Friday, July 20, 2018

Chipping Away at the Anechoic Effect: Now the New York Times Protests the Demise of the AHRQ National Guidelines Clearinghouse

Background: the Quiet Announcement of the Death of the Clearinghouse

On June 1, 2018, we wrote:

Apparently as of late April, a terse announcement appeared on the website of the US AHRQ National Guideline Clearinghouse:


The AHRQ National Guideline Clearinghouse (NGC, guideline.gov) Web site will not be available after July 16, 2018 because federal funding through AHRQ will no longer be available to support the NGC as of that date. AHRQ is receiving expressions of interest from stakeholders interested in carrying on NGC's work. It is not clear at this time, however, when or if NGC (or something like NGC) will be online again. In addition, AHRQ has not yet determined whether, or to what extent, the Agency would have an ongoing role if a stakeholder were to continue to operate the NGC. We will continue to post summaries of new and updated evidence-based clinical practice guidelines until July 2, 2018. For any questions, please contact Mary.Nix@ahrq.hhs.gov.

There was no further explanation.

This announcement has been largely anechoic, noted only by a few blogs and websites, e.g. the American Bar Association.

We went on to summarize the importance of this clearinghouse as a reasonably comprehensive source of material about the myriad clinical practice guidelines that have been promulgated ostensibly to improve medical care.  Its importance was recently enhanced by the addition of ratings of the trustworthiness of particular guidelines derived from standards developed by the US Institute of Medicine (look here).  In turn, these standards were necessary because many published guidelines were afflicted with methodologic problems.  Some amounted to little more than informal recommendations of experts.  Many guidelines were suspected of being influenced by commercial sponsors or by the financial relationships of the people involved in developing them.  Pharmaceutical, biotechnology, device and other firms that market health care goods and services have long been interested in meddling in guideline development to assure that guidelines put their products and services in a favorable light.

We concluded

Now we will lose an important resource for teaching, research, and evidence-based practice, whose loss will make it easier to hucksters to promote drugs, devices, and programs that are not as efficacious or safe as advertised.  But the good times will continue to roll.

We could call for the reinstatement of the AHRQ National Guideline Clearinghouse.  Ah, but we may as well try and catch the wind.

Again, note that as of June 1, 2018, nothing about the shutdown of the clearinghouse had appeared in the media, or in medical or health care scholarly journals.  We hoped maybe the post in our humble blog would start some discussion.

Further Media Coverage

At the time, despite our hopes, experience suggested nothing much would happen.  This time, however, we were wrong.

Stat News

The topic was picked up on June 13, 2018 by Stat News.  Ivan Oransky and Adam Marcus opened with:

Diagnostic and treatment guidelines aren’t sexy, but they play a vital role in the practice of medicine.

Oransky and Marcus found that the NGC was actually fairly heavily used, drawing 200,000 visitors a month.  After further summarizing the issue, they noted the ambiguous official justification for the closure of the clearinghouse.

'The decision to end support for the NGC was an Agency decision based on assessing how best to use our current resources, including both appropriated dollars and dollars from the Patient-Centered Outcomes Research Trust Fund,' the AHRQ spokesperson told STAT. The AHRQ budget for the 2019 fiscal year, as proposed by the Trump administration, 'will re-focus support to only the highest priority research programs.'

They also excerpted our conclusions above, and lamented,

With the date of death for the NGG barely a month away, America’s doctors — and their patients — may, to paraphrase another clearinghouse, already be losers.

Daily Beast

One month later (July 12, 2018) the Daily Beast published a longer account of the then impending shut down of the clearinghouse, written by Jon Campbell, an investigator for the Sunlight Foundation.  Campbell noted how

medical research like that maintained by the NGC can be politicized, [so] AHRQ drew the ire of then-congressmember Tom Price in 2016 when it published a study critical of a drug manufactured by one of his campaign donors. According to ProPublica, one of Price’s aides emailed 'at least half a dozen times' asking the agency to pull the critical research down. Price was the first director of HHS, AHRQ’s parent agency, under the Trump Administration, before resigning under pressure last year over his spending on chartered flights.

Note that we had discussed then Representative Price's intervention here.

Campbell interviewed several people, including your humble scribe, about the meaning of the AHRQ's actions, and concluded with

'Losing [the NGC] is really losing a valuable resource,' said Ana Maria Lopez, President of the American College of Physicians. She said the NGC is a primary source for her organization’s research, and noted that digital repositories like the NGC are only more critical today.

Other Coverage

Since then, Vox and CNN have covered the issue on July 16, the day of the planned shutdown. The surge of concern about the topic did not apparently prevent it from happening, however.

The New York Times Weighs In

Today, however I was surprised by the lead editorial in the New York Times today about the demise of the NGC, entitled "Want Reliable Medical Information? The Trump Administration Doesn’t." It included this pithy comparison:

The official explanation is maddening enough: a budget shortfall that roughly equals the amount Tom Price spent on travel during his brief tenure as department secretary. The site costs just $1.2 million a year to operate, and is maintained by an agency with a budget of more than $300 million.

It concluded hopefully with:

A better solution would almost certainly be for Congress to appropriate the money needed to keep the database up and running. It could do that simply by renewing the Affordable Care Act fund that was covering the database’s operating costs, and that is scheduled to expire in 2019.

Of course, Congress will take that action only if constituents demand it. But in a country that has voted representatives in and out of office based on their health care policies, and that prides itself on drawing attention to intractable diseases (we dump ice buckets on our heads to raise funds to fight A.L.S., and walk countless miles for breast cancer), evidence-based medicine should be an easy sell. 

I am not holding my breath.  However, I never thought this issue, perhaps a small on given the huge political dysfunction that grips the country, would make it much farther than my blog post of June 1.  So we can hope. 

Furthermore, there has been movement towards preserving some of the clearinghouse's functions.  As discussed in Modern Healthcare on July 17, 2018, the ECRI Instsitute plans to resurrect the site.  It would no longer be free, but will be based on a subscription model which ECRI hopes will keep the costs reasonable.  So at least that is real progress since June 1.  

Discussion

Many people bemoan the current political situation, but some feel there is nothing they could possibly do the improve things.  We have been publishing this blog since 2004 with the hopes that chipping away at the anechoic effect which has hid the severity and nature of health care dysfunction might actually help to improve things.  However, at times we wondered if we were having any effect.  What good are individual actions like blog posts? 

It seems that most of us have little individual power.    Collectively, though we may have more than we realize.  Small individual actions can add up. I hope the at least partial resurrection of the National Clinical Guidelines Clearinghouse will provide an example that will inspire further individual actions to address health care dysfunction, and the much larger political and economic dysfunction that generate it, and that now threatens us all.  

Sunday, July 15, 2018

A Physician Who Had Run Clinics Which Proselytized Patients is Now a Government Health Care Leader Positioned to Enforce Her Religious Beliefs on Patients and Citizens Who Do Not Hold Such Beliefs

Introduction: Physicians' Values and Organizational Missions

Physicians professional values require them to put the interests of their individual patients ahead of all else, including the physicians' self interest.  The AMA Principles of Medical Ethics, for example, includes

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

Similarly, in health policy and public health, the goal ought to be putting the health of patients as a group, and the public at large, ahead of other considerations.

