.") But as  corruption, and crime are increasingly linked to the most powerful leaders in the US, it becomes harder to deny that we have a huge problem with corruption in general, and thus maybe it becomes harder to deny we have a huge problem with health care corruption (see also our posts on conflicts of interest, crime, and specifically bribery, extortion, fraud, and kickbacks in health care.)

US Governmental Corruption in the Headlines

Last month we noted that mainstream media are now beginning to discuss how the US has a history of not adequately investigating corruption, and has developed a culture of impunity that is fostering corruption.

Yesterday, the Washington Post reported that 200 US Representatives (all Democrats) filed a lawsuit charging the President of the US with accepting emoluments (payments or gifts meant to influence him, that is, the moral equivalent of bribes) from foreign governments, and charged that this violated the US Constitution.  While there is controversy about whether these lawmakers have the "standing" to pursue this lawsuit, at least some legal scholars insisted that it is corruption that is at issue:

Legal scholars consulted by the congressional plaintiffs said their complaint is distinctive because of the special standing granted to Congress.

'The Framers of our Constitution gave members of Congress the responsibility to protect our democracy from foreign corruption by determining which benefits the president can and cannot receive from a foreign state,' said Erwin Chemerinsky, the incoming dean of the law school at the University of California at Berkeley.

'When the president refuses to reveal which benefits he is receiving — much less obtain congressional consent before accepting them — he robs these members of their ability to perform their constitutional role,' Chemerinsky said. 'Congressional lawmakers . . . have a duty to preserve the constitutional order in the only way they can: by asking the courts to make the President obey the law.'

The same article noted that this is just the latest lawsuit on this matter:

News of the lawsuit emerged less than 24 hours after attorneys general in the District and Maryland, both Democrats, filed suit alleging that payments to Trump violated the Constitution’s anti-corruption clauses. In another lawsuit filed against Trump by business competitors, the Justice Department recently defended Trump’s actions, arguing that he violated no restrictions by accepting fair-market payments for services.

That article also explained that the lawsuit was about corruption, albeit not in so many words.

The conflicts created are so vast, Frosh said, that Americans cannot say with certainty whether Trump’s actions on a given day are taken in the best interest of the country or that of his companies.

'Constituents must know that a president who orders our sons and daughters into harm’s way is not acting out of concern for his own business,' Frosh said. 'They must know that we will not enter into a treaty with another nation because our president owns a golf course there.'
Recall that Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In response to these lawsuits, today an op-ed in the Guardian asserted
We’re now witnessing kleptocracy on an unprecedented scale in America. And there’s barely even a fig leaf of cover. Trump has openly enmeshed his private financial interests in national policy. To say that this creates an appearance of corruption would be far too polite. This is the real deal: sketchy dealings all the way down.
Health Care Beginning to be Characterized by the Taboo Word "Corruption"  

Meanwhile, much more quietly, people in health care are starting to talk more openly about the possibility that health care corruption is as real a problem as government corruption.  Last November, I attended the first academic conference explicitly about health care corruption, albeit in Canada.  In May, I was on a panel at a plenary session entitled "Corruption and Patient Harm in the Medical-Industrial Complex" at the Lown Institute/ RightCare Conference in the Boston area (agenda here).

Late in May, the leaders of the Lown Institute and RightCare (Vikas Saini and Shannon Brownlee) published an article in the Huffington Post entitled, "Corrupt Health Care Practices Drive Up Costs And Fail Patients." The authors asserted:

'Corruption' is not a term most Americans would probably apply to what goes on inside American health care. But if corruption is defined as persons or institutions wielding power for their own gain, then our health care system is riddled with it. And it is not only costing us billions of dollars, it is harming untold numbers of patients like Ralph Weiss. Examples abound.

Also late in May, the Hastings Report included an article entitled "Closed Financial Loops: When They Happen in Government, They're Called Corruption; in Medicine, They're Just a Footnote" by Kevin De Jesus-Morales, and Vinay Prasad. The authors accused the medical profession from hiding true corruption in the guise of manageable conflicts of interest, per the abstract:

Many physicians are involved in relationships that create tension between a physician's duty to work in her patients’ best interest at all times and her financial arrangement with a third party, most often a pharmaceutical manufacturer, whose primary goal is maximizing sales or profit. Despite the prevalence of this threat, in the United States and globally, the most common reaction to conflicts of interest in medicine is timid acceptance. There are few calls for conflicts of interest to be banned, and, to our knowledge, no one calls for conflicted practitioners to be reprimanded. Contrast our attitudes in medicine with public attitudes toward financial conflicts among government employees. When enforcement of rules against conflict of interest slackens in the public sector, news organizations investigate and publish their criticism. Yet even when doctors are quoted in the media promoting specific drugs, their personal financial ties to the drug maker are rarely mentioned. Policies for governmental employees are strict, condemnation is strong, and criminal statutes exist (allowing for corruption charges). Yet the evidence that conflict is problematic is, if anything, stronger in medicine than in the public sector. Policies against conflicts of interest in medicine should be at least as strong as those already existing in the public sector.

I will just ignore the irony presented by our apparent inability so far to actually affect what appears to be massive corruption affecting the current US government.


We live in perilous times, but at least people are starting to recognize some perils, rather than hiding them with euphemisms or treating their very mention as taboo.  If the US republican experiment survives, at least maybe we can learn from the experience to address conflicts of interest, crime, and corruption in spheres outside of government, particularly health care.

 So to repeat an ending to one of my previous posts on health care corruption....  if we really want to reform health care, in the little time we may have before our health care bubble bursts, we will need to take strong action against health care corruption.  Such action will really disturb the insiders within large health care organizations who have gotten rich from their organizations' misbehavior, and thus taking such action will require some courage.  Yet such action cannot begin until we acknowledge and freely discuss the problem.  The first step against health care corruption is to be able to say or write the words, health care corruption.

