Monday, February 10, 2020

What the Heck Happened to Surprise Billing Legislation? (Or, it’s never too late for the lobbyists to win.)

With constituents pressing for something to remedy unexpected liabilities incurred from “surprise” medical bills, it was expected that surprise medical bill legislation would pass federally in December 2019 as part of an end-of-year legislation package. House and Senate committees had worked for months on consensus legislation that was ready to go, but that fell through at the last moment. What happened?

Some background on the issue: Surprise bills are something of a battleground between payers (insurers) and providers (doctors/hospitals). Insurers want to lower bills, and providers want to raise them. More and more, hardball is being played. If large groups of specialty providers remain out-of-network, they can often make a great deal more money than if they signed a contract for a number agreeable to the insurer. Patients – who can get nightmarish huge bills and be legally liable for them – are the roadkill in this tug-of-war. Private equity firms, who are now buying up group medical practices on the assumption that they can increase earnings substantially, have recently become a major player in the dynamic. Dr. Poses had a good post in September on their role and on their lobbying/advertising efforts. Private equity firms like Blackstone and KKR put a TON of money into the radio and TV ads that urged people to call their legislators to oppose "government rate-setting."

We’re not talking chump change, here. A recent analysis showed that surprise billing charges in excess of negotiated rates amount to as much as FORTY BILLION dollars annually.

Surprise billing legislation – state and federal - to date has taken two approaches. One approach is to fix the bill with out-of-network doctors based in some way on what an in-network doctor makes. This “benchmarking” approach advantages the insurance companies and self-funded employers.

The other is to rely on arbitrators to settle the dispute about amounts between provider and insurers. Experience has shown that this is in practice highly advantageous to the provider – to hospitals and to specialty groups (and in some cases to their private equity investors). This second approach drives up already-high U.S. medical costs. This major downside, in my opinion, makes it far more in the public interest to lean toward the benchmarking type of solution, while striving for fairness.

The bipartisan consensus agreement, known as the Murray-Alexander bill after Democrat Patty Murray and Republican Lamar Alexander, was initially based on a benchmarking approach, but after compromises that were made, had room for outside arbitration for amounts over $750. The Congressional Budget Office estimated that its passage would save TWELVE BILLION dollars in insurer medical costs, enabling lowering of premiums (this does not even include out-of-pocket patient savings). But, of course, those twelve billion dollars in saved costs are also twelve billion dollars in lowered revenue to providers and their owners.

And so, this bipartisan deal was torpedoed at the last moment by another bipartisan team, Democrat Richard Neal (House Ways and Means committee chair) and Republican Kevin Brady. Everything also indicates that Senate Minority Leader Chuck Schumer – who pushed Murray to back off from her support - was instrumental in killing the deal. Nancy Pelosi, too, was an enabler, allowing Neal to kill the bill. She was heard assuring industry representatives that "we are not going to give a handout to big insurance companies."

As journalist Jon Walker tweeted:
Disgraceful. @SpeakerPelosi is going around trying to keep your premiums sky high to pay off private equity firms and bad actor hospitals.

Everything about the spiking of the deal indicates that money talks, and loudly, with large donations having been made to Schumer’s Senate Majority PAC by the Greater New York Hospital Association and with donations too to Richard Neal from private equity.

And so the legislation is dead until and unless Schumer and Neal can get their preferred (and price-raising) approach adopted. Meantime, real people are suffering from getting huge bills they have no control over. As Elizabeth Rosenthal observed recently, practices that are both routine and legal in the medical industry are nonetheless in essence fraudulent. The business model of U.S. medicine is fraud – and a very profitable business model it is.

NOTE 1: Although a number of states have passed surprise bill legislation, it is critical to get something passed on a federal level, because most large employer-based plans are federally regulated and state laws don’t apply.

NOTE 2: Benchmarking and arbitration are not the only possible approaches. Another suggestion is to abolish the practice of separate bills from doctors for services provided in hospitals.

Friday, February 07, 2020

The Big Spin Out: 2020 Revolving Door Update

In  2020, cases of the revolving door accumulated quickly. 



The Old School Outgoing Revolving Door

Let us begin with cases of the old fashioned outgoing revolving door, that is, of people leaving leadership positions in governmental bodies which regulate health care or make health care policy, then soon obtaining jobs in the health care industry, particularly organizations which they previously regulated or were affected by the policies they made.

Dr Vindell Washington from National Coordinator for Health Care Information Technology to Alphabet

Per FierceHealthCare, January 7, 2020:

Alphabet, the parent company of Google and Verily Life Sciences, continues to bolster its ranks of healthcare experts with the latest hiring of Vindell Washington, M.D.

Verily Life Sciences hired Washington as its new chief clinical officer as part of its health platforms team, Verily Life Sciences representative Kathleen Parkes confirmed to FierceHealthcare Tuesday.

Washington served as the national coordinator for health IT from August 2016 to January 2017.

As one of the highest health IT policy leaders, Washington brings to Verily a deep understanding of the industry. He is an emergency medicine physician by training.

So he moved from a position with significant influence over government health IT policy to a big IT company involved in health care.  Admittedly though, this moves comes three years after he left the ONC.

Dr Kate Goodrich from Chief Medical Officer of the Center for Medicare and Medicaid Services (CMS) to Humana Inc

Per Louisville Business First, January 17, 2020:

Humana Inc. has hired away a key regulatory insider from the federal government.

Dr. Kate Goodrich will leave the chief medical officer role at Centers for Medicare & Medicaid Services in February. Politico reported Thursday Goodrich will become a senior vice president for the company.

CMS is the agency that oversees both Medicare and Medicaid, the government-backed health plans. Goodrich was also director of the Center for Clinical Standards and Quality, the CMS website states.

Note that Humana's business is heavily influenced by the actions of CMS.

Humana's core business is providing Medicare Advantage plans, a private version of the federal health plan for seniors. It has about 4.1 million members in Medicare Advantage plans, according to its latest financial disclosure.

The Medicare Advantage segment brought in about $37.1 billion of revenue in the nine months ended Sept. 30, 2019.

Mary Sumpter Lapinski from Government Affairs at Bristol-Myers-Squibb to Counselor to the Secretary of the Department of Health and Human Services (DHHS) for Public Health and Science, then to Vice President of Global Governance Affairs for Greenwich Biosciences


Note that in this case, someone recently reported as transiting the outgoing revolving door has also had in the past transited the incoming revolving door.

Per a Buzzfeed News article, January 24, 2020 (which also discussed the larger revolving door problems involving the pharmaceutical industry and the Trump administration):

Mary-Sumpter Lapinski, who worked in government affairs for Bristol-Myers Squibb from 2002–2007, served as a counselor to the health and human services secretary for public health and science. As of April 2019, Lapinski is the vice president of global government affairs for biopharmaceutical company Greenwich Biosciences.

Again, most recently she moved from a senior position in DHHS affecting public health and science to a biotech company.

Roxana Weil, Lead Toxicologist from the Center for Tobacco Products at the Food and Drug Administration (FDA) and Gabriel Muniz who inspected tobacco manufacturers for the FDA to Juul Labs Inc

Per Bloomberg (via the Detroit News, February 5, 2020):

Juul Labs Inc. has hired former Food and Drug Administration employees and is recruiting more researchers as it prepares for a crucial regulatory hurdle that will determine the future of the top U.S. e-cigarette maker.

So

Roxana Weil, formerly a lead toxicologist at the agency’s Center for Tobacco Products, joined Juul as principal scientific adviser in September. Gabriel Muniz, who worked in an FDA division that inspects tobacco manufacturers, joined Juul last month as a director of regulatory compliance.

Note that

The company and its peers must submit applications to the FDA by May 12 in order to continue selling their products. The deadline is a defining moment for the e-cigarette industry, which has been under fire following a surge in teen vaping and a lung-injury outbreak that sickened thousands and was later tied to THC.

For Juul, securing a swift clearance is critical. The company has seen its once-rich valuation drop since the broader vaping backlash began. Failing to win the FDA’s blessing could shut it out of a market it has dominated.

So they moved from regulating tobacco to a company essentially involved in selling tobacco analogues.  Note that the tobacco company Altria made a major investment in Juul (look here.)

The Au Courant Incoming Revolving Door

In the Trump era, many people have come through the incoming revolving door, that is, people with significant leadership positions in health care corporations or related groups have attained leadership positions in government agencies whose regulations or policies could affect their former employers.

There are two recent examples

Brad Smith, Chief Operating Officer of Anthem's Diversified Business Group to be Director, Center for Medicare and Medicaid Innovation (CMMI) at the DHHS

Per FierceHealthcare, January 6, 2020:

The Trump administration has selected Brad Smith to serve as the director of the Center for Medicare and Medicaid Innovation (CMMI), where he will oversee the creation and stewardship of value-based payment models.

Smith most recently was the chief operating officer of Anthem’s Diversified Business Group, a division of the insurance giant that includes provider services. He was also the co-founder and CEO of palliative care services company Aspire Health.

Anthem is a health insurer which provides Medicare supplements and Medicare Advantage programs, so its business is greatly affected by any changes in how Medicare or Medicaid makes payments.

Amanda Adkins, Executive for Cerner Corp, Now Running for the House of Representatives as a Republican

This could be called a running start that will likely lead through the incoming revolving door.

Per the  Kansas City Star, January 23, 2020:

Cerner executive Amanda Adkins has taken a leave of absence from the company to focus on her campaign to unseat Democratic Rep. Sharice Davids.

Adkins, a former Kansas Republican chair, launched her bid for Kansas’ 3rd congressional district in September, but initially planned to remain as Cerner’s vice president of strategic growth through the campaign.

But as of last week, according to a company spokeswoman, Adkins went on unpaid leave after from her role after 15 years with the health care IT giant.