However, we have often discussed how leaders of large health organizations seemed to put other considerations ahead of individual patients', patients' collectively, or the public's health.  Most of those examples of mission-hostile management involved putting organizational finances, or the leaders' own finances ahead of patients' and the public's health.  For example, in 2017 we discussed a New York hospital CEO who seemed to put revenue generation in support of his own very generous paycheck ahead of quality of care and patient safety (look here).  Also, the revered Mayo Clinic seemed to let patients with more remunerative commercial insurance coverage get attention before poor patients who have only government insurance, despite its stated mission "providing the best care to every patient" (look here).  Before November, 2016, our examples of mission-hostile management were mainly hospitals and health systems, insurance companies, and pharmaceutical, biotechnology and device companies.


That was then.  This is now.

A Physician Who Seemed to Put Her Religious Beliefs Ahead of Patients' Interests

Late this spring, we noticed the appointment of a US government health care leader which raised concerns about mission hostile management, but in a new dimension. The appointment was summarized by Rewire on May 30, 2018,

Diane Foley, who ran a Christian organization operating two Colorado anti-choice 'crisis pregnancy centers,' or fake clinics, was quietly installed on Tuesday as deputy assistant secretary for population affairs, where she will lead the office responsible for the Title X federal family planning program.

The U.S. Department of Health & Human Services (HHS) said little about Foley in its announcement of her appointment to the Office of the Assistant Secretary for Health, saying she 'has a long and distinguished career working in the healthcare and the public health arenas.'

Foley will oversee the Office of Population Affairs (OPA), which administers Title X, a program providing family planning and related services to more than 4 million primarily low-income people in the United States, many of whom face systemic barriers to health care.

While Dr Foley's purview would be providing family planning services, she seems to opposed to the provision of most conventional family planning services,not only abortion, which is admittedly controversial, but also including contraception, and adoption.  For example, as reported by Tonic (a part of Vice News) on June 5, 2018, she said in a speech on 2016 that a pregnant woman has three choices

parent the child, give it up for adoption, or have an abortion .... She said that having the baby is thought of as 'death to [the parents] and the life they thought they were going to have,' adding, 'The next choice is, let’s do an adoption plan. Well, that’s a double death, because not only does it interrupt [the parents] plans for the next several months, right? But then their child is going to be adopted, and they’re going to grow up thinking they’ve been abandoned by their parents. So they’re going to have all kinds of issues with their life. So that’s a double death. That’s worse.'

Given her opposition to adoption, it is not much of a surprise that she seems opposed to even talking about the simplest forms of contraception. The Rewire article stated,

Foley suggested that it may be considered 'sexually harassing' to demonstrate in a classroom how to use a condom on a banana, the Colorado Springs Independent reported in 2010.
Foley is a physician.  Another Tonic (from Vice) article on June 5, 2018, noted that an official DHHS statement about Dr Foley's hiring stressed,

that Foley is a board-certified pediatrician with 30 years of experience, most recently in private practice in Colorado.
 
The DHHS official leadership bio for Dr Foley went into more detail,

Dr. Foley is a graduate of Marion College (now Indiana Wesleyan University) and of Indiana University School of Medicine. She is a Diplomat of the American Board of Pediatrics, a member of the Society of Adolescent Health, and served on numerous other national boards and committees.

Also,

Dr. Foley has spent her professional career in the clinical practice of pediatrics with a focus on adolescent health. Originally from Indiana, Dr. Foley founded and served as medical director of Northpoint Pediatrics shortly after completing a residency in pediatrics. She spent the next seventeen years establishing what is still one of the largest pediatric practices in central Indiana. During this same period, she also served as a pediatric clinical instructor for pediatric and family practice residency programs at the Indiana University School of Medicine. Dr. Foley’s areas of special interest are adolescent gynecology, prevention and treatment of sexually transmitted diseases, healthy family formation, and global health, all of which she continued to focus on after her move to Colorado in 2004.

Most recently, she was in part-time clinical practice at a certified Centers for Medicare & Medicaid Services Critical Access Hospital in Lamar, Colorado.
As a physician, Dr Foley's prime directive was to put the interests of individual patients ahead of her self-interest.  If Dr Foley had religious convictions that would not allow her offering women patients mainstream management approaches to family planning, for example, adoption or contraception planning, Dr Foley could have chosen to practice in a setting where she need not have ever offered those options, for an example relevant to pediatrics, neonatology.  However, it seemed that Dr Foley chose to explicitly put herself in situations where she could combine proselytizing with practice.  As described in a Slate article of June 1, 2018, stated,

Until last year, she was the president and CEO of the Life Network, an organization that operates two anti-abortion crisis pregnancy centers in Colorado Springs that run abstinence-only education programs for teens. The purpose of crisis pregnancy centers is to convince women not to have abortions, sometimes after luring them in with deceptive advertising that makes them seem like abortion clinics or general health facilities. 'Through our pregnancy centers we have the opportunity to see God use the miracle of ultrasound to change and save lives,' Life Network’s website says. The first element of its mission is 'presenting the gospel of Jesus Christ.'
The fundamentally deceptive nature of these clinics seem to suggest that Dr Foley violated another provision of the AMA Principles of Medical Ethics

II. A physician shall uphold the standards of professionalism, be honest in all professional interactions,...

Thus, rather than avoid clinical situations in which abortion would be considered to be a management option, she chose to work in such settings in order to try to prevent patients from having abortions, based on religious grounds.  She worked in what looked like clinics, but which were dedicated to preaching the gospel.

Furthermore, the organization Dr Foley ran also specifically sought to deter young women from using conventional contraception. Tonic (part of Vice News) reported that the organization Dr Foley led

Life Network, the organization that Foley led until 2017, offers 'sexual risk avoidance programming,' aka abstinence-only sex ed, for middle and high school students, under the moniker Education for a Lifetime. As part of her work with that program, Foley told a reporter in 2010 that it’s too difficult to teach teenagers how to use condoms and that demonstrating how to use a condom on a banana could be considered 'sexually harassing.'

As an aside, in an interview reported by Tonic, Dr Foley seemed to espouse views on adverse effects of abortion that are unsupported by clinical research evidence,

'The way abortions are done, there is not enough supervision or regulation for them and it puts women at risk. There are not the same standards as other surgical centers, there are not the same requirements in terms of having the same hospital privileges in case something goes wrong,' she said. 'What I'm concerned about is that there is a sense that it's healthcare for women and there are a lot of things about it that are not good healthcare," Foley added. Abortion care has significantly lower complication rates than other common procedures (like wisdom tooth extraction and tonsillectomy), and patient satisfaction rates are much higher than they are for general medical care.

Another falsehood Foley has repeated, and that her former company Life Network also claims is true, is that abortion causes lasting mental-health problems. In a September 2016 presentation for Charis Bible College where Foley was introduced as the president of Life Network, she claims ... that this is a condition with an accepted diagnosis:

'There is actually a true, emotional diagnosis that is now starting to be recognized—even though if you look at national media and secular media, they still try to ignore the fact—but there is actually a diagnosis called post-abortion stress and also post-abortion traumatic syndrome, that is a result directly of someone having an abortion or being involved with an abortion that happens,' she said. 'Here is the thing that is incredible to me. I am a trained physician, went through training, got not one single lecture throughout the course of my training about this situation.'

The American Psychiatric Association does not recognize post-abortion syndrome or any related category as an identifiable mental health condition in the DSM-V , a manual that defines and classifies mental disorders.