Wednesday, June 07, 2017

Trumping Up a Health Care Charity - Trump Organization Received Increasing Revenue from a Children's Cancer Care Charity

While health and health care are clearly not central interests of the current US President, Donald J Trump, we have noted some disturbing stories about the effects of his leadership on health care.  Most importantly, prior to the election, a story appeared alleging that Mr Trump licensed his name, and actively supported the Trump Network, which sold dodgy vitamin supplements to gullible consumers based on the results of urine tests of unproven, at best, accuracy (look here). While Mr Trump is controversial, to say the least, on multiple levels, never in modern history can I recall a president who was alleged to have been a major player in what appears to be a health scam.

Moreover, since Mr Trump was elected we have noted his proposed and actual appointments to positions of power over health and health care people with severe conflicts of interest, sometimes with no or limited experience in and knowledge of health and health care, and sometimes who had acted against the values of health care professionals  (look here, here, here, here, here, here, here, here, and here ).  (Please note that since while our focus in health care dysfunction, we emphasize cases that are not extensively reported in the media and/or medical and health care literature.  So this list is hardly exhaustive.)

Now we have in the public arena a case in which Mr Trump apparently subverted the good intentions of a charity designed by his son to benefit children with severe illness, resulting in apparent private gain for Mr Trump.

The Beginnings of the Eric Trump Foundation and its Support of St Jude Childen's Research Hospital

An article in Forbes published this week recounted how Eric Trump set up a charity whose main goal was to support children's cancer care, and which would channel the maximum amount of money raised directly to reputable health care organizations.

Eric Trump set up his foundation as a public charity, a classification that allows it to raise most of its money from outside donors. In 2007, when he was 23, the first Eric Trump golf tournament took place, raising $220,000. A compelling sales pitch evolved--the free golf course and the donated goods and services assured donors that every penny possible went to charity. The Eric Trump Foundation employed no staff until 2015, and its annual expense ratio averaged 13%, about half of what most charities pay in overhead. His original seven-person board was made up of personal friends, an innocuous lot who helped sell tournament tickets, which last year ranged from $3,000 for a single all-day ticket to $100,000 for a pair of VIP foursomes.

For the first four years of the golf tournament, from 2007 to 2010, the total expenses averaged about $50,000, according to the tax filings. Not quite the zero-cost advantage that a donor might expect given who owned the club but at least in line with what other charities pay to host outings at Trump courses, according to a review of ten tax filings for other charitable organizations.

That is all admirable, to say the least. But apparently it was not to continue.

Donald Trump Demands His Pound of Flesh

Eric Trump's plans to minimize his charity's overhead soon collided with the wishes of his father, Donald J Trump, then CEO of the Trump Organization, now President of the United States.  Per Forbes, 

But in 2011, things took a turn. Costs for Eric Trump's tournament jumped from $46,000 to $142,000, according to the foundation's IRS filings. Why would the price of the tournament suddenly triple in one year? 'In the early years, they weren't being billed [for the club]--the bills would just disappear,' says Ian Gillule, who served as membership and marketing director at Trump National Westchester during two stints from 2006 to 2015 and witnessed how Donald Trump reacted to the tournament's economics. 'Mr. Trump had a cow. He flipped. He was like, 'We're donating all of this stuff, and there's no paper trail? No credit?' And he went nuts. He said, 'I don't care if it's my son or not--everybody gets billed.''

Katrina Kaupp, who served on the board of directors at the Eric Trump Foundation in 2010 and 2011, also remembers Donald Trump insisting the charity start paying its own way, despite Eric's public claims to the contrary. 'We did have to cover the expenses,' she says. 'The charity had grown so much that the Trump Organization couldn't absorb all of those costs anymore.' The Trump Organization declined to answer detailed questions about the payments.

Furthermore, the amount of money demanded by the Trump Organization rapidly increased.

The cost for Eric's golf tournament quickly escalated. After returning, in 2012, to a more modest $59,000--while the event brought in a record $2 million--the listed costs exploded to $230,000 in 2013, $242,000 in 2014 and finally $322,000 in 2015 (the most recent on record, held just as Trump was ratcheting up his presidential campaign), according to IRS filings. This even though the amount raised at these events, in fact, never reached that 2012 high.

The Forbes article alleges this occurred despite Eric's protestations to the contrary.

Remember, all those base costs were supposedly free, according to Eric Trump. The golf course? 'Always comped,' he says. The merchandise for golfers: 'The vast majority of it we got comped.' Drinks: 'Things like wine we were normally able to get donated.' And the evening performances from musicians like Dee Snider of Twisted Sister and comedians like Gilbert Gottfried: 'They did it for free.'

The Trump Organization Takes Over the Eric Trump Foundation

The move to claw back increasing amounts of charitable proceeds from the Eric Trump Foundation as payments to the Trump Organization seemed to coincide with a shift in the governance of the Eric Trump Foundation. Per Forbes,

In 2010, the year the economics of the tournament suddenly pivoted, four of the seven original board members, who were personal friends of Eric, left. Those 4 were eventually replaced by 14 new board members, the majority of whom owed all or much of their livelihoods to the Trump Organization. Six of them were effectively full-time employees, including Trump lawyer Michael Cohen and executive vice president Dan Scavino Jr., who both serve in political roles for President Trump. Another owns a company that billed the Trump campaign $16 million. Add in Eric himself, as well as his wife, Lara, and 9 of the 17 Eric Trump Foundation board members had a vested interest in the moneymaking side of the Trump empire. The foundation had become a de facto subsidiary of the Trump Organization.
'They were wearing two hats,' says Langan, the former director of golf, who says he sat in on meetings where he couldn't tell where the business ended and the charity began. 'You're dealing with people talking about the event and the charity who also at the same time are thinking about it as a corporation and as a business. It's a for-profit club. You know, they're trying to make money.'

Why this happened, and who orchestrated it were not clear. However, it does suggest that at best, the charitable nature of the Eric Trump Foundation was diluted, to the point that it conceivablye became a de facto part of the for-profit Trump Organization, a company whose majority owner was, and still is Donald J Trump.