Note that the Star article, unlike the others quoted above, provided at least a slightly detailed discussion of why this (potential) move poses a conflict of interest:

The Kansas City-based company is a major federal contractor with a $10 billion contract to design a new health care records system for the U.S. Department of Veterans Affairs. The new system is expected launch later this year.

Federal election rules prohibit federal contractors from giving directly to federal candidates. Craig Holman, a lobbyist for Public Citizen, a national group which advocates for tougher ethics standards, said Adkins’ unpaid leave protects Cerner from violating this rule.

But Holman said the fact that she can return from leave after the election still raises questions about a conflict of interest since she could end up on committees with oversight of the company’s contracts if elected to Congress.

'The conflict still persists,' Holman said in a phone call. 'The fact that she has not resigned and remains an employee of Cerner means that conflict of interest remains front and center.'

Summary

Sigh.  So while there is much discussion of corruption in high places, and its potential link to high crimes and misdemeanors, the revolving door quietly spins on well-oiled hinges, as it has for years, including many years before the current administration.  

So as we have repeatedly said,  most recently in October, 2019, ...

The revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,


The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door once again suggests how the revolving door may enable certain of those with private vested interests to have disproportionate influence on how the government works.  The country is increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

 The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.



Wednesday, January 29, 2020

Cybernetic Opioid Pushers: EHR vendor Practice Fusion to Pay $145 Million to Resolve Criminal and Civil Investigations

Considering the devastating and deadly opioid problems in this country, this news release from DOJ describes particularly despicable behavior from an EHR vendor and pharmas.

These problems are likely more widespread, but this EHR company got caught.

The company admitted that it solicited and received kickbacks from a major opioid company in exchange for utilizing its EHR software to influence physician prescribing of opioid pain medications, via "decision support" routines specifically designed by the drug company to increase drug company profits.

The DOJ reports that in exchange for “sponsorship” payments from pharmaceutical companies, Practice Fusion allowed the companies to influence the development and implementation of the CDS (clinical decision support) alerts in ways aimed at increasing sales of the companies’ products.  Practice Fusion allegedly permitted pharmaceutical companies to participate in designing the CDS alert, including selecting the guidelines used to develop the alerts, setting the criteria that would determine when a healthcare provider received an alert, and in some cases, even drafting the language used in the alert itselfThe CDS alerts that Practice Fusion agreed to implement did not always reflect accepted medical standards.

This story could certainly help explain why I could never get involved in EHR initiatives in pharma, despite having been at Merck in a science-support capacity, but seeking EHR involvement.  I had completed a Yale Medical Informatics postdoc and then faculty period authoring EHRs domestically and for a foreign country, and then had a period as a CMIO in Delaware. Yet, my many pharma applications over many years afterwards for EHR-related positions were mostly ignored.

The reason behind that shutout could likely be that I was known as being exceptionally honest, if only in part for my candid writing on EHR problems first on AOL 1999-2004, then at Drexel University and at this blog, at a time when the pundits and hyper-enthusiasts were pushing the technology uncritically and relentlessly.

Indeed, I would never have tolerated the types of conspiracy (DOJ's word) between EHR companies and pharma that are described in this DOJ release to help push drugs, any drugs - let alone opioids.

To make matters worse, this vendor is also described as cheating on the HHS EHR "certification" process.  The company is described as concealing from the certifying entity, known as an ONC-Authorized Certification Body (ATCB), that the EHR software did not comply with all of the applicable requirements for certification.

Apparently, no defendants were jailed.

I am posting the DOJ release in its entirety.  It is quite comprehensive, and I have nothing to add.

https://www.justice.gov/opa/pr/electronic-health-records-vendor-pay-145-million-resolve-criminal-and-civil-investigations-0
Department of Justice
Office of Public Affairs

FOR IMMEDIATE RELEASE
Monday, January 27, 2020

Electronic Health Records Vendor to Pay $145 Million to Resolve Criminal and Civil Investigations

Practice Fusion Inc. Admits to Kickback Scheme Aimed at Increasing Opioid Prescriptions

Practice Fusion Inc. (Practice Fusion), a San Francisco-based health information technology developer, will pay $145 million to resolve criminal and civil investigations relating to its electronic health records (EHR) software, the Department of Justice announced today.

As part of the criminal resolution, Practice Fusion admits that it solicited and received kickbacks from a major opioid company in exchange for utilizing its EHR software to influence physician prescribing of opioid pain medications.  Practice Fusion has executed a deferred prosecution agreement and agreed to pay over $26 million in criminal fines and forfeiture.  In separate civil settlements, Practice Fusion has agreed to pay a total of approximately $118.6 million to the federal government and states to resolve allegations that it accepted kickbacks from the opioid company and other pharmaceutical companies and also caused its users to submit false claims for federal incentive payments by misrepresenting the capabilities of its EHR software.

“Across the country, physicians rely on electronic health records software to provide vital patient data and unbiased medical information during critical encounters with patients,” said Principal Deputy Assistant Attorney General Ethan Davis of the Department of Justice’s Civil Division.  “Kickbacks from drug companies to software vendors that are designed to improperly influence the physician-patient relationship are unacceptable.  When a software vendor claims to be providing unbiased medical information – especially information relating to the prescription of opioids – we expect honesty and candor to the physicians making treatment decisions based on that information.”
The resolution announced today addresses allegations that Practice Fusion extracted unlawful kickbacks from pharmaceutical companies in exchange for implementing clinical decision support (CDS) alerts in its EHR software designed to increase prescriptions for their drug products. 

Specifically, in exchange for “sponsorship” payments from pharmaceutical companies, Practice Fusion allowed the companies to influence the development and implementation of the CDS alerts in ways aimed at increasing sales of the companies’ products.  Practice Fusion allegedly permitted pharmaceutical companies to participate in designing the CDS alert, including selecting the guidelines used to develop the alerts, setting the criteria that would determine when a healthcare provider received an alert, and in some cases, even drafting the language used in the alert itself.  The CDS alerts that Practice Fusion agreed to implement did not always reflect accepted medical standards.  In discussions with pharmaceutical companies, Practice Fusion touted the anticipated financial benefit to the pharmaceutical companies from increased sales of pharmaceutical products that would result from the CDS alerts.  Between 2014 and 2019, health care providers using Practice Fusion’s EHR software wrote numerous prescriptions after receiving CDS alerts that pharmaceutical companies participated in designing.

Practice Fusion executed a deferred prosecution agreement with the U.S. Attorney’s Office for the District of Vermont based on its solicitation and receipt of kickbacks from a major opioid company to arrange for an increase in prescriptions of extended release opioids by healthcare providers who used Practice Fusion’s EHR software.  As detailed in the criminal Information made public today, Practice Fusion solicited a payment of nearly $1 million from the opioid company to create a CDS alert that would cause doctors to prescribe more extended release opioids.  That payment was financed by the opioid company’s marketing department, and the CDS was designed with input from the marketing department.  Practice Fusion and the opioid company entered the CDS sponsorship because they believed that the CDS would influence doctors’ prescriptions of extended release opioids.  In marketing the “pain” CDS alert, Practice Fusion touted that it would result in a favorable return on investment for the opioid company based on doctors prescribing more opioids.

“Practice Fusion’s conduct is abhorrent.  During the height of the opioid crisis, the company took a million-dollar kickback to allow an opioid company to inject itself in the sacred doctor-patient relationship so that it could peddle even more of its highly addictive and dangerous opioids,” said Christina E. Nolan, U.S. Attorney for the District of Vermont.  “The companies illegally conspired to allow the drug company to have its thumb on the scale at precisely the moment a doctor was making incredibly intimate, personal, and important decisions about a patient’s medical care, including the need for pain medication and prescription amounts.  This recovery is commensurate to the nature of Practice Fusion’s misconduct, represents the largest criminal fine in the history of this District, and requires Practice Fusion to admit to its wrongs.  It is another example of pioneering healthcare fraud enforcement by the talented Assistant U.S. Attorneys and staff of this U.S. Attorney’s Office, working with their partners in law enforcement.  We cannot — and will not — tolerate technology companies influencing patient treatment merely because a pharmaceutical company provided a kickback.”

The criminal Information charges Practice Fusion with two felony counts for violating the Anti-Kickback Statute (AKS), 42 U.S.C. § 1320a-7b(b)(1), and for conspiring with its opioid company client to violate the AKS, 18 U.S.C. § 371.  This case is the first ever criminal action against an EHR vendor and the unique Deferred Prosecution Agreement imposes stringent requirements on Practice Fusion to ensure acceptance of responsibility and transparency as to its underlying conduct, and to invest heavily in compliance overhauls and an independent oversight organization.  The Deferred Prosecution Agreement requires Practice Fusion to pay a criminal fine of $25,398,300 and forfeit criminal proceeds of nearly $1 million.  In addition, the company will cooperate in any ongoing investigations of the kickback arrangement and report any evidence of kickback violations by any other EHR vendors.  To ensure transparency and public awareness of the company’s activities while the nation continues to battle an epidemic of opioid addiction, the Deferred Prosecution Agreement requires Practice Fusion to make documents relating to its unlawful conduct available to the public through a website.  Additionally, the Deferred Prosecution Agreement mandates that Practice Fusion retain an independent oversight organization that is required to review and approve any sponsored CDS before Practice Fusion may implement the CDS, and create a comprehensive compliance program designed to ensure such abuses are not repeated.

The civil settlement with the United States resolves Practice Fusion’s civil liability arising from the submission of false claims to federal healthcare programs tainted by the kickback arrangement between Practice Fusion and the opioid company.  It also resolves allegations of kickbacks relating to thirteen other CDS arrangements where Practice Fusion agreed with pharmaceutical companies to implement CDS alerts intended to increase sales of their products.  The $118.6 million settlement amount includes approximately $113.4 million to the federal government and up to $5.2 million to states that opt to participate in separate state agreements.