 So Dr Foley seemed to have engineered an ostensibly clinical career that put her in a position to proselytize patients in the guise of medical practice, not only about abortion, but about contraception.  It is not at all obvious that Dr Foley limited her anti-abortion, anti-contraception, and presumably even anti-adoption preaching to women who agreed with her religious views and who had no interest in any of these options.

Discussion

Dr Foley is certainly entitled to her religious views.  She is also entitled as a physician to avoid situations in which normal standards of care would push her to provide services to patients that conflict with her religious conviction.  But she is not entitled as a physician to proselytize in the guise of medical practice.

Furthermore, as a leader in a government health agency, she is not entitled to use that agency's power to enforce her personal religious beliefs on patients who do not hold such beliefs.  Given her career, though, there is every reason to worry that she will do so.  Furthermore, it was not clear why she was selected for this powerful government leadership position other than to allow her to proselytize.

We recently discussed other examples of people appointed to top positions in the US Department of Health and Human Services who seemed very hostile to the organization's mission.  Again, it seemed unlikely that these people were appointed for any reason other than to attack the mission.

Furthermore, like Dr Foley, they seemed to have been appointed to impose their personal religious views on the American population.  As we stated then, they all seem to be in a postion to undermine fundamental principles of US government enshrined in the Constitution, including prohibiting the government from establishing a religion or preventing the free expression of any religion, and equal application of the laws and provision of due process to all people, again regardless of their religious beliefs, race, ethnicity or sex.

We have been writing about health care dysfunction since 2003, and publishing this blog since 2004.  A major concern all along has been how threats to health care professionals' core values generate  health care dysfunction.  Up through 2016, these threats came principally from large private health care organizations.  While the US government was not always as good at defending these values as it could have been, at least it rarely presented its own set of active threats.  Under Trump, that situation has been changing for the worse.  This is obviously hugely dangerous, (and made more so by the regime's threats to other core values of US society, to US law, and the US Constitution.)

To prevent the decline and fall of US health care, and maybe the entire US experiment in representative democracy, health care professionals, academics, patients and citizens concerned about health care will have to join up with the larger populace to defend our core values while they still have any force.    



Sunday, July 08, 2018

"Hope in a Bottle" - Components of Purdue Pharma Stealth Marketing Campaign for Oxycontin Revealed by Legal Documents from Tennessee

Introduction: Disinformation and Stealth Marketing Campaigns

Back in the distant past the US government made some attempt to hold big health care corporations to account for misleading marketing practices.  We learned a lot about these practices from documents revealed in the resulting litigation, and in particular, about stealthy, deceptive systematic marketing, lobbying, and policy advocacy campaigns on behalf of big health care organizations, often pharmaceutical, biotechnology and medical device companies.  For example, in 2012 we found out about the stealth marketing campaign used by GlaxoSmithKline to sell its antidepressant Paxil.  This included manipulating and suppressing clinical research, bribing physicians to prescribe the drug, use of key opinion leaders as disguised marketers, and manipulation of continuing medical education.  Other notable examples included Johnson and Johnson's campaign to sell Risperdal (look here),  and the infamous Pfizer campaign to sell Neurontin (look here and here).  We also found that stealth marketing seemed to be partially responsible for the growing popularity of narcotics (opioids) starting in the 1990s (look here).

The organization and complexity of stealth marketing, lobbying and policy advocacy campaigns have often been sufficient to characterize them as disinformation.  For example, we characterized the campaign by commercial health insurance companies to derail the Clinton administration's attempt at health reform in the 1990s, as described by Wendell Potter in his book, Deadly Spin, as just that (look here).  The tactics employed in that campaign included: use of front groups and third parties (useful idiots?); use of spies; distractions to make important issues anechoic; message discipline; and entrapment (double-think).

Nowadays, the current Trump administration does not seem interested in pursuing unethical or corrupt practices by big health care corporations.  A health care corporate fraud strike force was downsized by the Trump administration as we noted in July, 2017.  By May, 2018, legal actions by the US government against apparently corrupt acts by large US health care organizations seemed to be falling off.  Only one significant settlement had made that year.  Bloomberg published a report with the headline, "White-Collar Prosecutions Fall to 20-Year Low Under Trump," on May 25, 2018.  Meanwhile, the administration pulled one former stealth marketer through the revolving door to serve in the White House (look here), and has been  pushing its own disinformation campaigns (look here).
 
However, some state attorneys general and local prosecutors have picked up the baton.  In particular, as the opioid epidemic continues, they have filed many lawsuits against corporations that profited from narcotics sales.

Sleazy Marketing Tactics Used to Sell Oxycontin

And glory be, one such lawsuit has led to the disclosure of the shady marketing tactics used by the now notorious Purdue Pharma to sell Oxycontin.  Several news reports summarized the lawsuit filed by the Tennessee Attorney General against that company.  As described by the Knoxville News Sentinel,

The lawsuit, filed by Tennessee Attorney General Herbert H. Slatery III, uses Purdue’s own company records and its staffers’ own words to show the firm’s founders and executives pushed medical providers to prescribe increasingly high doses of OxyContin for longer periods — even after Purdue promised the state it would stop.

It lays bare a marketing campaign that was highly regimented and highly profitable, built upon a foundation of lies and trickery, and specifically targeted Tennessee’s most vulnerable medical providers and patients, including the elderly and veterans.

'Purdue summarized the marketing for its opioid products with the tagline, ‘We sell hope in a bottle’ in one of the company’s hiring guides for incoming marketing employees,' the lawsuit revealed.



Targeting the Beleaguered

Hope could best be sold through the prescriptions of the most beleaguered prescribers:

Purdue told its sales staffers to target medical providers who were overworked, serving poor communities in Tennessee and had less training, calling them 'high value prescribers' who could be easily persuaded to increase prescriptions and dosages of OxyContin.
To do this, most likely the pharma representatives used psychological manipulation, such as assuring the practitioners that the representatives were their true friends in a hostile health care environment.  Such tactics were well-documented in articles by Ahari and Fugh-Berman, e.g., look here and here

Perverse Incentives for Sales Reps

The company provided perverse incentives to its pharmaceutical representatives (perverse, at least, from the standpoint of the patients' welfare and health professionals' values):

Sales staffers’ bonuses were tied to how well they pushed 'super core' providers — the Tennessee prescribers handing out OxyContin prescriptions at a rate guaranteed to cause fatal overdoses — to keep pushing the drug on their patients.

The firm even had a 'toppers club' for sales staffers who pushed the most OxyContin, awarding them trips and cash, the lawsuit stated.

Deceptions and Third-Party Strategies

Although none of the Tennessee pharma reps were "medical professionals," they

were trained to position themselves as medical experts and then supply providers with carefully scripted lies about the addictive and deadly properties of OxyContin, the internal records show.

'Do (providers) believe (in) me on info?' one sales staffer wrote. 'Buy-in … (Provider) buys me first.'
Again, to do this they likely traded on the misguided trust of the physicians generated by the representatives' psychological manipulations.

Practitioners were supplied with biased, and in today's argot, fake literature to give to the physicians,

literature from fake advocacy groups touting the safety of opioids and labeling the growing opioid epidemic as 'pseudoaddiction' that would level off if providers simply prescribed more OxyContin.

Sales staffers were trained to teach providers that the best way to keep patients from addiction was 'to actually prescribe more and higher doses' until the 'symptoms' of addiction went away, the lawsuit stated.