Eric Trump Launches an Ad Hominem Attack Against Critics of His Charity

Within a day of the Forbes article, Eric Trump was interviewed by the British Tabloid, the Daily Mail. Its headline was:

Eric Trump says critics of his children's charity are 'sick' and 'disgusting' after news report clobbers him for paying his company $100K for expenses – and he insists there was 'zero profit' to his family

To make a long story short, Mr Trump perseverated about the total amount of money his charity brought to St Jude, and fixated on the amount of a single payment made by the Trump Organization to the charity of $100,000 supposedly to offset the bills sent to the charity from the Trump Organization.

But $100,000 in one year's revenues for his family's company pales in comparison to the millions the foundation raises each year for child cancer research.

He maintained that

none of the money resulted in actual profit to the Trump organization - only reimbursements for costs that couldn't be paid through specific donations.

However, the Daily Mail article included no discussion of the escalating payments after 2011, allegedly reaching as high as $322,000 in 2015, and no justification that these were required only to cover costs.  Calling critics "sick" or "disgusting" was an ad hominem attack.  However, Mr Trump never did contradict the rising unexplained payments made by his foundation to his father's company. 


Eric Trump ought to be commended for his original goal, to benefit pediatric cancer care through a charity which had minimal overhead expenses.  While he apparently was able to maintain this mission for several years, it appears that his father, Donald J Trump, CEO of the Trump Organization and now President of the United States, was able to siphon increasing amounts of money from the charity back into his family-owned corporation, and to position his cronies as trustees of his son's charity.

While the Eric Trump Foundation seems to be continuing to raise substantial money for pediatric oncology care, his claims that the organization has virtually no overhead, and his own control of the foundation now appear dubious.  His father's ability to convert donated money into corporate revenue appeared at the least to compromise the stated mission of the Foundation

to support St Jude Children's Research Hospital

In the last few years its mission also appeared to be to support the revenue of the Trump Organization. Thus the transformation of the Eric Trump Foundation seems to fit the ethical definition of corruption per Transparency International

the abuse of entrusted power for private gain

albeit that the Eric Trump Foundation was entrusted to support St Jude at minimal overhead cost, and that the gain accrued privately not to Eric Trump, but to the Trump Organization and presumably its principal owner at the time, Donald J Trump.

This case, of course, just adds to many others in which non-profit health care organizations threaten their own missions at the apparent behest of and/or for the apparent benefit of their leaders, and in this case, their leaders' relatives.  So I could simply again point out that we need leadership of health care organizations that puts mission, and patients' and the public's health ahead of all other considerations, including revenue enhancement, and particularly ahead of the leaders' enrichment.

This is a special case, though, because the person who seemed to gain the most benefit from the machinations was not just another corporate CEO, but the future president.  Now, as president, Donald J Trump is the de jure leader of the entire government health care apparatus, including the Department of Health and Human Services, and all its associated agencies, and is the de jure leader of the entire government law enforcement apparatus, including the Department of Justice.  The leader of the US Internal Revenue Service, which enforces the laws and regulations about non-profit organizations, incidentally also answers to the President.

Thus as an advocate for more functional health care, disquieting is far too polite a term to describe the presidency in the hands of someone who apparently so cavalierly re-engineered for his personal benefit a charitable foundation meant to help sick children, who so cavalierly supported conflicted and ill-informed leadership of government health care agencies, and who so cavalierly licensed his name to a sketchy vitamin sales scheme.    

Friday, June 02, 2017

"The Most Complicated Piece of Health Care is the Revenue" (Say What?) - The Shameless Managerialism of a Hospital CEO


Managerialism, in my humble opinion, is one of the major reasons why the US health care system is so dysfunctional.  We have long discussed how people whom we first called "generic managers" have taken over health care.  Increasingly, health care organizations, including hospitals, pharmaceutical companies, health insurance companies, government agencies, etc are now led by people with management training, but not necessarily with any training or background in medicine, biomedical research, epidemiology, public health, or health care policy. We began noting how such generic managers often prioritize short-term revenue over all other concerns, presumably based on the shareholder value dogma taught in business schools (look here).  Worse, generic managers may be ignorant of, misunderstand, or be frankly hostile to the core values of health care professionals.  (See our posts on mission-hostile management.)

More recently, we found that our observations could be better described as aspects of "managerialism."  We noted an important article that in the June, 2015 issue of the Medical Journal of Australia(1) that made these points about managerialism:
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals

Many health care professionals mutter under their breath about the behaviors of their managerialist leaders, but there has been little open discussion of managerialism, and no organized movement against it.

Last week, I found an excellent example of how managerialism has become the norm in health care.

A UPS Executive Becomes a Hospital Executive

An article in the Buffalo News on May 26 recounted how one Mr Martin Boryzak ascended to the the position of CEO of Sisters Hospital and its St Joseph Campus.

His Highest Degree was an MBA

Per his Linked In page, from St Bonaventure University.

He Ascended to Hospital Management without Any Medical or Health Care Background

Per the Buffalo News,

The Buffalo native was working for the package delivery company in Philadelphia in 2009 when Catholic Health recruited him after his mother, a nurse in the hospital system, slipped his resume to management unbeknownst to Boryszak.

He joined 290-bed Sisters that year as director of finance and was also named vice president of operations at 123-bed St. Joseph Campus in 2012. In 2014, he rose to chief operating officer at Sisters.

He Believes He Has No Need for Health Care Background, Because It is All About the Revenue

Per the Buffalo News, first

Martin Boryszak, the new president and chief executive officer of Sisters Hospital and its St. Joseph Campus in Cheektowaga, came to health care from what seems like an unusual route – UPS.

The differences in the businesses are not as great as you might think. As Boryszak sees it, they both adhere to basic business principles.

Q: Does it matter whether you have an academic background in health care?

A: It depends on the person. The most complicated piece of health care is the revenue. And, in that respect, it's not unlike any other service industry. The best way to maneuver through that is not that unique. When half your revenue comes from the government and the other half is influenced by what the government does, it's a difficult thing to navigate. Once you figure that piece out all other business principles are applicable.