“Prescription decisions should be based on accurate data regarding a patient’s medical needs, untainted by corrupt schemes and illegal kickbacks,” said U. S. Attorney David L. Anderson of the Northern District of California.  “In deciding what is best for patients, electronic health records software is an important tool for care providers.  It is critically important that technology companies do not cheat when certifying that software.”

In addition to the kickback allegations, the civil settlement with the United States resolves allegations relating to two intersecting Department of Health and Human Services (HHS) programs, one at the Office of the National Coordinator for Health Information Technology (ONC) that regulates the voluntary health IT certification program, and one at the Centers for Medicare & Medicaid Services that oversees EHR incentive programs.  Specifically, the United States alleged that Practice Fusion falsely obtained ONC certification for several versions of its EHR software by concealing from its certifying entity, known as an ONC-Authorized Certification Body, that the EHR software did not comply with all of the applicable requirements for certification.  ONC’s certification criteria were designed to promote enhanced functionality, utility, and security of health information technology, and access to patient medical information across the care continuum.  HHS implemented the certification criteria for EHR software in multiple stages, known as editions.  To be certified under the 2014 Edition certification criteria, EHR software was required to allow users to electronically create a set of standardized export summaries for all patients.  When Practice Fusion sought certification of this 2014 Edition criteria, Practice Fusion falsely represented to the certifying body that its software met this data portability requirement, when several versions of its software did not.  The civil settlement resolves allegations that, at the time these versions of Practice Fusion’s software were certified, its software was unable to permit a user to create a set of standardized export summaries.  Additionally, after obtaining certification of the 2014 Edition criteria, Practice Fusion disabled access to this feature altogether.  Instead, Practice Fusion required users to contact it separately to request export of this critical patient data.

In addition to failing to satisfy the data portability requirement, Practice Fusion’s software allegedly did not incorporate standardized vocabularies as required for certification.  The United States alleged that by fraudulently obtaining certification for its products, Practice Fusion knowingly caused eligible healthcare providers who used certain versions of its 2014 Edition EHR software to falsely attest to compliance with HHS requirements necessary to receive incentive payments from Medicare during the reporting periods for 2014 through 2016 and from Medicaid during the reporting periods for 2014 through 2017.

“As new technologies continue to develop and evolve, so too do new and innovative fraud schemes,” said Shimon R. Richmond, Assistant Inspector General for Investigations of the U.S. Department of Health and Human Services. “We will continue to be vigilant in detecting and investigating these schemes in order to protect the safety of patients in federal health programs and to ensure the appropriate use of electronic health records in providing their care.”

“Today's announcement shows that Practice Fusion exploited technology to profit at the expense of a vulnerable population – patients seeking medical advice," said Timothy M. Dunham, Special Agent in Charge of the FBI's Washington Field Office, Criminal Division.  "The FBI is committed to working with our partners to bring to justice the perpetrators of healthcare fraud in all its forms, especially one that fans the flames of the already rampant opioid epidemic.”

The U.S. Attorney’s Office for the District of Vermont handled the criminal investigation and resolution.  The civil investigation was jointly handled by the Civil Division’s Commercial Litigation Branch and the U.S. Attorneys’ Offices for the District of Vermont and the Northern District of California.  The investigation was supported by the HHS Office of Inspector General and multiple HHS agencies and components.  The FBI’s field office in Washington, DC, also provided significant investigative support.

Except for the conduct admitted in connection with the criminal resolution, the civil claims resolved by the settlement are allegations only, and there has been no determination of liability as to such civil claims.

Friday, January 24, 2020

Transparency International's Corruption Perceptions Index 2019: Political Corruption in the US Worsens, and Results are Largely Anechoic



Transparency International has just released its 2019 version of the Corruption Perceptions Index.  This version emphasized public sector corruption.  Once again, it appears the US has a worsening corruption problem.  Once again, the results are largely anechoic.

Summary of the 2019 CPI

Methods

Per the TI summary

The CPI scores 180 countries and territories by their perceived levels of public sector corruption, according to experts and business people.

The CPI uses a scale from 0 to 100.  100 is very clear and 0 is highly corrupt.


Results

TI provides CPI results for 180 countries.



The US had a score of 69, tied with France for 23rd best.  The score has declined since 2015 (when it was 76).

TI designated the US as a country to watch, with the following explanation:

With a score of 69, the United States drops two points since last year to earn its lowest score on the CPI in eight years. This comes at a time when Americans’ trust in government is at an historic low of 17 per cent, according to the Pew Research Center.

The US faces a wide range of challenges, from threats to its system of checks and balances, and the ever-increasing influence of special interests in government, to the use of anonymous shell companies by criminals, corrupt individuals and even terrorists, to hide illicit activities.

While President Trump campaigned on a promise of 'draining the swamp' and making government work for more than just Washington insiders and political elites, a series of scandals, resignations and allegations of unethical behaviour suggest that the 'pay-to-play' culture has only become more entrenched. In December 2019, the US House of Representatives formally impeached President Trump for abuse of power and obstruction of Congress.

The report emphasized that many countries, including the US, had increasing problems with political integrity:

This year, our research highlights the relationship between politics, money and corruption. Unregulated flows of big money in politics also make public policy vulnerable to undue influence.

Countries with stronger enforcement of campaign finance regulations have lower levels of corruption, as measured by the CPI. Countries where campaign finance regulations are comprehensive and systematically enforced have an average score of 70 on the CPI, whereas countries where such regulations either don’t exist or are poorly enforced score an average of just 34 and 35 respectively.

Sixty per cent of countries that significantly improved their CPI scores since 2012 also strengthened their enforcement of campaign finance regulations.

In addition, when policy-makers listen only to wealthy or politically connected individuals and groups, they often do so at the expense of the citizens they serve.

Countries with broader and more open consultation processes score an average of 61 on the CPI. By contrast, where there is little to no consultation, the average score is just 32.

A vast majority of countries that significantly declined their CPI scores since 2012 do not engage the most relevant political, social and business actors in political decision-making.

Countries with lower CPI scores also have a higher concentration of political power among wealthy citizens. Across the board, there is a concerning popular perception that rich people buy elections, both among some of the lowest-scoring countries on the CPI, as well as among certain higher-scoring countries, such as the United States.

The Anechoic Effect Lives

At least the 2019 CPI got some attention in 2020, as did the 2017 version (look here).  I found articles briefly summarizing the US results in a few US media outlets: Bloomberg (behind a paywall), the Associated Press (here, via the New York Times), and Forbes. There was also one op-ed, again in the WaPo.

This was some improvement from how previous relevant results from TI research were covered earlier.   There was virtually  no coverage of a 2013 survey that showed 43% of US respondents believed that US health care was corrupt.

One could argue even so that the current coverage of the 2019 report was inadequate given the importance of the topic and the apparent worsening of the US corruption problem.  This lack of coverage inspired me to write this post, in the hopes of making the issue just a little less anechoic

Discussion

We have argued again and again that health care corruption is an important reason for US (and global) health care dysfunction.  As we wrote in 2019,  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.

Also,
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 got little attention.  Health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,
However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects some other places, mainly  presumably benighted less developed countries.  At best, the corruption in developed countries that gets discussed is at low levels.  In the US, frequent examples are the "pill mills"  and various cheating of government and private insurance programs by practitioners and patients.  Lately these have gotten even more attention as they are decried as a cause of the narcotics (opioids) crisis (e.g., look here).  In contrast, historically the US government has been less inclined to address the activities of the leaders of the pharmaceutical companies who have pushed legal narcotics (e.g., see this post). 

However, Health Care Renewal has stressed "grand corruption," or the corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements that result in fines that small relative to their  multi-billion revenues without admitting guilt.  Almost never are top corporate managers subject to any negative consequences.

We have been posting about this for years at Health Care Renewal, while seeing little progress on this issue.  Now the problem appears to be getting worse in the US.  We have argued that a major reason is the miasma of corruption now surrounding the top of the US government, specifically the Trump administration (see again this 2019 post).

Now the TI discussion of its 2019 Corruption Perceptions Index points to increasing problems of public sector corruption in the US. Many of the issues it cites have been discussed on Health Care Renewal, including: problems in "campaign finance regulation" and "perception that rich people buy elections" (see our discussion of dark money); and "policy-makers [who] listen only to wealthy or politically connected individuals and groups" (see our discussion of the revolving door and regulatory capture).

The op-ed by Hough in the Washington Post included this parallel discussion:

First, successful anti-corruption policy centers on transparency and accountability. Reports such as this one by the UNDP make a strong case that clear lines of accountability improve the quality of governance, and sharpen attempts to fight corruption. Openness and transparency also need to be default settings. These are both areas where the U.S. could improve. The tone set by Donald Trump, whether by refusing to publish his tax returns or personally profiting from his position as president is indicative of a much broader problem. Neither transparency nor accountability are ever absolute, but analysts find plenty of scope for the U.S. to improve.

Second, the more opaque and complex the relationship between money and power, the more difficult it is to pinpoint and counteract corrupt relationships. Again, getting this right is not an exact science — and there’s no perfect system for funding political activity. But campaign finance, along with lobbying, are what corruption scholar Michael Johnston calls influence markets — areas where the wealthy can trade money for influence on policy outcomes. In other words, the rules and regulations let rich benefactors buy themselves a hearing. Yes, there are countries in worse positions, but that doesn’t hide the fact that the U.S. is also far from a model pupil.

And third, fewer Americans now trust either the politicians that rule them or indeed the institutions that help shape public life. Successful anti-corruption is built around integrity management, which requires public servants to act in appropriate ways — but also be seen acting in such ways. The highest ethical and moral standards — and transparency about potential conflicts of interest and recognizing when personal and public interests clash — would let U.S. citizens begin to believe that a cleanup of American government was underway.

In summary, there is growing evidence of a worsening corruption problem in the US.  As of today, responses to it have been ineffective.  Political corruption, especially at the top of the US government, makes addressing health care corruption increasingly difficult.