The suit claimed that Purdue set up a "third party strategy," using "astroturf" organizations to pretend that influential health care professionals and sincere patient advocates supported ever increasing narcotics use:

The firm funded the creation of advocacy groups with names such as the American Pain Society and American Pain Foundation, and pamphlets, videos and social media campaigns to convince Tennesseans that OxyContin was a wonder drug — even as the number of fatal overdoses tied to it began to skyrocket.

The firm specifically targeted veterans with a web campaign titled 'Exit Wounds,' and called OxyContin the 'gold standard' for pain treatment.

'Long experience with opioids shows that people who are not predisposed to addiction are unlikely to become addicted to opioid medications,' veterans were told. 'When used correctly, opioid pain medications increase a person’s level of functioning.'
Third party strategies have been widely used in public relations/ propaganda/ disinformation campaigns. 

Profits Before Patients, and the Law

Purdue Pharma reps were instructed to keep pushing narcotic prescribing by physicians who were in danger of being sanctioned.

The lawsuit reveals Purdue’s sales staffers were instructed to ignore police warnings, indictments and overdose deaths involving Tennessee medical providers and to continue to call on them to hand out high-dose OxyContin — the firm’s most profitable brand — so long as they still had prescription pads.

The lawsuit and Purdue’s internal records link the firm’s sales staffers to some of Tennessee’s most notorious pill mill doctors, including one of the largest such operations in East Tennessee.

Purdue staffers called one medical provider, who is not identified in the lawsuit, 48 times — after law enforcement told the firm the provider had prescribed fatal doses of OxyContin and was running a cash-for-pills clinic.

A Nashville Public Radio report additionally noted that

According to the lawsuit, Purdue reps also continued to call on doctors after:

Law enforcement identified two particular doctors responsible for significant diversion
Credible reports of patient overdoses
A provider admitting to heroin addiction
Muggings over controlled substances outside a pharmacy linked to a provider
Admission by a provider he was running a pill mill
Observing a patient being coached in a waiting room
Choreographed pill counts and urine screenings
Standing-room-only waiting rooms
Clearly, generating more revenue by selling more drugs trumped respect for ethics or the law. 

Summary

Thus, Purdue Pharma appeared to use the same sort of multi-pronged deceptive marketing approach to ramp up prescriptions of its potent narcotics, even as more and more people became addicted.

While we have been (probably appropriately) distracted by larger scandals, managers of big health care corporations have continued their cynical tactics that put profits ahead of patients, and ahead of professional values. It is likely that deceptive marketing, and full blown stealth marketing is flourishing even more in the shadows created by a government that seems to put the profits of President and family's company ahead of taking "care that the laws be faithfully executed."

At least to some degree state law enforcement is beginning to step into the breach.  As a Tenessee attorney who is also involved in lawsuits against Purdue said (per NPR)  "I think it helps all of us engaged in this fight to better understand what has happened and ultimately to get more quickly and more efficiently to a resolution,..."

So to conclude,

 We have long advocated better awareness of insidious disinformation campaigns in health care, which we previously separated into stealth systematic marketing, lobbying, and policy advocacy campaigns.  Furthermore, we have long advocated more vigorous regulatory and law-enforcement action against them.  Remember that many of the stealth marketing campaigns we discussed came to light through regulatory and law enforcement action.

Yet what sense does that make when the federal regulators and law enforcers operate under a regime that was perfectly happy to use disinformation to secure its election?

It apparently makes no more sense than advocating for better federal law enforcement measures to reduce conflicts of interest and corruption in health care under an extraordinarily conflicted and corrupt regime (look here.)

The fish is rotting from the head. 

So in parallel with what we said then, the only way we can now address health care deception, crime, and corruption is to excise the deception, crime and corruption at the heart of our government.

Sunday, July 01, 2018

Growing Health Care and Grand Governmental Corruption - But Still Anechoic After All These Years

Here we go again.  We have long been concerned about health care corruption as a major cause of health care dysfunction. Our last post on the topic was in January, 2018.


Summary: the Corruption of Health Care Leadership as a Major Cause of Health Care Dysfunction

As we wrote in August, 2017, 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 somewhere else, 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, 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.

While we at Health Care Renewal have written about this for years, we saw little improvement.  However, in the past few years we began to feel a little more encouraged.  For example, we had long complained that US law enforcement had not been devoting enough effort going after the corruption of the leadership of large health care organizations, thus effectively allowing these leaders' impunity. However, the US Department of Justice during the Obama administration made some modest attempts to decrease such impunity.  One such measure was the formation of a Health Care Corporate Strike Force.

As reported by Law.com,

the strike force was created in the fall of 2015, with five dedicated lawyers working on about a dozen of the most complex corporate fraud cases in the health care space.

Andrew Weissmann, the then-chief of the DOJ’s fraud section, told a health care conference in April 2016 that the section was placing 'a heightened emphasis' on corporate health care fraud investigations. He pointed to the recently established Corporate Fraud Strike Force that he said would focus resources in investigation and prosecution of larger corporate health care law violations, as opposed to smaller groups or individuals.

Unfortunately, that strike force was downsized by the Trump administration as we noted in July, 2017.  Perhaps that could have been viewed as just a minor setback.

However, we noted in May, 2018, that legal actions by the US government against apparently corrupt acts by large US health care organizations seemed to be falling off.  At that point, we found only one significant settlement made this year.  We also found a report by Bloomberg, with the headline, "White-Collar Prosecutions Fall to 20-Year Low Under Trump," on May 25, 2018.

 Increasing Evidence of Corruption in the Trump Administration


We had noted in January that corruption in the US was becoming even more systemic, and worse, it appeared that the administration itself was fundamentally corrupt. We noted sources that summarized Trump's personal, family, and the Trump administration's corruption, a website, entitled "Tracking Trump's Conflicts of Interest" published by the Sunlight Foundation, and two articles published in the Washington Monthly in January, 2018, "Commander-in-Thief," which categorized Mr Trump's conflicted and corrupt behavior.  The second, "A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

The evidence of corruption has only gotten more substantial since then.

April, 2018: The New York Magazine Timeline

In April, 2018, New York Magazine published "501 Days in Swampland," a time-line of  starting just after the 2016 presidential election.   Its introduction included,
The rewards of government would now be reaped by a single man — and the people would bear the cost.

More than at any time in history, the president of the United States is actively using the power and prestige of his office to line his own pockets: landing loans for his businesses, steering wealthy buyers to his condos, securing cheap foreign labor for his resorts, preserving federal subsidies for his housing projects, easing regulations on his golf courses, licensing his name to overseas projects, even peddling coffee mugs and shot glasses bearing the presidential seal. For Trump, whose business revolves around the marketability of his name, there has proved to be no public policy too big, and no private opportunity too crass, to exploit for personal profit.

The timeline was  organized by mode of malfeasance.  Pages were devoted to how foreign governments and private entities curried favor with Trump by lavish spending at his hotels, golf clubs, and other properties.  More pages were devoted to dubious dealings by Trump's family and friends, and officials in his administration.  Yet more recounted relationships with lobbyists and "petty graft."

Although it was not focused on health care corruption, some of the cases it listed involved health care and public health:

[Under Trump's Hotel in DC - 2017]

7/17 E-cigarette-makers hold their annual conference at the hotel. Ten days later, the FDA announces it will delay federal oversight of e-cigarettes until 2022.

Note that this suggests not just regulatory capture, but the possibility of a quid pro quo bribe.