Q: What keeps a hospital CEO up at night?

A: Where is your revenue coming from....
According to Mr Boryszak, hospitals are just another business.  Keep the money coming in, and everything will be fine.

What About the Hospital Mission, the Care of Patients, the Values of Health Care Professionals?

The closest Mr Boryszak got to any of these issues was in his reflections, if that is the word, about his career at UPS.

I liked what I did, but wanted a balance with some type of calling. I wanted to feel that I was making a difference. It wasn't a function of UPS because it has great people and is a great company. I enjoyed every minute there but felt as though there was something more. I was recruited and never really thought about health care, but what better industry to drive change

He said not a word about what hospitals actually do.  He could not even define the "sort of calling," the sort of "difference" he might make, the kind of change that should be driven. 


There you have it in a nutshell.  Here is an MBA running a hospital that feels not the slightest need for training or experience in medicine, biomedical research, epidemiology, public health, or health policy. He wanted to do something involving a "calling," and would "drive change,"  but expressed precisely nothing about the nature of the calling in the hospital setting, or the sort of change to be driven.  He thinks the most complicated issue in health care is "revenue."  Presumably he feels revenue is more complicated than determining a difficult diagnosis, managing an acutely ill patient, counseling a patient with chronic illness, or consoling a patient who is dying, if he even understands that those are some of the things that go on in a hospital.  Furthermore, he seems to feel entirely comfortable issuing orders to health care professionals who need to take on such tasks, and more.

Thus has managerialism been normalized, or maybe I should say thus has deviancy been defined down.

As an aside, the reporter interviewing Mr Boryszak also seemed entirely comfortable with the notion of an MBA without health care experience or training, and apparently without understanding of health care professionals' values running hospitals, and entirely comfortable with the notion that the most complicated thing about health care is generating revenue.  The reporter never even slightly challenged any of this.

Thus has managerialism been normalized.

So as we have said endlessly,...  

We need far more light shined on who runs the health care system, using what practices, to what ends, for the benefits of whom.

True health care reform would enable transparent, honest, accountable governance and leadership that puts patients' and the public's health over ideology, self-interest, and self-enrichment.

Can that happen in a world in which the business CEO is viewed as the highest form of life? 


1.  Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM.  The scourge of managerialism and the Royal Australasian College of Physicians.  Med J Aust 2015; 202: 519- 521.  Link here.

Monday, May 29, 2017

Robert Martensen's A Life Worth Living

Robert Martensen, A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era (New York: Farrar, Straus & Giroux, 2008).
    In recent years, doubtless because of the anxious disquiet of so many who have witnessed experiences of their friends and families, books examining “end-of-life issues” have become so numerous as almost to constitute a little genre of their own. At first glance, Dr. Martensen’s book appears to fall neatly within this category. The emergency physician and medical historian recounts numerous memorable patient stories, discusses technology overuse at end of life and the ambiguities of "medical futility" when most doctors have seen the occasional almost-miraculous recovery, and says he wants the book to assist those with “difficult choices.” Martensen is perceptive and balanced about the terrors and disruptions of serious chronic illness, and its shifting, confusing territory, and I think the book is of real potential use – as he wishes – to those facing advanced illness.

But though parts of A Life Worth Living are a worthwhile contribution to this sub-genre, the book as a whole – as its title indicates – is more: a broad reflection on what does make life worth living, and how dealing with the inevitable distresses of life can go much better or worse depending both on personal meanings, efforts, and decisions and also on societal conditions (including realities of the medical system).

Martensen does not confine his reflections to one end of life. His chapter on sick children is imbued with great respect for them and their situation. With both children and very old people, the triangulated nature of interactions with the families can present many problems. Martensen wonders whether we are wronging minors by allowing parents to make exclusive decisions on treating them, telling a haunting story of a girl who underwent many brutal procedures before her death from cancer, including amputations of her legs, hips and lower pelvis.

Another valuable chapter dealt with the factors that can make life for people with serious limitations either rewarding or hellish. He contrasts the reasonably good life led by a mentally limited individual he knows with good family support and enough connections to obtain a part-time job with the horrible conditions of many folk he regularly sees who come into his ER in distress. Martensen is quietly outraged:
When I decided to become a doctor in the 1970s, I never expected to practice in an America where the dire has become an everyday experience for so many…For the past thirty years, however, life has not gotten better for our most vulnerable. Through Democratic and Republican administrations alike, compassion has been scarce, despite political and commercial expressions to the contrary. Though our health care approaches squander billions on extravagant treatment regimes that end up accomplishing little, as a society we refuse to adopt the small, even tiny, adjustments that could easily reduce the clawing uncertainties that now degrade millions.

Martensen talks about the jolting contrast of seeing a diabetic die in his emergency department as a result of having to scrimp on his expensive insulin, right before attending a luncheon where a university chancellor triumphantly announced the legislatively-permitted transformation of his hospital to an “entrepreneurial private-public partnership” that would expand to add new, lucrative, heart and stroke centers, while the hospital would be permitted to cease functioning as a public hospital and state funding for indigent care at the hospital would be phased out.

Martensen, who at the time was serving as the hospital’s “chief ethics officer,” tartly reflects that ethics committees are never consulted about these critical big issues. If administrators actually cared about ethical issues and not just about window-dressing, he reflects, they would “include [an ethicist] to opine on large-scale change, just as they do a score of lawyers.”

Martensen is troubled, too, when he is urged (perhaps too early, in his mind) to press grieving parents for organ transplants that will be financially beneficial for the hospital. 

Though he's acutely aware of the bigger picture, Martensen doesn't let that interfere with attending to the details of what we all need to try and do within a system we cannot control to have the best outcomes possible for ourselves, for family, and for patients. He is hopeful and humane about the quest for meaning and dignity in difficult circumstances.
Martensen covers such wide territory that the book (like this review) can be a bit disjointed, even though everything truly relates to his title and central theme. But that's a minor flaw. This short, engaging, readable book packs an enormous punch, and I heartily recommend it.