So we welcome any additional attention to health care corruption, or the larger corruption within the US government that is making health care corruption even harder to address.

But even if we can take that step, when the fish is rotting from the head, it makes little sense to try to clean up minor problems halfway towards the tail. Why would a corrupt regime led by a president who is actively benefiting from corruption act to reduce corruption? The only way we can now address health care corruption is to excise the corruption at the heart of our government.

It is now over three years since Trump was inaugurated, and there has been no real progress.  The fish is still rotting, and so is health care.  What will it take to make something happen?



Friday, January 10, 2020

Who Owns, and Who is Accountable for the New US For-Profit Medical Schools?




Mysteries still abound in the not so wonderful world of health care dysfunction, so once again, quick, the game's afoot...

The current mysteries involve beneficial ownership.  Beneficial ownership questions are important to anti-corruption campaigners.  Beneficial ownership simply refers to "anyone who enjoys the benefits of ownership of a security or property, without being on the record as being the owner." (per Wikipedia). Concealing who really owns a company enables concealing sources of funds (as in money laundering), market power (when the owner also owns competitors), and sources of political influence, and enables those benefiting from the actions of the company to escape responsibility for their consequences.

We recently discussed the mystery of the beneficial ownership of a local pharmaceutical company, an issue that became more interesting when it was revealed it was owned by the Sackler family, the owners of the now somewhat infamous Purdue Pharma.  A while back we discussed the mysteries surrounding the ownership of several offshore medical schools (look here and here).

I was recently involved in a conversation about the rise of onshore, that is US based for-profit medical schools, four of which are now known to exist.  It turns out that their ownership is also rather unclear.

That for-profit medical schools now exist in the US is not widely known.  The best, and nearly only public discussion of the topic appeared in a 2017 article in JAMA [Adashi EY, Krishna GR, Grappuso PA. For-profit medical schools - a Flexnerian legacy upended.  JAMA 2017; 317: 1209-10.  Link here.]  It listed four such schools that were operating or in development.

Rocky Vista University College of Osteopathic Medicine

Rocky Vista was the first for-profit to open.  Its President is Clinton E Adams DO.  The university website is silent on its ownership.  Some searching reveals, however, that it, along with St Georges University in Grenada, is owned by Medforth Global Healthcare Education, whose CEO is Dr Andrew Sussman, who was "most recently Executive Vice President of Clinical Services at CVS Health."

However, who owns Medforth, and hence to whom Dr Sussman reports, is unclear.  We do know that in 2014, "Canadian private equity firm Altas Partners LP and pan Asia firm Baring Private Equity Asia have acquired a substantial stake in St George’s University," per Reuters.  A reference on the financial website Mergr suggested that Atlas and Baring targeted Medforth per se.  Who, in turn, actually owns Atlas and Baring, and to whom at those firms the leadership of Medforth, and thus ultimately the leadership of Rocky Vista report, is unclear.


Ponce Health Sciences University

The President of Ponce Health Sciences University is Dr David Lenihan.  According to his welcome statement,

Ponce was acquired by University Ventures Corporation in September 2014, to operate Ponce Health Sciences University and appoints Dr. David Lenihan. Dr. David Lenihan is used to taking risks. It is evidenced by his academic training in neuroscience, chiropractic and law. Also, his foray into the administrative side of science education. Recently, the greatest risk it has taken is the acquisition and transformation, through Arist Medical Sciences University, of the Ponce Health Sciences University. As the main academic officer of Arist, Lenihan guided the process of purchase and evolution of the School, a widely recognized institution with around 40 years of training professionals of excellence in the field of health in the south of Puerto Rico.

According to Bloomberg,

Arist Medical Sciences University, Public Benefit Corporation was founded in 2014. The company's line of business includes the operation of colleges and universities.

Arist Medical Sciences University is apparently part of Arist Education System.  Its website states

Arist Education System is an investment of Bertelsmann — a global media, services and education company.

Furthermore, it claims

Bertelsmann stands for entrepreneurship and creativity. This combination promotes first-class media content and innovative service solutions that inspire customers around the world. Bertelsmann’s supply of capital will support innovative graduate and professional health and human sciences programs that are making a positive impact.

So it appears that Ponce is now owned by Bertelsmann.  What a diversified global media company is doing running a medical school is not clear.

Nor is the identity to the person at Bertelsmann to whom the leadership of Arist, including Dr Lenihan, reports.  Although the Bertelsmann website lists the company's top executives, and the top managers of the Bertlesmann Education Group, the chain of command for the US for-profit medical school is not apparent.


California Northstate University College of Medicine

According to the university website, the president is Alvin Cheung, Pharm D.  The university has a board of trustees, but does not provide their biographies or explain their role.

The website provides no information about the ownership of the university, although a 2016 Sacramento Bee article stated "Backers raised more than $50 million to fund the school." I can find business listings for a California Northstate University LLC, eg here, stating it is a privately held business, but containing no information about ownership or if the business leadership is the same as the listed medical school leadership. Thus the ownership of California Northstate University LLC, and thus presumably of the medical school, is entirely opaque.


Burrell College of Osteopathic Medicine

The President is John Hummer MHA.  There is a board of trustees, chaired by Robert V Wingo, with biographies provided but whose role is not explained.

An article in the Las Cruces Sun-News from 2016 called it "a first-of-its-kind, privately funded U.S. medical school."  An Albuquerque Journal article from 2015 stated.


Burrell is entirely financed by private investors, led by Santa Fe businessman Dan Burrell in partnership with the Rice Management Co., which oversees Rice University’s $5.6 billion endowment fund. Although most public attention has centered on Burrell, a well-known real estate mogul, Rice Management is actually the majority investor in the project, estimated to cost a total of $105 million,

Other investors were not named.  Thus only some of the investors in, presumably therefore the owners of Burrell are known.  The rest are anonymous.

Discussion

The ownership of three of the four new US for-profit medical schools is unclear.  One is a private LLC whose ownership is entirely opaque.  One is partially owned by two private equity firms, whose investors are anonymous.  It may also have other, again anonymous owners.  One is owned by a group of investors, some local, some named, and some anonymous.

Anti-corruption campaigners have pushed to reveal the beneficial ownership of all corporate entities.  Transparency International's report on the problem of anonymous beneficial ownership (look here) states:

In the vast majority of countries, it remains legal for companies to hide the identity of their beneficial owners. Embezzlers use anonymously owned companies to move, launder and spend tainted money in the global financial system without being detected. Documents in the Panama Papers, for example, show how kleptocrats and their families used anonymous companies to secretly control state assets and purchase global real estate. Criminals including terrorists, human traffickers, sanctions-busters, drug dealers and tax evaders also use anonymous companies for the same reasons.

Thus anonymous ownership of any US medical school is highly troubling.  Physicians swear oaths to practice with honesty and integrity.  The institutions they train in should be above suspicion of wrong doing and corruption.  Hence medical schools should avoid practices associated with money laundering, fraud, and corruption.

Medical students, faculty, patients and accrediting boards should not trust medical schools who keep their ownership secret.

The people accountable for all four new for-profit medical schools' conduct and operations are likewise unclear. While the schools' hired managers cannot escape responsibility, it is the owners who are ultimately accountable.  But since some of the owners of three of the four new for-profit US medical schools are anonymous, some of the people actually accountable for those schools are also anonymous.


Maybe Sherlock Holmes could help...



but in his absence, medical students, faculty, patients and accrediting boards should not trust medical schools who keep the identity of those accountable for them secret.

Finally, a note about the one school which is apparently now a subsidiary of a publicly held German-based corporation.  Ultimately, the board of directors and top management of that corporation should be held accountable for that school.  However, even in this case, it would inspire more confidence of the exact lines of reporting from medical school to corporate leadership were more clear.

As Adashi et al noted, "the very notion of a for-profit medical school, anathema to generations of medical educators, is still the subject of mixed reviews."  The authors were optimistic that the higher standards for medical schools put in since the Flexner report led to the abolition of proprietary medical schools, and perhaps the supposed greater transparency of the modern era would make it possible for the new proprietary medical schools to educate students well.

However, the current for-profit schools' opacity should lead to great skepticism.  Flexner wrote:

[I]t is universally conceded that medical education cannot be conducted on proper lines at a profit, - or even at cost

His words may very well still be right.

Finally, what we now know about the new for-profit US medical schools suggests we must reexamine our fascination for "market based" approaches to health care, when almost nothing about any part of health care resembles, or could resemble a free market (see this post).  We need to make health care more transparent, and shine more sunshine on the nooks and crannies, like for-profit, anonymously owned US medical schools. 

ADDENDUM (14 January, 2020) - This post was re-posted on the Naked Capitalism blog here.




Wednesday, January 01, 2020

The Risks of Attending an Offshore Medical School: Students at Offshore Medical Schools Killed or Injured by Gas Explosions

US and Canadian medical education has a peculiar gray zone.  A substantial proportion of US and at least some Canadian doctors have received their medical degrees from offshore medical schools.  These are medical schools located in other countries, mainly the Caribbean, that exist only to train students for North American practice.  They are often owned by for-profit US or Canadian based companies, have little accountability to their host countries' governments, or to the US or Canada, and have generally flown under the radar despite being an important component of North American medical eduction..

Many questions have been raised by the quality of training received by students at such offshore schools.  We have recently discovered new risks to offshore medical students, in particular, that of dangerous living conditions.  We were alerted to two cases since 2018.


Gas Explosion Injured Two Medical University of the Americas (MUA) Students, Both Fatally, on Nevis in 2018

As reported by WINN FM on November 15, 2018

At around 8:00 pm on October 3, an explosion rocked the medical university and sent two American students to the hospital with severe burns across their bodies. The two students were subsequently flown to the United States for treatment.