[Under Officials & Their Pals - 2017]

1/24 During his confirmation as secretary of Health and Human Services, Tom Price fails to disclose an insider deal he got on $520,000 in stock in a biotech company. As secretary, he will be in a position to approve a drug the company has developed.

[2018]


1/31 CDC chief Brenda Fitzgerald is forced to resign over her purchase of stock in one of the world’s largest tobacco companies. She bought the shares a month after taking over the agency tasked with reducing tobacco use.

[Under Lobbyistss & Other Sleaze - 2018]

1/29 Alex Azar, a former lobbyist who worked his way up to the presidency of a drug company, is sworn in as secretary of Health and Human Services. Azar, whose company hiked the price of insulin and other drugs under his watch, is now in charge of making drugs more affordable.

[Under Petty Graft - 2017]

6/2 David Shulkin’s chief of staff falsifies an email to suggest that the VA secretary needed to travel to Europe to receive an award. Shulkin’s 11-day trip with his wife, most of which was devoted to sightseeing, cost taxpayers $122,344.

8/4 HHS Secretary Tom Price takes a private jet at taxpayer expense to St. Simons Island, an exclusive resort where he owns land. The trip, like many of the 26 flights Price took on corporate jets, could have been accomplished with a routine commercial flight.

9/29 HHS Secretary Price is forced to resign over the nearly $1 million in taxpayer money he spent taking military planes and private jets, often to visit family and friends.

This list also included several other examples, not directly health care or public health related, suggesting quid pro quo bribery.  For example, in 2017 at the Trump International Hotel in Washington, DC:

10/4 At its annual board meeting, the National Mining Association is addressed by three Cabinet members: Commerce Secretary Wilbur Ross, Labor Secretary Alexander Acosta, and Energy Secretary Rick Perry. 'Coal is fighting back,' Perry exults over breakfast with the country’s top mining executives. 'Clearly the president wants to revive, not revile, this vital resource.' Five days later, the Trump administration announces the repeal of Obama’s Clean Power Plan, which would have encouraged states to replace coal with wind and solar energy. The plan would have cut climate-warming pollution from coal plants by a third and saved taxpayers and consumers as much as $93 billion a year. The venue for the mining board’s meeting: the Trump International Hotel in Washington, D.C.




So the evidence base of conflicts of interest and outright corruption is becoming more massive, includes cases relevant to health care and public health, and includes examples that seem like outright bribery.


June, 2018: the ProPublica Database of Spending at Trump Properties

In June, 2018, ProPublica reviewed questionable spending amounting to $16.1 million since the beginning of Trump's candidacy for president at Trump properties by the US government, and by Trump's campaign, and by state and local governments.  Its introduction included,

Since Donald Trump declared his candidacy for president in late 2015, at least $16.1 million has poured into Trump Organization-managed and branded hotels, golf courses and restaurants from his campaign, Republican organizations, and government agencies. Because Trump’s business empire is overseen by a trust of which he is the sole beneficiary, he profits from these hotel stays, banquet hall rentals and meals.

Note that

The use of taxpayer dollars at Trump hotels is under scrutiny in a closely watched lawsuit in Maryland federal court. The District of Columbia and the state of Maryland sued Trump, citing a venerable anti-corruption provision of the U.S. Constitution known as the Emoluments Clause. It prohibits any financial gift, or emolument, from benefiting a sitting public official, including the president.

June, 2018: Public Citizen's Corporate Presidency's Hotel Swamplandia

Meanwhile, Public Citizen released a report on money spent at Trump's hospitality properties.  

In its introduction

For those seeking to get on Trump’s good side, it certainly helps to fork over some cash at one of his properties. There simply is no other plausible explanation why so many companies, business groups and foreign governments are spending big money eating, drinking, socializing and sleeping at Trump’s properties around the country. And there’s always the chance that the president himself will show up, as he did in June....

Also,

Trump came to office with the most blatant corrupting conflicts of interest in the history of American politics, so what followed should not be a surprise. By spending money at his properties, corporations and foreign governments are being transparent about their desire to curry favor with the president and influence the Trump administration’s policies.

Information on how much is being spent at Trump properties for political events is available, but remains unknown for the vast majority of spenders at Trump properties. An exception was the Saudi embassy, whose $270,000 in spending at the D.C. hotel was disclosed through a PR firm’s filing with the Justice Department. That said, we were able to document $1.75 million in spending, with more than half coming from the Republican Party.

Examples of spending by health care and public health related organizations included

Allign Technology [medical device company]
American Association of Orthodontists
Curetivity Foundation [supports St Jude Hospital]
National Drug & Alcohol Screening Association
University of Wisconsin
Vapor Technology Association [trade assocation for manufacturers of e-cigarettes]

So it seems that various large health care and public health related organizations are happy to shovel money  into the Trump Organization, and hence into the pocket of the president himself, if doing so can advance their business agendas.


Meanwhile Corruption, Even of a President, Remains a Virtually Taboo Topic

And still, we don't talk about it. 

 As noted above, corruption in health care has always seemed a taboo topic.  In November, 2017, we noted that once again, a report by Transparency International that showed that in an international survey of corruption perceptions, substantial minorities of US respondents thought that US corruption was increasing, and was a particular affliction of the executive and legislative branches of the national government, other government officials, and top business executives.  There was virtually no coverage of these results in the US media, just as there was virtually no coverage of a 2013 survey that showed 43% of US respondents believed that US health care was corrupt.

Similarly, the reports listed above have generated little discussion.  Despite the extensive and ever-increasing list of apparently corrupt acts by the Trump and cronies, grand corruption at the top of US government, with its potential to corrupt not just health care, but the entire country and society, still seems like a taboo topic.  The US news media continues to tip-toe around the topic of corruption, in health care, of top health care leaders, and in government, including the top of the US executive branch.  As long as such discussion seems taboo, how can we ever address, much less reduce the scourge of corruption?  The first step against health care corruption is to be able to say or write the words, health care corruption.


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.

Friday, June 22, 2018

Have They Finally Got to You? - the Firing of Dr Gu

Introduction - Dr Gu's History of Activism Made Him Unpopular at Vanderbilt

We first wrote in February, 2018, about the plight of Dr Eugene Gu, a surgical resident at Vanderbilt University Medical Center (VUMC).  Dr Gu has a history of political activism, resulting in being  blocked on Twitter by President Trump after Dr Gu criticized him online, until a court forced Trump to unblock him on First Amendment grounds.  After Dr Gu posted a photography of himself kneeling in support of the protest of football player Colin Kaepernick, the mother of a pediatric patient apparently refused permission for Dr Gu to treat her child based on the kneeling post, and VUMC responded by suspending him.

Dr Gu Fired

The story reappeared in the media in June, first in the Duke University Chronicle, then in the Tenneseean and USAToday.  From the latter,

A Tennessee doctor who became a social media sensation because of statements on President Donald Trump, racism and Colin Kaepernick - and who later sued the president over First Amendment rights - is losing his job at Vanderbilt University Medical Center.

Dr. Eugene Gu, 32, a Vanderbilt surgery resident, said Friday that Nashville's biggest hospital is ending his five-year residency after only three years.

Technically, Vanderbilt has decided not to renew his contract with the hospital, Gu said, but he argues the effect is 'no different than being fired.'

Dr Gu argued that the reason he was effectively fired was that VUMC disapproved of his political views as expressed on social media.