Tuesday, May 23, 2017

Evidence-Based Policy Making? - Dumb Things Politicians Say About Health Care Policy

There have been multiple legislative attempts at major health care reform in the US.  Typically, such attempts feature considerable public debate, including speechs, congressional committee hearings, sometimes progressing to debates by the House and Senate.  (For example, see this Frontline chronology of the proceedings up to the passage of the Affordable Care Act, aka "Obamacare," in 2009.)  Usually the discussion includes some real experts on health care policy, and some real health care professionals, and at least appears to reference some data about medicine, health care, and health economics. Whether previous debates were truly evidence-based is not clear, but it appeared to me that they at least acknowledged the importance of evidence, and maybe even at times a rigorous approach to it.

However, the proceedings up to the passage of the American Health Care Act seemed somewhat different.  There were no public committee hearings or debates.  Per a Los Angeles Times article in April, 2017 (via the Chicago Tribune):

President Trump and House Republicans, in their rush to resuscitate a bill rolling back the Affordable Care Act, are increasingly isolating themselves from outside input and rejecting entreaties to work collaboratively, according to multiple healthcare officials who have tried to engage GOP leaders.

In particular,

And senior House Republicans and White House officials have almost completely shut out doctors, hospitals, patient advocates and others who work in the healthcare system, industry officials say, despite pleas from many healthcare leaders to seek an alternative path that doesn’t threaten protections for tens of millions of Americans.

'To think you are going to revamp the entire American healthcare system without involving any of the people who actually deliver healthcare is insanity,' said Sister Carol Keehan, president of the Catholic Health Assn., whose members include many of the nation’s largest medical systems.

While the experts have been shut out, some of its supporters of the AHCA in the US House of Representatives have been free with their explanations of their actions.  Some have been rather alternative, so to speak.   Some recent examples, in chronologic order,

Rep Roger Marshall (R-Kansas): the Poor "Just Don't Want Health Care"

As reported by the Washington Post, March 9, 2017

'Just like Jesus said, ‘The poor will always be with us,’ ' Marshall said in response to a question about Medicaid, which expanded under Obamacare to more than 30 states. 'There is a group of people that just don’t want health care and aren’t going to take care of themselves.'

He added that 'morally, spiritually, socially,' the poor, including the homeless, 'just don’t want health care.'

'The Medicaid population, which is [on] a free credit card as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising. And I’m not judging; I’m just saying socially that’s where they are,' he told STAT, a website focused on health-care coverage.

The problem is that Marshal, who is a physician, did not provide evidence that there is some essential characteristic of the poor that causes them to make bad health decisions, or discus whether perhaps the poor face constraints on their health care decision making that the rich do not.  The implication appears to be that Marshal is treating an promoting an ideological or religious opinion as if it were derived from epidemiology.

House Speaker Paul Ryan (R-Wisconsin) The Problem with "Obamacare" is "the People Who Are Healthy Pay for the People Who Are Sick."

As reported by MSNBC, March 9, 2017

Take today, for example, when the GOP House Speaker did a little presentation on Capitol Hill for reporters in defense of his controversial American Health Care Act, which some have begun calling 'Trumpcare.' At one point during the slideshow – complete with Ryan’s sleeves rolled up – the Wisconsin Republican tried to explain what he sees as the Affordable Care Act’s fatal flaw:

'The fatal conceit of Obamacare is that we’re just gonna make everybody buy our health insurance at the federal-government level, young and healthy people are going to go into the market and pay for the older, sicker people. So, the young healthy person is going to be made to buy health care, and they’re going to pay for the person, you know, gets breast cancer in her 40s or who gets heart disease in his 50s. […]'

'The whole idea of Obamacare is … the people who are healthy pay for the people who are sick. It’s not working, and that’s why it’s in a death spiral.'

As MSNBC reported, the problem is with that is

that Ryan doesn’t seem to understand what “insurance” means.

Look at that quote again: The whole idea of Obamacare is … the people who are healthy pay for the people who are sick.' Well, yes. The whole idea of health insurance is to establish a system in which the people who are healthy pay for the people who are sick.

This really isn’t that complicated. In fact, it’s incredibly common for the vast majority of Americans: we pay premiums, the money goes into a pool, funds from that pool pay for care. It’s Insurance 101.

If Ryan disapproves of this model – which is weird, given that his own reform bill is built on consumers getting coverage through traditional insurance – there are effectively three alternatives. If the healthy aren't going to pay the sick, who will? The sick can try to pay for themselves, the government can pick up the tab, or the sick simply won't get care.

Rep John Shimkus (R-Illinois) Why Should Men Have to Purchase Prenatal Care? 

As reported by the Washington Post, March 9, 2017, regarding a hearing in the House of Representatives Energy and Commerce Committee

'What mandate in the Obamacare bill does he take issue with?' Doyle asked Shimkus, using the formal parlance of congressional committees.

'What about men having to purchase prenatal care?' Shimkus said.

At that point, one could hear the room start to stir.

'I’m just . . . is that not correct?' Shimkus said. 'And should they?'

Rep Shimkus, apparently like Rep Ryan, does not seem to understand the concept of health insurance.  The Post article put it this way,

Here’s how insurance expert and columnist Nancy Metcalf answered a similar question from a Consumer Reports reader that year:

Health insurance, like all insurance, works by pooling risks. The healthy subsidize the sick, who could be somebody else this year and you next year. Those risks include any kind of health care a person might need from birth to death — prenatal care through hospice. No individual is likely to need all of it, but we will all need some of it eventually.

So, as a middle-aged childless man you resent having to pay for maternity care or kids’ dental care. Shouldn’t turnabout be fair play? Shouldn’t pregnant women and kids be able to say, 'Fine, but in that case why should we have to pay for your Viagra, or prostate cancer tests, or the heart attack and high blood pressure you are many times more likely to suffer from than we are?' Once you start down that road, it’s hard to know where to stop. If you slice and dice risks, eventually you don’t have a risk pool at all, and the whole idea of insurance falls apart….