On Wednesday (Nov 14) Acting Commissioner of Police, Hilroy Brandy disclosed that a faulty knob on the stove caused the explosion. He said one of the injured females was the actual occupant of the apartment and a female friend had come over to study. One of them lit a cigarette which ignited the gas.

That explosion eventually proved fatal to one medical student, as reported again by WINN FM on November 21, 2018:

One of the students who sustained major burns in an explosion and fire on Nevis in October has succumbed to her injuries.

28-year-old Nada Magdy Khalil of East Brunswick, New Jersey was one of two female students of the Medical University of the Americas (MUA) in Nevis inside the apartment when it exploded on Oct 3.

WINN FM confirmed that Khalil died on Sunday, November 18 in Florida where she had been receiving treatment.

The other student was very severely injured

The other victim is 31-year-old Gayane Borisovna Balasanyan from San Francisco; she is still hospitalized in Miami, Florida with burns across 90% of her body.
According to her GoFundMe page, Ms Balasanyan died in January, 2019.


There is no other publicly available  information on this explosion. Importantly, there has never been a public response from MUA, or its owners:

Since the explosion, the medical university has not issued a statement on the matter.

Gas Explosion Severely Injured Two Saba University School of Medicine (SUSOM) Students in 2019

There was an unnervingly similar case one year later, as reported by Saba News on October 15, 2019:

Saba’s emergency services were rushed to a dormitory building on Thais Hill Road in The Bottom around 7:30am Saturday, for a gas explosion that left one man severely burned.

A loud crack was heard throughout The Bottom that morning and a large plume of white smoke was seen coming out of the building and drifting into the sky. Several village residents also reported feeling the explosion’s aftershocks, which prompted them to call the Caribbean Netherlands Police Force KPCN and the Saba Fire Department.

Police, firefighters and the Ambulance Department were then dispatched to the building.

The dormitory is a privately-owned building that mainly houses students of Saba University School of Medicine (SUSOM).

Again, two students were injured:

One student was severely burned in the incident and was taken to A.M. Edwards Medical Center for treatment. He was later flown to Miami, Florida, for further medical attention.

A second victim was treated for smoke inhalation and was admitted at A.M. Edwards Medical Center for observation. She was released several hours later.

There is a GoFundMe page which is apparently for the student most seriously burned in this explosion.  It was created 3 days after the explosion, but I could find no other followup information on the explosion or the student.  Again, I could find no public response from SUSOM.

Who Should be Accountable?

These cases have been uncannily anechoic.  While the students injured were from the US, their fate has received no coverage in the US media.  Nor have the cases received recognition in the US health care literature, particularly the medical education literature.

The silence from the medical schools involved is quite unsettling.  That immediately leads to an obvious question.  Just who at these schools might be responsible for their students' physical safety?  Who currently runs and is accountable for both Caribbean schools is not glaringly obvious.

The website for the Medical University of the Americas lists an Executive Dean, but no President or CEO, or Board of Directors.  Its Wikipedia page states:

Medical University of the Americas (MUA) is a for-profit medical school in Saint James Windward Parish, Saint Kitts and Nevis.

Buried in the MUA 2018 catalog, however, is this statement:

Medical University of the Americas is a foreign profit corporation owned by R3 Education Inc. which is registered with the Florida Department of State, Division of Corporations to do business in Florida as Medical University of the Americas.

Saba University School of Medicine has a President, Dr Joseph Chu, according to its website. Its Wikipedia page does not state whether it is non-profit or for-profit.  However, like that  of MUA, the SUSOM 2018 catalog states

Saba University School of Medicine is a foreign profit corporation owned by R3 Education Inc.  which is registered with the Florida Department of State, Division of Corporations to do business in Florida as Saba University School of Medicine.

R3 Education Inc turns out to have a remarkable history, which we  discussed back in 2013.   To summarize what we found then...

The couple who founded two Caribbean medical schools which catered almost entirely to US and Canadian students ran into significant legal trouble.  Founder David Leon Fredrick and his wife, Dr Patricia Lynn Hough were indicted for tax evasion for failing to report income from the two medical schools they allegedly owned, and later sold.

The schools were Saba University School of Medicine, on Saba, and the Medical University of the Americas, on Nevis.  The initial legal proceedings revealed that while Saba University School of Medicine was apparently first set up by a non-profit foundation (or NGO) run by the couple, somehow it became for-profit owned by Mr Fredrick and Dr Hough, and Saba and the Medical University of the Americas were subsequently sold to a private equity group, Equinox Capital.  R3 Education Inc, owned by Equinox Capital, appears to have been given responsibility for running the schools, along with St Matthew University.

Before jury selection started, Mr Fredrick disappeared.  Dr Hough was eventually convicted of defrauding the US Internal Revenue Service, and income tax evasion, after trial testimony to the effect that the couple concealed money in a Swiss bank, got $36 million from the sale of the schools, and bought an airplane, two houses, and a condominium.

Left mysterious at that time were Mr Fredrick's whereabouts, where the money that the couple received from the sale of the medical schools went, and how a school that began as a non-profit organization run by the couple became a for-profit corporation owned by them.  The case should have lead to some concerns about the leadership and governance of the off-shore medical schools that now train increasing numbers of would be US and Canadian physicians.

In 2014 we provided something of an update. Mr Fredrick and Ms Hough made more than $35 million from the sale of the schools.  Ms Hough eventually went to prison.  Mr Fredrick's whereabouts remained unknown.  My internet searching in 2019 failed to produce any new information about him.


Now in 2019 we do not know much more about who is really accountable for MUA and SUSOM.  According to the Bloomberg corporate information website,

R3 Education Inc. operates as a holding company that acquires and manages for-profit educational institutions such as Saba University School of Medicine, the Medical University of the Americas, and St. Matthew's University. The company was incorporated in 2007 and is based in Devens, Massachusetts.

According to his LinkedIn Profile, the CEO and Chairman of R3 Education is Steven Rodger, of Greenwich, CT. For 23 years he has also been Managing Partner, Equinox Capital.

The Equinox Capital website make it clear that it still owns three Caribbean medical schools:

Saba University: Since its founding in 1993, more than 1,500 physicians have earned their M.D. at Saba University (www.saba.edu). Saba University School of Medicine has been accredited by the Accreditation Commission on Colleges of Medicine (ACCM) and its program has received approvals from licensing boards in New York, California and Florida. The campus is on Saba, which is located very near St. Maarten.

Medical University of the Americas: Since its founding 1998, Medical University of the Americas (www.mua.edu) has awarded approximately 500 M.D.’s. The MUA program is accredited by the Accreditation Commission on Colleges of Medicine (ACCM) and its program has received approvals from the licensing board in New York. MUA is located on Nevis, near St. Kitts.

St. Matthew’s University (www.stmatthews.edu) offers both a medical and a veterinary program. Since 1997, almost 1,500 students have obtained their M.D. and D.V.M. degrees from St. Matthews. The program is accredited by the Accreditation Commission on Colleges of Medicine (ACCM). St. Matthews is located in the Cayman Islands.

Who are the leaders of MUA and SUSOM who are accountable for what happens to their students, including their physical safety?  What allegiance do they owe their for-profit, private equity owners?  Who is responsible for the governance of the schools?  What responsibility does the private equity firm that owns the schools bear? All these questions remain unanswered.

The Perils of Offshore Medical Schools

US and Canadian medical students are promised a lot on the flashy websites (eg for MUA and SUSOM) for offshore medical schools. They may depend more on their medical schools for basics like housing than would students at American and Canadian schools. Yet they end up in physical environments with which they may be unfamiliar, and which may expose them to unexpected perils.

We should not forget that the US invasion of Grenada in 1983 was rationalized by the physical risks to US medical students at St George's University School of Medicine. The school was then a private for-profit owned by its founder Dr Charles R Modica and partners (but now partially owned by a private equity firm, Atlas Partners, per their news release.)   As the New York Times reported at the time, some students

told of bullets crashing through their dormitory rooms, of fears of being taken hostage, of a week of campus confinement under the Government's 'shoot to kill' curfew, of soldiers pointing guns at them

In particular,

Many of the students said that supplies of food and water began running low Tuesday after a weeklong curfew had been imposed by Grenada's military leaders following the slaying of Prime Minister Maurice Bishop on Oct. 19. Under the terms of the curfew, people on the street were to be shot on sight, the students said.

'I saw soldiers with guns during the curfew,' said Miss Nelson, 'and while none of them ever threatened me, several of my friends told me guns had been aimed at them, and they were terrified.'


[US Department of Defense image, Grenada invasion, 1983, via WikiMedia]


In the 21st century, the risks may be of gas explosions in accommodations more basic. and risky than students may have expected.    Yet who is ultimately accountable for disclosing and mitigating the risks?  In the case of MUA and SUSOM I cannot tell.

For would-be medical students trying to cope with the vagaries of medical school admissions in the US and Canada, the apparently easier accessibility of off-shore medical schools may be attractive.  Yet such accessibility may come with costs, and risks.  Until more is known about the risks, caveat emptor.


While Eckhert wrote in 2010(1) that the increasing presence of offshore medical graduates in the US "obligates U.S. medicine to take a closer look at these educational programs," no such scrutiny has occurred since then.  While offshore medical schools account for the training of an increasing proportion of US (and presumably Canadian) physicians, we know next to nothing about their leadership and governance.  This seems to be just another part of the decreasing accountability of the leadership of US health care, and the increasing opacity of the governance and stewardship of US health care organizations.  True US health care reform would make leadership transparent and accountable.

 Reference

1.  Eckhert NL.  Private schools of the Caribbean: outsourcing medical education.  Acad Med 2010; 85: 622-630.  Link here.




Sunday, December 22, 2019

The Terribly Difficult Things Health Care CEOs Must Do to Make the Big Bucks: Back-to-Back Meetings, Complicated Schedules, Fatiguing Driving?!