'The take-home message here is that there is an unwritten rule for surgical residents and that is rule is, always make your program look good and always make your hospital look good, and often that means stay silent,' Gu said.

VUMC denied that:

Vanderbilt said in an email statement Friday that the decision not to renew Gu's contract was not a result of his criticism of Trump, his lawsuit, or his public opposition to racism. The hospital has said previously that all disciplinary actions against Gu relate to his work performance and professionalism.

'Regarding other allegations that Dr. Gu is making about the Medical Center, I would ask that you please consider these as allegations and nothing more,' John Howser, a spokesman for the hospital, said in the email. 'To date, we have not engaged in a point by point rebuttal of Dr. Gu’s many claims over the past two-plus years. At this time we will continue to maintain this stance.'

VUMC, however, has not provided any clear evidence of deficient performance or insufficient professionalism.  The Duke Chronicle article noted arguments that Dr Gu made suggesting that it may not have had much such evidence.  First,

After an appeal, a May 17 letter to Gu from VUMC General Counsel Michael Regier—delivered at the request of Jeffrey Balser, president and CEO of VUMC—cited a 'lack of sufficient improvement in performance and conduct in key areas' after the probation. The letter, which was obtained by The Chronicle, indicated that the most "significant areas of concern" were 'patient care, communication, and medical knowledge.'

However, Dr Gu cited one example of a criticism of his performance that seemed rather trivial.

when he was serving on consult call, meaning he would respond to any surgical needs throughout the night. There was a patient for whom he was supposed to identify the course of treatment—which he did, correctly, as he did with the imaging and other relevant details. His colleagues, nevertheless, 'nit-picked' Gu about 'every little detail on the case'—claiming he didn’t 'dot all of his i’s and t’s' by not providing the patient’s height and weight—which Gu said were irrelevant.

Also, he noted that

Kyla Terhune, the residency program director for general surgery, was two-faced in her interactions with him. A text message obtained by The Chronicle showed that Terhune wrote 'Nice presentations' to Gu after he spoke at the Veterans Affairs Medical Center Tumor Board. He said she complimented him for his performance after going through two surgeries for him. But when it came time for performance review, Terhune said his performance was 'terrible' in those same instances, Gu noted.

Given the local and social media attention this story has received, one might wonder why, if VUMC had such a strong case against Dr Gu, it has avoided ever airing any details about it.

Furthermore, the article noted an apparent anomaly in the narrative of how the patient's mother came to complain about Dr Gu.

Before the story broke, VUMC declined to comment more than a dozen times, saying that it does not comment on personnel matters. After it was published, Howser wrote in a statement that Gu did not need to change his political views.

'Dr. Gu has never been told that he must change his political views or the substantive content of his personal participation on social media platforms,' the statement read. 'He has been advised of the need to adhere to VUMC’s social media policy, which requires that persons who are identified as representatives of VUMC clearly state that their views are their own. He has also been advised that resident physicians should be professional and respectful in their interactions and communications with and about one another.'

In the kneeling photo, one cannot make out that his badge says Vanderbilt Medical Center on it, even when zoomed in on. Gu's Twitter bio had no reference to Vanderbilt, though he had tweeted about Vanderbilt seven times prior. Twice, he tweeted that his views communicated on Twitter do not represent VUMC.
Yet Vanderbilt, after first suspending Dr Gu, ended his residency prematurely.  Since surgical residency normally lasts five years, it seems reasonable to say Dr Gu was fired, and that such Vanderbilt's action will likely damage his career.  Since Vanderbilt has not provided any convincing evidence that Dr Gu was incompetent or unprofessional, one is left with the nasty suspicion that it fired him because refused to stay silent about political beliefs that did not accord with those of Vanderbilt leadership.


Discussion

This story suggests that in our current political era, health care professionals, particularly trainees or others at the bottom of the totem pole, may be increasingly beholden to the political sensibilities of their bosses, and hence increasingly wary of espousing political views that run counter to those of their bosses. 

While it is reasonable for residency programs to require their trainees to be professional, since when did "professional" mean stifling political views that might offend hospital corporate leadership?

As we wrote in February,

 It may not be unreasonable to expect physicians and physician-trainees, as medical professionals, to avoid getting into political arguments with patients.  However, it is unreasonable to expect physicians to avoid making any public political comments that could ever be expected to offend any patient or relative.

And this case also raises the question of whether it was the patient's mother's offense, or the Department Chairman's offense, that mattered.

Attempts to censor political speech in academia are unfortunately not rare (see the website of FIRE, the Foundation for Individual Rights in Education, for many examples).  However, they have not seemed to be that frequent in medical education. (Our most recent example before this case was from 2015.)

I wonder, though, if the ongoing attacks on free speech and the free press (e.g., look here and here) by the current President and his cronies are emboldening censorship in US society.  The President does set the tone and agenda for the country.  A president who personally threatens free speech and a free press will encourage other would-be censors to crawl out of the woodwork. 

We will only be able to restore the freedoms promised in our Constitution, and ostensibly inherent in the nature of academic organizations, if we can get a new president who upholds the worth of these freedoms, and actually will preserve, protect and defend the Constitution of the United States.

Musical Interlude

Some lyrics from Dr Wu, Steely Dan, by Fagen and Becker

Are you with me Doctor Wu
Are you really just a shadow
Of the man that I once knew
She is lovely yes she's sly
And you're an ordinary guy
Has she finally got to you
Can you hear me Doctor





Tuesday, June 12, 2018

Dander Still Up. Drowning in Great Dismal Swamp. Film at Eleven.

Maybe this is the last in my series of dander-raising essays, as recent national and world events have most definitely left so many of us with a raging case of TDS. (Trump Derangement Syndrome, look it up it's a thing).

So many damned browser tabs sitting there open. So little time.

Or maybe not. Who knows. Where are all these suicides coming from?

My editor keeps telling me, "don't let it make you paralytic." Hey, I'm trying.

Just sensing a kind of coalescence in all the corruption our bloggers keep writing about. How do we even differentiate these activities across so many sectors of society. We were going to see our swamp drained. He promised. But instead there's just this big brand new bodacious cesspool. There it is in all the revolving-door sectors. Federal government. Private sector. Health care non-profits and even academia.

Just read back over recent weeks and months of this, your favorite blog.

The coalescence of corruption is certainly made easier by our enjoyment of a remarkable and possibly quite barmy Confabulator-in-Chief. He's just sort of paved the way for what one pundit recently characterized as a sort of race-to-the-bottom. No corruption is too small (cone of silence? nifty office furniture? wipe out environmental health? give Big Pharma another bye?). Or, of course, too large.

None of this is terribly new, just the way it's all melded into what the cancer biologists call a syncytium. There are no winners and losers in all this. Just a lot of organelles swimming around and causing havoc at our expense. Just a bunch of top-level narcissists and then, under them, a phalanx of careerist stronzi streaming out of academic backwaters and think tanks to grab their fifteen minutes of ... what?

Surely not fame, unless you're looking for a spot on an SNL cold open. Microphone time maybe? Let's call out a few of them.

The careerist gets fifteen minutes, max, by the way. The turn-over in government, especially, in the federal executive, is many-fold that of any previous administration. If this were tennis we'd all have whiplash. Everybody seems to be trying to find their own inner Scaramucci.