Rep Mo Brooks, (R-Alabama): "People who Lead Good Lives" Do Not Get Sick

As reported by Vox on May 2, 2017, Rep Brooks said in an interview on CNN to explain why people with pre-existing conditions should personally pay for their health insurance

allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool that helps offset all these costs, thereby reducing the cost to those people who lead good lives. They’re healthy; they’ve done the things to keep their bodies healthy. And right now, those are the people who have done things the right way that are seeing their costs skyrocketing.

He seems to be arguing first that people who virtuous ("good") are healthier than others.  He certainly provided no evidence for this assertion, which, like the assertion by Rep Marshall above, appears to be ideological or religious judgment disguised as epidemiology.

Rep Paul Labrador (R - Idaho) "Nobody Dies Because They Don't Have Access to Healthcare"

As reported by CBS News on May 6, 2017

Labrador made the comments the day after the U.S. House passed a GOP-led health care bill repealing and replacing chunks of Obamacare. Labrador, a member of the conservative House Freedom Caucus, was responding to an audience member who expressed concern about how the bill would affect Medicaid recipients.

'You are mandating people on Medicaid accept dying. You are making a mandate that will kill people,' the audience member said, before being drowned out by Labrador's response.

'No one wants anybody to die,' Labrador said. 'You know, that line is so indefensible. Nobody dies because they don't have access to health care.'

It is not completely clear whether Rep Labrador meant access to health care, or access to health care insurance. A person with appendicitis, acute bacterial pneumonia, a myocardial infarction, etc, etc who fails to seek acute care because of lack of a means to pay for it could well die. As an absolute, this statement is obviously untrue.  

Mick Mulvaney, Director of the Office of Management and Budget: "The Person Who Sits at Home, Eats Poorly and Gets Diabetes" Does Not Deserve Health Insurance

As reported by the Huffington Post on  May 12, 2017

he drew a distinction between people like Kimmel’s son, born with a congenital heart disease, and people who end up with conditions like diabetes. 'That doesn’t mean we should take care of the person who sits at home, eats poorly and gets diabetes,' Mulvaney said, according to a Washington Examiner account consistent with real-time social media reports. 'Is that the same thing as Jimmy Kimmel’s kid? I don’t think that it is.'

This is not exactly the clearest statement but it seems to imply that only people who make unhealthy life-style choices get diabetes, which certainly as an absolute is not true; and furthermore that people who develop diseases due to poor life-style choices do not deserve care.  The juxtaposition suggests that driving this is an ideological or religious judgment about who is deserving.

Video diversion: would Mr Mulvaney think this person deserves "health care?"


In 2003 I published an article entitled "A Cautionary Tale: the Dysfunction of American Health Care," which summarized the views of health care professionals about the causes of health care dysfunction.  One of the major findings was the importance of " attacks on the scientific basis of medicine."  In turn, I hypothesized that some of these attacks stemmed from the rise of post-modernism, then a fashionable intellectual affectation on university campuses, mainly of the avant garde left-wing.  I wrote then:

Postmodernism is 'an attempt to question the fundamental philosophical and political premises of the West.   It argues that many of the concepts we take for granted—including truth, morality, and objectivity—are culturally ‘constructed’'  To postmodernists, truth is just what the powerful say is true.

Now it seems that post-modernist "thought" has escaped the confines of left-wing humanities departments, and infiltrated political discourse, and for some unfathomable reason, seems to particularly affect some of those who profess to be conservative. After all, in January, KellyAnne Conway, a senior White House adviser, defended the administration's arguments as "alternative facts." (Look here.)

Facts, however, are stubborn things.  Evidence is evidence, no matter what politician it might offend.  Basing legislation on the sorts of alternative thinking displayed in the cases above could lead to real life, or life and death consequences for the sick, injured and vulnerable.  True health care reform requires clear thinking and the input of people who actually know something about health care. 

Friday, May 19, 2017

Will the Current Crises Finally Prompt America to Address How it is Haunted by Corruption and Impunity?

There is one tiny silver lining in the political storm clouds swirling over the US.  Some of the issues about which we have been ranting on Health Care Renewal are no longer so easily dismissed.  We have long harangued about the ruinous effects of health care corruption, the role of impunity in enabling worsening corruption, our lack of good ways to challenge these problems, and our ongoing inablity to even discuss what amounts to taboo topics (which we dubbed the "anechoic effect.")  In response, we have been called alarmists, nay-sayers, and worse.  Now the parade of crises created by the Trump regime have made these problems salient to American society.

Corruption is a Huge Problem and We are Ill-Equipped to Deal With It

We have frequently discussed outright corruption in health care as one of the most important causes of health care dysfunction.  Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.

Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.

The report did not get much attention.  Since then, health care corruption has been nearly a taboo topic in the US.  When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects benighted less developed countries.  On Health Care Renewal, we have repeatedly asserted that health care corruption is a big problem in all countries, including the US.  But even after Pope Francis decried health care corruption, the topic remained anechoic.

Yet somehow, a substantial minority of US citizens, 43%, seemed to believe that corruption is an important problem in US health care, according to a TI survey published in 2013 (look here).  But that survey was largely ignored in the media and health care and medical scholarly literature in the developed world, and when it was discussed, it was again in terms of results in less developed countries.  Health Care Renewal was practically the only source of coverage in the US of the survey's results.

So imagine my surprise when Vox published an article on May 17, 2017 entitled "The US is Terrible at Investigating Politicians.  Blame the Constitution."   The article opened with a discussion of mechanisms in place in some other countries explicitly designed to cope with severe corruption of public officials.  The author then noted,

Designing investigations into high-level misconduct is extremely difficult. Every nation has tough choices to make, and none has come up with a perfect solution — though it’s clear that the US system is uniquely bad.

The author noted that the US Constitution provides no clear mechanisms for addressing corruption, and in their absence, at best "we'ver jerry-rigged things instead."