On Health Care Renewal, we have been decrying American health care dysfunction since 2004 (look here).  For years, the US consistently has had the most expensive health care system of any developed country.  For that exhorbitant price, it provides at best medicocre access to and quality of care.

We have long contended that a major reason for health care dysfunction is perverse incentives, including those that allow top health care leaders to become rich by putting money ahead of patient care.  We have presented case after case supporting this point.  So what do health care CEOs have to do to make so much money?

The Hardest Part of CEOs' Days

A recent post in Beckers Hospital Review discussing what "the brightest executives in the healthcare industry" think are the hardest parts of their days.  Here is the summary, edited for brevity:

1. Andrew Agwunobi, MD, CEO UConn Health (Farmington, Conn.): 'when we lose, or are facing the possible loss of good talent.'

2. Wael Barsoum, MD, CEO of Cleveland Clinic Florida (Weston): 'if I hear about an issue that came up with a patient where they felt like we could've done better. It is hard to read letters that said we didn't do something up to their expectations.... these reports and issues are very rare' 

3. David Dill, CEO of LifePoint Health (Brentwood, Tenn.): 'shaking the nagging feeling that I didn't get everything done that I need to, mainly because I didn't mark 10 things off a list like I used to'

4. Suresh Gunasekaran, CEO of University of Iowa Hospitals & Clinics (Iowa City): 'We hold ourselves to a very high standard ...  sometimes, very rarely, we don't hit that standard.... I take a lot of personal responsibility for those failures

5. Tom Jackiewicz, CEO of Keck Medicine (Los Angeles): 'Since it takes awhile to get on my calendar, I need to ensure I am managing my own emotions to maintain my focus so everyone gets the attention they deserve'

6. Dr. Divya Joshi, CEO of OSF HealthCare's Children's Service Line (Peoria, Ill.): 'when an initiative gets stuck and is unable to move forward because there are so many people involved or options to pursue....  Beyond that, I would say when I don't have the answer to something.'

7. Ketul Patel, CEO of CHI Franciscan (Tacoma, Wash.): 'days full of meetings that are back-to-back'

8. Chris Van Gorder, CEO of Scripps Health (San Diego): 'there are bad things that happen occasionally. That burden falls on me.... when something happens to a patient that shouldn't have happened or if one of my employees is attacked by a patient, those days are difficult'

9. Prathibha Varkey, CEO of Yale New Haven (Conn.): Health's Northeast Medical Group. 'driving between the different practices,... driving can be physically exhausting'

10. Kevin Vermeer, CEO of UnityPoint Health (West Des Moines, Iowa) 'when I must make tough decisions that impact people's lives'

11.Andrea Walsh, CEO of HealthP artners (Bloomington, Minn.). 'juggling priorities on my calendar'

12. Jeff Welch, CEO of Florida Medical Center and Tenet's Miami-Dade Group (Fort Lauderdale, Fla.): 'making sure that everything our organization does is for the betterment of the patient and the community'

13. Albert Wright, PharmD, CEO of WVU Hospitals and WVU Health System (Morgantown, W.Va.): 'it's just keeping everybody rowing in the same direction. The other challenge is that we've been on this huge growth boom ... .Trying to keep up with the growth has been a challenge because you want to help others and save some of these challenged hospitals, but you have to grow at a pace that is safe and people can keep up with'
Things are tough all over.  As a physician, I am unimpressed.  I do realize that some of the lists above included vague references to "bad things that happen," "issues that come up," not hitting a "standard," making "tough decisions," etc.  However, without further detail, I wonder if these refer to anything  comparable to the urgent  issues and decisions that doctors and nurses can face on any given day?

Many of the issues cited with more specificity seem trivial, to be charitable.  So the hardest part of being a CEO could be not completing your daily to-do list; attending back-to-back meetings; trying to focus on people with whom you meet; driving around a lot; or juggling calendar priorities?


These are not exactly the sort of hardship postings that seem to demand lavish compensation.



The Money They Make

Yet we have noted that CEOs do get lavish compensation.  The CEOs above who complained of the most trivial hardships, who have to wrestle with busy schedules, multiple meetings, and heavy traffic etc are often paid ... millions.  Consider the following examples, which are  based on the most recent compensation data I could find:

David Dill, whose worst day would be one in which he did not check off his to-do list, is in line for a $25 million dollar plus golden parachute (look here).  According to Salary.com, his total compensation in 2017 was $5,372,271. It may be higher now.

Tom Jackiewicz, whose worst day would be one in which he had to manage his emotions to focus on people with whom he was meeting, had a total compensation of $2,322,895 reported on the USC 2019 form 990.

Prathibha Varkey, whose worst day involved a lot of driving, made $187,024 reportable compensation from Yale New Haven Health Services Corporation, $748,096 reportable compensation from related organizations, and $226,128 other compensation, totaling $1,161,248 according to the Yale Health Service Corporation form 990 from 2019 via ProPublica.

Andrea Walsh, whose worst day was one in which she had to juggle priorities on her calendar, made $1,085,956 as Executive Vice President for Marketing in 2017, the last year for which full 990 data is available from HealthPartners via ProPublica.  Her current compensation is likely more.

The things you have to do to bring in those big bucks.

For Comparison, The Hardest Parts of Physicians' Days
 
So let's see... in my clinical career as an academic general internist, I faced 100 hour work weeks as an intern.  From internship through my career as a hospital-based educator, I had to cope with numerous life-threatening medical emergencies, numerous acute situations in which bad decisions could lead to patients unnecessarily dying or ending up disabled or chronically ill.  I had to tell patients they had incurable illnesses, and console the family those who were dying.  Furthermore, many other doctors have had more difficult lives.  Think about what trauma surgeons do every day, just for one example.

I am sure my colleagues in nursing could come up with their own harrowing lists.


On a personal level, there were many times I would have given anything for a day when the worst problem I had to encounter was a full schedule, boring meetings, or being stuck in traffic.


So tell me again why hospital CEOs make the big bucks, often much bigger than those made by health care professionals in the same institution?

Summary

Inflated executive compensation in health care is rarely challenged, but when it is, the responses are formulaic.  Justifications are usually made by public relations flacks who are accountable to these executives, or the executives' cronies on their boards of trustees.  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 were authored as public relations talking points. Additional examples appear here, here here, here, here, and here, here and here

The talking points 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 the examples above suggest that the work of a top health care manager hardly is as difficult as that of a health care professional.  And as we have discussed, these talking points are otherwise easily debunked.  But that certainly has not stopped executive compensation from rising year after year. 

The plutocratic compensation given leaders of non-profit hospitals is usually justified by the need to competitively pay exceptionally brilliant leaders who must do extremely difficult jobs.  Yet even leaders whose records seem to be the opposite of brilliance, or whose work does not seem very hard, often end up handsomely rewarded.

Other aspects of top health care managers' pay provide perverse incentives.  While ostensibly tied to hospitals' economic performance, their compensation  is rarely tied to clinical performance, health care outcomes, health care quality, or patients' safety.  Furthermore, how managers are paid seems wildly out of step with how other organizational employees, especially health care professionals, are paid.

Exalted pay of hospital managers occurred after managers largely supplanted health care professionals as leaders of health care organizations.  This is part of a societal wave of "managerialism."  Most organizations are now run by generic managers, rather than people familiar with the particulars of the organizations' work. 

That CEOs would view the minor travails of bureaucratic life as so significant suggests how deep they are within their managerialist bubbles, and how little they understand and relate to what their organizations actually are supposed to do, provide health care on the ground to real patients. 

Rather than putting patient care first, paying generic managers enough to make them rich now seems to be the leading goal of hospitals. I postulate that managerialism is a major reason the US health care system costs much more than that of any other developed country, while providing mediocre access and health care quality.

Improving the situation might first require changing regulation of executive compensation practices in hospitals, improving its oversight, and making hospital boards of trustees more accountable.  But that would be just a few small steps in the right direction

True health care reform might require something more revolutionary, the reversal of the managers' coup d'etat, returning leadership of health care to health care professionals who actually care about patients and put their and the public's health first, ahead of their personal gain.  Of course, that might not be possible without a societal revolution to separate managers from the levers of power in government, industry, and non-profit organizations. Remember the most salient example of managerialism now for most people in the US is a an executive with a Wharton business degree as the President of the United States.

Wednesday, December 11, 2019

How to Reduce the Conflicts of Interests in Health Care in a Country Whose Leader Has Flagrant, Unconstitutional Conflicts of Interest?

Introduction: Conflicts of Interest in Health Care


Our first post about conflicts of interest appeared on December 22, 2004, and was about "senior NIH scientists [who] were collecting hundreds of thousands of dollars in consulting fees and stock from industry."  We were not the first to be concerned about the problems resulting from financial relationships among health care professionals, academic health care institutions, and other health care non-profits on one hand, and the commercial health care industry on the other.

In 2009, the US Institute of Medicine, now part of the National Academy of Medicine published a report entitled "Conflict of Interest in Medical Research, Education, and Practice" which included specific recommendations for reducing them.  Unfortunately, despite the prestige of the then IOM, the report seemed to vanish without much of a trace (look here)

A report from the IOM which recommended decreasing conflicts of interest affecting the production of clinical practice guidelines was similarly anechoic (look here and here). Egregious examples of conflicts of interest in medicine and health care continue to appear in the media. For example, per a Dec 6, 2019, ProPublica article, a newly disclosed US government database listed 8000 that shows that  disclosed "8,000 'significant' financial conflicts of interest worth at least $188 million since 2012" affecting researchers funded by the National Institutes of Health.  Moreover, the conflicts disclosed in such databases or discussed in the media may just be the tip of the iceberg.