Just now, in fact, it seems to've gelled intoone great big scandal. Adam Serwer in The Atlantic: "there is only one scandal." While the Chest Thumper-in-Chief runs around doing what he does best--sullying the western world and laying down cover for his army of swampy miscreants--the careerists continue to run up a debt whose bill will surely come due. Of course by then, so many will have cashed out. Guess who'll be left to pay the tab. You, me, our sickest, our poorest. Mother Earth.

In the private sector it may take years for the ins and the outs to get in and then back out. But of late in both Big Pharma and in Health IT, both the revolving door and the Invasion of the Body Snatchers (aka baleful effect of activist investors and hedge funds) have taken their toll and we pick up the pace. Most recent casualty: Bush family scion and alleged wife-beater Jonathan B, thrown out of possibly the most innovative, but not quite profitable enough, athenahealth EHR company he once founded. Offed just now by the Elliott organization, which is headed up in turn by ultra-right political donor Peter Singer. (Here and here and pretty much everywhere--don't get stuck in his cross-hairs.)

Ah, yes, these are the glory days for the Big Families. Donorship gets you a whole party of your own. The Prince-DeVos family, the Koch family, the Uihlein family, the Mercer family. And Las Vegas Gambling Tycoon Sheldon Adelson, who almost single-handedly handed Binyamin Netanyahu an unearned win in Jerusalem.

Their common goal: effacement of government, Ron Reagan's great "problem child," in favor of its replacement the Great Dismal Swamp.  (In fact much of the real GDS, out of North Carolina, was actually bought up by Betsy DeVos's brother Erik to train Blackwater mercenaries.)  So now, on to the Great Dismal Swamp of outsourced everything. Outsourcing, along with the revolving door and the Anechoic Effect, these form the inner dynamic, the secret history of what's happening now. Outsource security. Outsource VA health care. (See my earlier blog on a secretary's attempt to resist that.) Outsource public education. Outsource, or at least deregulate, clinical trials of unproven drugs. Privatize, don't shade your eyes (apologies to Tom Lehrer).

(Note that in the course of all this privatizing the common weal, these Big Dogs not infrequently can turn on each other. Singer turns on Bush. Koch the Elder turns on Koch the Younger. The dollar is king and the beat goes on and Throw Momma From the Train.)

Other major features of this secret history:
  • The Scorching of the Earth. Both literally (health consequences of climate change), and figuratively: the flaming rhetoric of the careerists. The most glaring recent example, albeit outside of our health purview, White House National Trade Council Director and temporary-in-from-the-cold academic Peter Navarro, awarding "a special place in hell" to Canada.  (Wait, what?!? Canada?) Why? Because it dared to cross his new boss. Cross the boss, thump the chest. Ten points for the thumper, zero points for the country--either one. We'll learn later this year, and again in 2020, whether there's enough of the vaunted "base" left to be snookered by all this guff. The chest-thumpers may discover a special place in hell meted out to folks closer to home. The charlatans. The quislings. Pretty clear now who they all are.
  • The Swamp-Ooze of the Careerists. Navarro's one high placed example. Another newly high-placed with a more direct impact on health care, and also flaming the air waves, is National Economic Council Director and former CNBC correspondent Larry Kudlow. In the recent presidential travels Kudlow did not speak cosmologically of heaven and hell, but only politically. He called Canada's measured response "betrayal." On health insurance, he's agin it. It kills jobs, per Mr. Kudlow. And he ought to know how things really work, right? In 2007 he famously predicted the continued success of an earlier deregulatory GOP economic policy suite in that once-great organ National Review. William Buckley turned over in his grave. The headline read: "Bush Boom Continues." The following tag line: "you can't call it a recession." (Emphasis his.) The date: December 10, 2007. (Despite which, get well quick Larry. Maybe find a less stressful job would help.)
  • Health and the Environment. Ah, yes, and in environmental health we have Scott Pruitt heeding HMV while lining his own pockets and lobbying for his wife's Chick-fil-A franchise (honest I can't make this stuff up), all the while dumbing down any expertise on health. This dumbing down and anti-science motif pervades the Great Dismal Swamp. Never before has there been such a dearth of scientific, pedagogical, or health expertise in any of the departments that so direly need those capabilities. Interestingly, the small-bore corruption of these characters seems more prominent in the upper, Pruitt-like, echelons than in the Small Fry. Or are we just not hearing about the little guys?
  • Lesser Careerists. You can't have a syncytium without both big and little organelles. The little guys are actually among the more damaging, as they tend to be true believers with claimed expertise that goes poof when examined closely. Among the most famously wrong-minded recent ones we have the Press Secretary herself, Ms. Sanders, who from the depths of her health policy experience pronounced last fall that “I can’t think of anything worse than having the government be more involved in your health care instead of less involved.” Oh, Miss Sarah, I can. Even more peculiar is the role of the rather more obscure Ms. Katy Talento, of the White House Domestic Policy Council. She gets to act as conduit and house pundit for the new HHS secretary Alex Azar. It's fascinating. In several easily-reached venues she's described, by self or others, as "an epidemiologist." Harvard's master of science (not MPH) degree in epidemiology and public health can be obtained, as she did, in something between three and twelve months. Not exactly a board certification. Then she went on to build her career in ideological rightist causes and organizations, including anti-abortion campaigns and one notable set of pronouncements on the supposed link of birth control to miscarriage.

    Came the time for Azar to prep his new boss on last month's Big Speech on reducing drug costs, Talento broadcast the news that "no ox would be gored." Said she, "This is a fearless president and he doesn't know or care why things have always been done. It's not like your typical Republican authorizing committee that protects this model that they helped write for decades...." Wait, one little thing. It didn't happen. The big play available, as I said in a previous post, would've been having Medicare bargain for prices. Instead--and clearly Azar could've tried and failed to get this--the Caregiver-in-Chief declared that drug prices in the US should come down by having other countries pay more. What so strange about this is not merely the absurdity of such a statement, coming from a former Pfizer top exec. It's the fact that here's a lower-level careerist who went straight into RNC speech writing and working for a right wing southern Republican (Tillis, NC), then became the "epidemiologist" for Mr. Azar.

    Hold the phone. Among all the young staffers willing to sell their souls to get the Big Show on their CVs--don't they know it's a shabby little show?--what about the wonderful lady who dissed the ailing John McCain as inessential (just now he's incredibly essential), because, after all, he's going to die soon? Out the door she went, but of course her Republican friends got her a soft landing. Her name is Kelly Sadler, a real comer. Or goner.
  • The Rise of the Druggists. Last but not least, part of the secret history that, now I see it, has really got the dander way up, is how in health care and health policy, Pharma's now fully the tail-that-wagged-the-dog. CVS is moving into health care--see Dr. Poses's recent posting on just how well that organization understands their responsibilities. Actually having pharmaceutical and pharmacy folks elbowing out health care professionals who understand professionalism, it's not a new thing. Philadelphia Big Donor Leonard Abramson founded U.S. Healthcare and made a mint when he discovered how easy it was to make Managed Care actually Denied Care, then, with this proof-of-concept, cashing out and selling to Aetna. That goes way back. More recently, though, the pace of They Come at Night has picked up, viz. the firing of David Shulkin MD at the VA and the hiring of Alex Azar at HHS. These clearly result from both the privatization motive and the Pharma tail wagging the dog. At least two of the three branches of the federal government understand the business model of Pharma. They don't come anywhere near understanding the professional ethics of doctors--even while relying on their personal physicians to exercise such ethics.
  • Business ethics in medicine, as practiced by Pharma, have been laid out in many, many places in this blog. I and others have laid the blame for a big chunk of the opiate crisis at the door of Purdue pharma and the Sackler family. I regret to remind that the early Sacklers were physicians. But they were first and foremost business folk, possessed of a truly novel business model, which may be called outright dissimulation. (For a fascinating and harrowing description of one high-functioning Ivy-League opiate addict's experiences at Yale, with all its Sackler money and Oxy pills traded on the New Haven Green, see this Guardian piece.)