So it is good that there is now some minimal public recognition that we in the US have not developed an effective approach to corruption.  The unasked question, of course, is why not.  Just becauses our constitution is more than 200 years old is not really an excuse.  Constitutions can be amended and laws can be written.  I submit that we have been in a long-standing state of denial about the existence of corruption, based perhaps on an erroneous conception of American exceptionalism, and enabled by those who have gotten rich off corruption, and for a long time have been using substantial resources to keep the problem anechoic.

Now we pay the penalty for our perhaps wilfull ignorance.

Impunity Enables Worsening Behavior

We have long railed against the impunity of top leaders in health care.  We have gone on ad infinitum about the parade of legal settlements made by large health care organizations after allegations of often egregious misbehavior, including episodes of bribery, fraud, kickbacks, and other crimes.  Typically, such settlements allowed the organizations to walk away after paying a monetary penalty that may have appeared big, but was tiny compared to the monay that could have been made from the misbehavior.  In particular, almost never does anyone at the organizations who authorized or directed the bad behavior, particularly top executives, suffer any negative consequences at all, even when they may have made huge bonuses because of the revenues such behavior generated.  The continuing impunity of top health care leaders only seems to encourage future bad behavior.

So imagine my surprise when Vox published on May 18, 2017, an article entitled, "Trump isn’t a toddler — he’s a product of America’s culture of impunity for the rich."

Its author, Matthew Yglesias, indicted President Trump as a long time beneficiary of impunity, whose behavior was enabled by impunity, and who is thus typical of American corporate leaders.

He’s a man who’s learned over the course of a long and rich life that he is free to operate without consequence. He’s the beneficiary of vast and enormous privilege, not just the ability to enjoy lavish consumption goods but the privilege of impunity that America grants to the wealthy.

Trump’s 'law and order' attorney general wants to throw the book at relatively small-time drug offenders. Trump himself has spent his entire career skating away from lawbreaking with a fine paid here and a political contribution there. He’s an unusual figure, but also very much an exemplar of his era and a product of a decades-long ideological campaign to do as much as possible to empower the wealthy and powerful.
Imagine my increased surprise when USA Today published on May 17, 2017, and ediorial by Christian Schneider that similarly asserted that Trump has a

core belief that as long as you're an A-lister, there are no rules worth obeying.

Trump as a Long-Time Beneficiary of Impunity

Trump asserted on the infamous Access Hollywood tape

And when you're a star, they let you do it. You can do anything.

Mr Yglesias documented,

What’s beyond question, however, is that Trump’s expressed view that a rich and famous man like him can get away with anything is both sincere and largely correct. From his empty-box tax scam to money laundering at his casinos to racial discrimination in his apartments to Federal Trade Commission violations for his stock purchases to Securities and Exchange Commission violations for his financial reporting, Trump has spent his entire career breaking various laws, getting caught, and then essentially plowing ahead unharmed. When he was caught engaging in illegal racial discrimination to please a mob boss, he paid a fine. There was no sense that this was a repeated pattern of violating racial discrimination law, and certainly no desire to take a closer look at his various personal and professional connections to the Mafia
Mr Schnider noted

His entire adult life, Trump has been able dodge legal trouble simply by using his bank account as a shield. When Trump Management was sued by the government in 1973 for refusing to rent apartments to people of color, Trump and his father were able to settle without any admission of guilt. When students at Trump University sued him for defrauding them, Trump simply wrote a check for $25 million to make it all go away.

Marriage in the tank? He's got a pre-nup. Casino business going belly-up? He goes to bankruptcy court, walks away, and writes another book praising his own genius.

Trump's Impunity is the Current Vivid Case of a Problem of Historic Proportions

Trump's current actions are, per Mr Yglesias,
entirely emblematic of America’s post-Reagan treatment of business regulation. What a wealthy and powerful person faced with a legal impediment to moneymaking is supposed to do is work with a lawyer to devise clever means of subverting the purpose of the law. If you end up getting caught, the attempted subversion will be construed as a mitigating (it’s a gray area!) rather than aggravating factor. Your punishment will probably be light and will certainly not involve anything more than money. You already have plenty of money, and your plan is to get even more. So why not?

I might quibble that the US problem with corruption and impunity goes back years before President Reagan's administration.  However, still

beyond Trump, America is desperately in need of a larger political reckoning as well.

The entire culture of civil fines and settlements without admission of wrongdoing that dominates American business regulation is fundamentally odd. If the rules say you can’t keep your casino afloat with an unapproved loan and you respond to that by getting a shady secret unapproved loan to keep your casino afloat, shouldn’t you be out of the casino game? If compliance with money laundering rules is mandatory and you don’t comply, shouldn’t you be shut down?

Any given case obviously presents its nuances, and not every case can be taken to the mattresses. But the settlement racket too easily lets regulators feel like they’re putting points on the board even while criminals continue to roam the streets, having learned the lesson that they’re untouchable. That, fundamentally, is Trump’s problem. Not that he can’t control himself, but that he’s been taught he doesn’t have to. 


Sometimes crises do illuminate long festering problems.  If the US survives the current serial crises, maybe we will be able to develop a more open, rational and effective approach to corruption and impunity, including their health care variants.  

So to repeat an ending to one of my previous posts on health care corruption....  if we really want to reform health care, in the little time we may have before our health care bubble bursts, we will need to take strong action against health care corruption.  Such action will really disturb the insiders within large health care organizations who have gotten rich from their organizations' misbehavior, and thus taking such action will require some courage.  Yet such action cannot begin until we acknowledge and freely discuss the problem.  The first step against health care corruption is to be able to say or write the words, health care corruption.

Thursday, May 18, 2017

Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records

Channeling Lyndon Johnson on Walter Cronkite, in clinical medicine, when you've lost Boston (including MGH), you've probably lost the health IT war.

Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records
May 12, 2017
By Drs. John Levinson, Bruce H. Price and Vikas Saini

It happens every day, in exam rooms across the country, something that would have been unthinkable 20 years ago: Doctors and nurses turn away from their patients and focus their attention elsewhere — on their computer screens.

By the time the doctor can finally turn back to her patient, she will have spent close to half of the appointment serving not the needs of her patient, but of the electronic medical record.