It should be no surprise that conflicts of interest remain prevalent despite various reform efforts.  Such conflicts benefit the parties involved inthem but harms to other people may not be obvious.  Consider, for example, a pharmaceutical company paying a key opinion leader thousands of dollars to give talks and write articles that might help it market a particular product.  The key opinion leader makes more money.  The pharmaceutical company may sell more product.  Disadvantaged are the patients whose physicians were persuaded by this ploy to prescribe the drug when other drugs or approaches might have benefited those patients more.  But these patients and physicians may never connect their less than optimal outcomes with the conflicts of intereat that enabled their bad results.  Those who do not realize how conflicts of interest hurt them are not likely to campaign against these conflicts.  Howver, those who benefit from the conflicts are likely to resist any efforts to reduce them.

But if at first you don't succeed, try, try again...

The New BMJ Article

In December, 2019, the British Journal of Medicine published "Pathways to independence: towards producing and using trustworthy evidence" (Moynihan R, Bero L, Hill S et al.  BMJ 2019; 367: l6576. Link here.), with authors from eight different countries.  They argued that:

endemic financial entanglement is distorting the production and use of healthcare evidence, causing harm to individuals and waste for health systems. Building on the evidence and practical examples cited below, we propose pathways towards financial independence from industry across healthcare decision making.

The article provided a good quick summary of the reasons that various kinds of conflicts of interest can harm patient care, education, research, and health policy making, and proposed the following:

Research

Governments require independent production of evidence used for healthcare decision making, including the evaluation of new treatments, tests, and technologies

Governments require that public healthcare organisations, including regulatory and health technology assessment agencies, receive no industry funding and that their advisers have no financial relationships with industry

Groups conducting research synthesis, including systematic reviews, ensure reviewers have access to all information on study methods and all relevant study results, including clinical study reports, and are conducted without industry funding and by authors with no financial relationships with companies that could benefit from the outcomes

Education

Professional, advocacy, or academic groups engaged in educational activities for health professionals or the public or advocacy affecting regulatory or policy decisions, move to end reliance on industry funding and end financial relationships between their leadership and industry

National governments work with professional associations and licensing bodies to develop policies that ensure educational activity supported by industry cannot contribute to accreditation of health professionals

Medical journals and their editors move to end reliance on healthcare industry income

Practice

Professional groups, hospitals, health services, and governments prohibit marketing interactions between industry and decision makers, including practising professionals, and actively support development of healthcare information independent of commercial interests

Professionals, policy makers, and the public move to reliance on practice guidelines produced and written by groups that have no financial relationships with industry and that have access to evidence, including research synthesis, free of industry influence

Research funding bodies and academic institutions modify academic metrics and incentives explicitly to reward academic collaboration with public agencies and civil society groups as well as industry

These proposed pathways arise from our analysis of the relevant evidence and examples from around the world. The list is not comprehensive or definitive and is designed to inform intensified debate and development of detailed recommendations.

The authors did not claim their pathways were "comprehensive or definitive," but hoped they would "encourage development of more detailed practical recommendations for change."  Will this new push to challenge prevalent conflicts of interest in medicine and health care make a difference?  On one hand, the international approach could be more successful than the previous Institute of Medicine reports which focused only on the US.  On the other hand, since the IOM reports came out, the reign of conflicts of interest in the US has only gotten worse, especially within the US government.  Yet the new BMJ article depends on government to go down many of the proposed pathways.  

Emoluments from Home and Abroad

Concerns about conflicts of interest affecting the US government date back hundreds of years, but had largely been forgotten.  The actions of the current Trump administration have awakened interest in how the framers of the US Constitution tried to forestall conflicts of interest affecting the executive branch of government.The Constitution includes two clauses that appear to forbid certain specific conflicts of interest.  They had been largely forgotten, and their meaning obscured by their use of now archaic language.

Article I, Section 9 states:

No Title of Nobility shall be granted by the United States: And no Person holding any Office of Profit or Trust under them, shall, without the Consent of the Congress, accept of any present, Emolument, Office, or Title, of any kind whatever, from any King, Prince, or foreign State.

Article II, Section 1 states:

The President shall, at stated Times, receive for his Services, a Compensation, which shall neither be encreased nor diminished during the Period for which he shall have been elected, and he shall not receive within that Period any other Emolument from the United States, or any of them.

The word "emolument" is now rarely used  However, at the time of the writing of the Constiution its meaning was payment, thing of value, profit, advantage, or gain.  An NPR article described the efforts of one law professor, John Mikhail, a professor at Georgetown Law School, to research the meaning the framers would have understood.  He:

looked at all the known dictionaries between 1604 and 1806 that define emolument -- 40 books in all. He said only three gave definitions in ways favorable to Trump, 'kind of a narrow, even technical meaning, tied to the salary or official duties of an office,' while the other 37 used 'a broader meaning that would encompass sort of the profits of ordinary market transactions.'

Almost all of the dictionaries used the word profit in their definitions. The two other go-to words were advantage and gain.

The Foreign and Domestic Emoluments Clauses As Prohibitions of Conflicts of Interest Involving the US President and Other Government Officials

John Medwed, the WGBH legal analyst, explained the origin of the "foreign emoluments clause," (Article I, Section 9)  this way,

it emerged out of a fear that wealthy Europeans would ply American ambassadors with gifts and somehow curry favor and influence foreign policy. And back in the 1700s, that was a real concern. Benjamin Franklin famously received a diamond encrusted box from the king of France. And that caused titillation all through the upper crust, this concern that the French would dictate our foreign policy. That's what led to the emoluments clause.

So the foreign emoluments clause seems to forbid all officials of the US government from receiving any payments, gifts, or anything else of value from foreign governments. 



In Vox, Ian Milhiser, a senior legal correspondent with extensive legal background, put it this way:

There is a reason the Constitution singles out transactions with foreign governments as forbidden. As Alexander Hamilton explained in the Federalist Papers, 'one of the weak sides of republics, among their numerous advantages, is that they afford too easy an inlet to foreign corruption.' In a monarchy, the chief executive shares an identity with the state, so a king or queen 'has so great a personal interest in the government and in the external glory of the nation, that it is not easy for a foreign power to give him an equivalent for what he would sacrifice by treachery to the state.'

But in a republican state, where leaders serve temporarily and keep their finances separate from that of the nation, 'persons elevated from the mass of the community, by the suffrages of their fellow-citizens, to stations of great pre-eminence and power, may find compensations for betraying their trust.

The framers, in other words, believed that federal officials would be uniquely vulnerable to the corrupting influence of a foreign state. The foreign emoluments clause offers a shield against that corruption — assuming that it is enforced.

So there seems to be a very good argument that the framers of the US Constitution tried very hard to prevent a certain kind of conflicts of interest, those arising from a US government official receiving financial or material benefit from a foreign government.


Similarly, Milhiser succinctly wrote,

the domestic emoluments clause limits the president’s ability to profit off of either the federal government or a state government.

Thus the framers also sought to prevent the President and other officials form self-dealing, and from having conflicts of interest involving state governments.

President Trump's Numerous and Conspicuous Violations of the Emoluments Clauses, that is, Numerous and Flagrant Conflicts of Interest

The emoluments clauses remained largely obscure for over 200 years, probably because they were mostly respected, until the regime of Donald Trump.

We noted, most recently here, several well documented sources listing thousands of examples of Trump and cronies' conflicts of interest and corruption, including many instances about his conflicts of interest that seem to violate the emoluments clauses.

These conflicts largely arise from a historically unprecedented situation.  Trump is the only known president to have maintained ownership of extensive business operations while in office.  Per Wikipedia,

The Trump Organization is a group of about 500 business entities of which Donald Trump is the sole or principal owner. About 250 of these entities use the Trump name. The organization was founded in 1923 by Donald Trump's grandmother, Elizabeth Christ Trump, and father, Fred Trump, as E. Trump & Son. Donald Trump began leading it in 1971, renamed it around 1973, and handed off its leadership to several of his children in 2017.

The Trump Organization, through its various constituent companies and partnerships, has or has had interests in real estate development, investing, brokerage, sales and marketing, and property management. Trump Organization entities own, operate, invest in, and develop residential real estate, hotels, resorts, residential towers, and golf courses in various countries. They also operate or have operated in construction, hospitality, casinos, entertainment, book and magazine publishing, broadcast media, model management, retail, financial services, food and beverages, business education, online travel, commercial and private aviation and beauty pageants. Trump Organization entities also own the New York television production company that produced the reality television franchise The Apprentice. Retail operations include or have included fashion apparel, jewelry and accessories, books, home furnishings, lighting products, bath textiles and accessories, bedding, home fragrance products, small leather goods, vodka, wine, barware, steaks, chocolate bars, and bottled spring water.

Since Trump is the major owner of the Trump Organization, profits made by it largely go to him.  Thus a payment to that organization, less operating costs and whatever interest other owners, essentially his children, have, is a payment to him.

Emoluments from Foreign States

As summarized in the voluminous "Tracking Corruption and Conflicts in the Trump Administration" report section of the Global Anti-Corruption blog, the Trump Organization has been paid numerous times by foreign government.

Payments to Trump Organization Hotels

Attention has particularly focused on a single property, the Trump International Hotel in Washington, DC.  Per the report,

A number of concerns center on the Trump International Hotel in Washington, D.C., and in particular on whether foreign governments, or agents of foreign governments, may seek to curry favor with the Trump Administration by booking rooms and events at the hotel.

[Interior, Trump International Hotel DC]


In particular,

a leaked email from September 2017 indicated that, despite public assurances to the contrary, President Trump is 'definitely still involved' in the D.C. hotel’s business. Moreover, shortly after the election, the hotel hosted a promotional event aimed specifically at foreign diplomats, which almost 100 diplomats attended. Since then, there have been numerous reports of private companies and foreign governments paying for rooms and events at the Trump International Hotel, including in 2018 an Amazon subsidiary with billions of dollars in government contracts. As of May 4, 2018, the patrons at the hotel included 59 political groups, eight foreign governments, and 25 business interest events (industry or lobbying).