I have observed this myself in my own personal experiences in recent years observing clinicians in situ.  I (unfortunately) have also been on the receiving end of the resultant distractions, via a dead parent, at the very hospital where I did my residency training in pre-HIT days.

Electronic medical records, or EMRs, were supposed to improve the quality, safety and efficiency of health care, and provide instant access to vital patient information.

Instead, EMRs have become the bane of doctors and nurses everywhere. They are the medical equivalent of texting while driving, sucking the soul out of the practice of medicine while failing to improve care.

"Texting while driving" is, in fact, an excellent metaphor.  The practice of medicine is often a highly-demanding activity, cognitively speaking, just as driving is.  Slip up even for a moment, and accidents and catastrophe can occur.
To fix them, hospital administrators and clinicians need to work together to demand better products from EMR manufacturers and to urge government to relax several provisions of the HITECH Act, the 2009 law that spawned many of the problems with EMRs.

I do not think this is feasible, nor do I think it would solve the problems.  More on that below.

How did technology that has increased efficiency in every other industry become such a drag on health care? For starters, people who take care of patients did not design or choose these systems. They were foisted upon us.

Doctors and nurses know that good diagnosis and treatment requires listening attentively to their patients. They spend years learning to parse the clues that patients offer, both the physiological and personal, in order to provide the right care.

The sound of medicine is not the click of a mouse. It is the human voice. Let’s bring it back.

To do this well takes time and undivided attention.

"Undivided attention to the patient" and "use of health IT" under the current paradigms are incompatible.  The terms do not belong in the same sentence.  Again, more on that below.

... Instead of making this easier, most EMRs create extra work. A lot of extra work, thanks to endless prompts with multiple choice answers that hardly ever fit the facts and that demand click after click to get anything done.

Want to order a simple test? That requires getting through multiple prompts. Need to write a prescription -- an exercise that used to take less than 15 seconds? Another set of clicks.

Template madness is the coin of the realm.

Four screens of hundreds, from just one EHR, of many EHRs that a clinician might need to use in practice of medicine.

Typing, filing, mailing results and placing referrals all used to be done by assistants. Now, EMRs put that burden on clinicians, and we must do it during office visits, or “encounters,” as EMRs call them. And when the wrong button is clicked, the wrong test or drug is ordered, or it does not go through at all, delaying medical care.

It’s death by a thousand clicks, and it happens every day.

Another excellent metaphor, a derivation of "death by a thousand cuts."  However, in this case, it is not just referring to death of the ability to maintain medical practice and retain sanity (and health of the practitioner), but also injury and death of patients.

We are frustrated by EMRs because they pull us away from our patients. We are driven mad by the fact that EMRs in different locations do not talk to each other. And we think it’s just wrong that much of the EMR’s busywork is about optimizing billing for the hospital.

The lack of interoperability is likely protective against, in effect, mass copy-and-paste on a grand scale through importation of a chart from one EHR to another, resulting in propagation of errors.  In any case, interoperability needs to take a back seat to operability (usability).

Who is to blame? Start with EMR manufacturers, who lobbied Congress to require every hospital and doctor’s office to install an EMR system; hospital administrators who bought technology that conveniently pushed billing duties onto doctors and nurses; and federal regulators, who imposed on EMRs numerous quality metric requirements that do nothing to improve care.

Everyone in healthcare is to blame, including clinicians who DID NOT SPEAK OUT until obvious issues crated the terrible state clinicians find themselves in now.

We do not want to go backward. We believe that computing is essential to the future of medicine. We simply want all EMRs to live up to their promise of improving care and making patient information readily available.

I've been calling the problems out for close to two decades now.

The issue becomes:  what to do about it?

My area of Medical Informatics research in the early 1990s was to move away from the traditional GUI paradigm of menus, widgets, control buttons, etc to explore novel (and menu-free) paradigms of EHR-based data content visualization, navigation and querying.  The commercial companies, when shown this, had no interest in even considering such ideas.

Other avenues to enhance the traditional GUI interface - e.g., AI-based "wizards" of one sort or another that anticipated likely down-the-line choices from currently entered data and presented the choices to the user, better-designed EHR roadmaps and/or AI based on data entry to-the-moment to  allow simpler and less time-consuming navigation, etc. - all proved not very helpful due to the complexity of the domain, not to mention its specialties and subspecialties.  This experience informed my decision down the line to move to specialized and malleable paper forms for the clinicians, and data entry clerical teams, for high risk and/or high volume procedural or critical care areas such as invasive cardiology, cardiac surgery and the ED.

See my Aug. 2016 post "More on uncoupling clinicians from EHR clerical oppression" at for a specific, highly successful example.

It is my belief that the "traditional" model - GUI-based EHRs with the typical paradigms, and clinicians doing the bulk of the data entry that itself is bloated relative to the actual clinical need, and tying all human-computer interaction to a computer screen roughly at the resolution of one or two legal-sized pieces of paper, can never be improved to the point of not impairing the clinical workday.

The entire health IT enterprise needs to be rebooted (rethought), especially regarding roles, workflow, and most especially the "data capture load per clinician".

When I was writing about EHR issues in the late 1990s and into the 2000s, I was called a Luddite and alarmist (or worse, e.g., see my 2010 posts "The Dangers of Critical Thinking in A Politicized, Irrational Culture" at and "More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?" at

It appears I was correct.

My issuing the prediction that the current model of health IT is irreparably broken (or, said differently, that the health IT experiment - and it has been an experiment - under its current paradigms has failed), and needs a top-to-bottom rethinking, will probably be taken the same way.

Until it isn't.

-- SS

Friday, May 12, 2017

Massive ransomware cyberattack in U.K. Hits 16 Health Institutions, many doctors reported that they could not retrieve their patients’ files, but not to worry - no patient information was looked at or compromised

Perhaps doctors and nurses are clairvoyant?  Who needs records, anyway?

Cyberattack in U.K. Hits 16 Health Institutions
New York Times