The report notes that the foreign governments that have "spent substantial sums at this D.C. hotel, with the possible intention to ingratiate themselves with the administration" included Bahrain, Azerbaijan, Saudi Arabia, Kuwait, Turkey, Malaysia, Philipines, Afghanistan, Iraq, Ukraine, and Romania.

More broadly, in the Citizens for Responsibility and Ethics in Washington (CREW) report on Trump's conflicts of interest:

Since President Trump took office, officials from 65 foreign governments, including 57 foreign countries, have visited a Trump property. Altogether, foreign officials account for 137 visits in total, 97 of which have been made to the Trump International Hotel in Washington, D.C.

Many of these visits have come from large events hosted by foreign governments, some of which switched venues to hold annual events at Trump properties after he became president. The embassy of Kuwait had, for example, typically held its annual national day celebration at the Four Seasons prior to President Trump’s election. The last three years, however, it’s held the event at the Trump hotel in D.C. In 2018, the Romanian consulate in Chicago moved its own national day celebration to the Trump hotel in Chicago after hosting it at the Chicago Cultural Center five years in a row.

While events like these are likely to be incredibly costly—and thus raise the likelihood of the president financially benefiting from payments made by foreign entities—neither the Trump Organization nor the Trump administration has released the financial details beyond an annual payment to the Treasury the Trump Organization claims represents profits from foreign government funds.

Turkish officials have made 14 visits to Trump properties, more than any other country. This can partially be credited to two annual conferences on U.S. relations with Turkey that have been held at President Trump’s D.C. hotel. This year, two advisors to President Recep Tayyip Erdoğan and the ministers of trade, defense, and treasury all attended the event.

Other events have drawn officials from countries that span continents or regions. In February, the Embassy of Kuwait in D.C. held a Kuwaiti independence day celebration at the Trump Hotel, with officials from all over the Middle East and North Africa in attendance. The 13 foreign officials in attendance included representatives from Kuwait, Yemen, Saudi Arabia, Oman, Iraq, Sudan, Yemen, and Libya.

Other officials have patronized Trump businesses around the time they met with President Trump. The Romanian President and Nigerian Vice President both visited the Trump hotel while in D.C. for meetings at the White House, and the Romanian Prime Minister is known to have stayed there.

[Trump Tower Chicago]



Payments Derived From Real Estate Transactions

If that were not enough, there are numerous instances of payments to or benefits received by the Trump Organization from foreign governments that do not involve its hospitality business. 

The Global Anti-Corruption Report noted that foreign governments and entities associated with them have rented and purchased Trump real estate.  These included "foreign government banks such as the Bank of India and Industrial & Commercial Bank of China."  Also,

the government of Qatar bought an apartment in one of President Trump’s New York towers for $6.5 million. As of June 2018, Qatar owned four units in the building for which it has paid a total of $16.5 million. Additionally, at least seven foreign governments—including Iraq, Kuwait, Malaysia, Saudi Arabia, Slovakia, Thailand, and the European Union—rented units at Trump World Tower in New York in 2017. (The Trump Organization does not own Trump World Tower, but it does manage the building, which means it benefits indirectly from renters in the form of management fees paid by those who own the units.) While most of the governments had also rented their units in 2015 and 2016, two of them—Iraq and Slovakia—only began renting in 2017.

Then again,

President Trump has a long history of lucrative financial dealings with Saudi Arabian partners, including those in or close to the Saudi government.

The Trump Organization is currently developing a luxury resort on the Indonesian island of Bali. The Bali local government provided public land for the project, granted numerous licenses and permits, and is planning to build (at government expense) a toll road extension that will substantially shorten the drive from the airport to the Trump resort—a decision that has raised concerns that the government may be deliberately undertaking an infrastructure project to curry favor with the U.S. president. (On August 13, 2019, Donald Trump Jr. attended an event in Indonesia to celebrate the development of two Trump properties in the country. Though the event was not affiliated with the United States government, pictures of the event reveal that several Indonesian government officials)


In addition,

The Trump Organization developed a luxury hotel in Panama City, and the Panamanian government has stepped in to aid the project in various ways, including government-funded repair of privately-owned sewage and drainage systems, use of the hotel for various government functions, and favorable permitting and tax decisions—decisions that, while not illegal or necessarily improper, raise significant concerns about conflicts of interest. The drama concerning this property continued in February 2018, as the building’s majority owner, Orestes Fintiklis, tried to fire the Trump Organization for mismanaging the hotel’s finances, but the Trump Organization refused to leave, instigating a standoff in which the police were called; the Panamanian government is currently investigating whether there was 'punishable conduct' by the Trump Organization.

Other Payments to the Trump Organization by Foreign States

Other Trump Organization operations have benefited from the actions of foreign governments, in particular,


in February 2017 President Trump reaffirmed the U.S. commitment to the so-called 'One China Policy.' Within a week of this announcement, the Chinese government granted the Trump Organization long-coveted Chinese trademarks for the 'Trump' brand. As of June 2017, the New York Times reported that President Trump had 123 trademarks registered and provisionally approved (meaning they would be approved within three months if there were no objections) in China.

Emoluments from the US Government

Independent of the salary and benefits President Trump receives from the government, the Trump Organization has received payments made by the US government.  The Global Anti-Corruption blog report noted in general that

One of the most direct ways that President Trump can profit from the presidency is by making decisions that effectively require U.S. government agencies to purchase goods or services from the Trump Organization.

Specific instances it listed included:

One of the most direct ways that President Trump can profit from the presidency is by making decisions that effectively require U.S. government agencies to purchase goods or services from the Trump Organization.

Department of Defense at Trump Tower: The Department of Defense has followed its standard practice of setting up a separate headquarters near the President’s private residence—in this case also in Trump Tower.

Trips to Mar-a-Lago and other Trump Properties: As of September 3, 2019, President Trump had spent 293 days at properties owned by the Trump Organization, with the bulk of that time at the Trump National Golf Club in Bedminster (90 days) and Mar-a-Lago resort in Florida (99 days).... On these visits, the Secret Service must pay the Trump Organization directly for any costs related to protecting the president. In fact, a Government Accountability Office report concluded that the Secret Service paid about $60,000 to the Mar-a-Lago resort for four trips between February and March 2017 alone

Trump Properties Abroad: If President Trump or his immediate family travel abroad and choose to stay at a Trump property, the U.S. government will pay the Trump Organization to rent space for the Secret Service and any additional necessary support. For example, the State Department paid at least $60,000 to the Trump Organization’s golf resort in Scotland when President Trump stayed there in July 2018.

Emoluments from US States

Payments by state governments to Trump via the Trump Organization have not been tracked so assiduously, but the Global Anti-Corruption Blog report noted,

At least 33 state-level officials also visited Trump properties, including nine governors, two lieutenant governors, and 15 members of state legislatures.... If these visits are taxpayer funded—and ongoing public records requests are seeking to find out—officials could be diverting public funds into the president’s private trust. This concern appears to have been borne out in a recent investigation by the Portland Press Herald, which found that former Maine Governor Paul LePage and his staff spent at least $22,000 in Maine taxpayer money staying at the Trump International Hotel over a two-year period—an amount far in excess of the state spending limit for this type of expense.

Furthermore,

Public pension funds in California, New York, Texas, Arizona, Montana, Michigan, and Missouri—with more than five million members—have millions of dollars invested in The CIM Group, a Los Angeles-based investment group that owns The Trump SoHo Hotel and Condominium. Through 2017, the CIM Group paid Trump International Hotels Management LLC 5.75% of Trump SoHo’s operating budget, resulting in millions of dollars in payments. Thus, these state pensions paid millions of dollars almost directly to the Trump Organization through the CIM Group.

Also,

In 2017, the Trump Organization announced a new mid-priced hotel chain, Scion (soon followed by another chain, American Idea). The first Scion hotel was granted a tax break in 2018 worth over $6 million from the Mississippi Development Authority.

Summary

The article by Moynihan et al in the BMJ is the latest effort to challenge conflicts of interest affecting health care professionals and academic health care organizations.  There are many barriers to the success of such reform efforts, most notably resistance from people who are directly benefiting from ongoing conflicts: in this case, health care professionals and management of the commercial firms making the payments to them that generate the conflicts.

In the US, we now have a particular barrier to addressing conflicts of interest in health care. Moynihan et al call on national governments to take various actions to reduce such conflicts.  However,  the US government is now led by a President whose personal conflicts of interest are voluminous, severe, and brazen.  Many of them appear to directly violate provisions of the US constitution that forbid emoluments (payments, gifts, or transmission of other things of value) to the President by foreign states, the US government, or state governments.  The government under Trump has shown little interest in challenging conflicts of interest or corruption unless doing so would politically benefit the president. So once again, it is difficult to see how we might meaningfully challenge conflicts of interest affecting American health care without challenging the monstrously conflicted executive branch of our own government.

That will not be easy.


Discussion of Trump's conflicts of interesti the media, and several civil lawsuits targeting them have not discouraged the President from continuing to enrich himself from foreign, the US, and state governments.

It is not obvious how these presidential conflicts of interest could otherwise be reduced or eliminated.  While the US House of Representatives has recently focused on possible impeachment of President Trump, unconstitutional conflicts of interest have not been a focus.  A New York Times op-ed just noted his continuing conflicts of interest, but lamented

The Democratic-controlled House has done an especially poor job of calling attention to this corruption. It hasn’t even conducted good oversight hearings — a failure that, as Bob Bauer, an N.Y.U. law professor and former White House counsel, told me, 'is just astonishing.'
It is possible that Trump will lose the next election.  However, that would leave him, unconstitutionally conflicted, in office until 2021, if he does not attempt to ignore such electoral results, as he has threatened.  He has already threatened to ignore election results he deems illegitimate (look here).

So it seems that we in the US are stuck with the continuing prevalence of conflicts of interest and corruption adding to health care dysfunction, unless health care professionals and the public band together to do something more direct to challenge them.