    Actually, I've talked to a lot of pharma execs and they're often quite ethical and responsible. They have their hands full fighting off the PBM companies. They get singled out for their K Street spending, but many of them actually have rather low budgets for that, the recent Novartis scandal notwithstanding. Other execs blush at this Novartis nonsense and want nothing to do with it. I say all this mainly to point out some dreadful outliers. It's not just the brand name drug makers, either. Teva, the Israeli generics giant, is allegedly a real problem. As I write this, good old Ron Wilson, the Wisconsin Republican who just keeps on giving his gifts, is blocking his Ranking Member Claire McCaskill from obtaining information Teva's contributions to the opioid crsis. He's saying leave it to the courts.

OK, as I just hinted, I agree with you. None of this recent stuff is really secret. Not even really novel. It's just coalesced like never before into into a dismal swamp. (Orwellian doublespeak: yes, we've seen the swamp drained. Of what? What was he promising to drain? Yes, drained, if that meant getting rid of people ("Deep State"?) who know stuff. So people who don't know stuff can get on with the business of ripping us off.)

Hence in my current rant I just wanted to point to those commonalities that are, right about now, more egregious than ever. Honestly, they are. When the history is written, it will prove me right. Oh, wait, Alexander Hamilton wrote it already, hundreds of years ago.
When a man unprincipled in private life desperate in his fortune, bold in his temper, possessed of considerable talents, having the advantage of military habits—despotic in his ordinary demeanour—known to have scoffed in private at the principles of liberty—when such a man is seen to mount the hobby horse of popularity—to join in the cry of danger to liberty—to take every opportunity of embarrassing the General Government & bringing it under suspicion—to flatter and fall in with all the non sense of the zealots of the day—It may justly be suspected that his object is to throw things into confusion that he may “ride the storm and direct the whirlwind.”

Tuesday, June 05, 2018

Why Did CVS Health Betray its Charitable Giving Policy and Social Responsibility Agenda to Donate to a Sketchy Non-Profit Devoted to Trump's Agenda?

Many big health care organizations, including for-profit corporations, have high-minded mission statements, and proclaim their social responsibility.  Unfortunately, we have shown that many leaders of such organizations seem indifferent to these seemingly exemplary goals, and even exhibit mission-hostile management.

A recent example involving CVS Health provided an unprecedented example of mission-hostile management, or something worse.

Introduction: CVS Health and the Promotion of Social Responsibility

CVS Health is a huge corporation that runs a large chain of pharmacies, many of which contain MinuteClinics, touted as quick albeit limited sources of primary care, staffed by nurse practitioners. 




It thus employees numerous health care professionals with strong professional values.  For example, the American Pharmacists Association has a code of ethics which includes respecting the covenantal relationship between pharmacists and patients, promoting "the good of every patient," acting with "honesty and integrity," serving "individual, community and social needs."

CVS Health proclaims its "social responsibility." This includes "keeping the planet in balance," and making "quality health care more affordable, more accessible and more sustainable."

CVS claims to act socially responsible by making charitable contributions for

improving health and health care nationwide. We support programs that improve access to health care services, provide chronic disease management and promote smoking cessation and prevention.

That seems fine and dandy, but then....

CVS Will Stop Funding America First Policies After Three of its Leaders were Revealed to Have Made Racist, Misogynistic, and pro-Nazi Remarks

CNN reported on June 1, 2018, that 

CVS Health said Friday that it would no longer donate to America First Policies, a nonprofit group that works to promote President Donald Trump's agenda, after CNN and other outlets reported racist comments made by staffers of the organization.


The details were,

[Carl] Higbie has a history of making racist, sexist, Islamophobic and anti-LGBT comments. Some of his more inflammatory statements were that the 'black race' had 'lax' morals and that Americans should be allowed to shoot undocumented immigrants crossing the border with Mexico. Following CNN's January report, Higbie resigned from his position as chief of external affairs for Corporation for National and Community Service, which manages volunteer services for the federal government. He joined America First Policies in March.

Higbie initially apologized for his remarks but later defended them and said they were taken out of context.

John Loudon, a policy adviser for the group, has also made inflammatory comments about Muslims and women, CNN's KFile reported in May, such as calling Barack Obama 'the Islamchurian candidate' and joking about 'crack whore Dem voter.'

In May, Mediaite reported that Juan Pablo Andrade, another America First Policies adviser, praised Nazis and said that, 'The only thing the Nazis didn't get right is they didn't keep f***ing going!' Andrade claims the video is out of context and he was quoting someone else. He has said he is looking for the full video, which would exonerate him.
One wonders if CVS Health had vetted America First Policies prior to making its contribution, since the presence in the latter's leadership of three such people suggest there just could be a bit of a corporate culture problem.

In any case, the CVS Health response came courtesy spokesperson Carolyn Castel:

Comments made by employees of America First Policies that were reported after we made our contributions are unacceptable to us. We have zero tolerance for discriminatory actions or behaviors, and as such we will not be making contributions to this organization in the future.

CVS Health's denial of further donations to America First Policies seemed admirable, but begged the question of why it made its initial donation.  In the Providence Journal, Brian Amaral reported on June 1 that  CVS justified its initial contribution to America First Policies as a way to “to support the tax cuts signed into law last year,” saying that it “supported this legislation and used the tax savings it created to invest in the growth and success of our employees,...”

However, that rationale seemed at best very loosely related to CVS Health's stated policy of making donations to improve health and health care.  I suppose that perhaps if tax cuts did lead to happier CVS employees, the indirect result would be better health care.  However, at least the purpose of the contribution did not seem in direct conflict with the stated goals of CVS charitable giving. 

Nonetheless, the result of the CVS Health contribution to America First Policies seemed retrospectively a spectacular case of mission-hostile management.

But wait, there is more.


America First Policies Also Advocated Multiple Positions at Odds with CVS Health's Support of Social Responsiblity

As noted above,  CVS Health suggested that it supported America First Policies because it was dedicated to tax reforms that would result in increased CVS Health's revenues.  Their website does list "tax cuts that put America first," as one of its issues.

CVS Health's comments suggested that this is America First Policies' only issue.  It is not.  The America First Policies website lists advocacy on 13 other issues.

One is "repeal and replace Obamacare."  In particular,

America First Policies believes Obamacare is a disaster, burdening our country with rising premiums, unaffordable deductibles, fewer insurance choices, and higher taxes. Congress needs to repeal and replace this law, including rescinding the individual mandate and eliminating taxes that drive up costs,

This issue certainly has to do with quality and accessibility of health care.  However, whether most CVS Health employed health care professionals, or customers think that dismantling the Affordable Care Act would lead to better or worse, or more or less accessible health care is doubtful.  Certainly CVS Health management did not explicitly justify how supporting America First Policies was informed by the company's stated objectives for charitable giving that supports health and health care.


Another issue addressed by America First Policies is "securing our border."  In particular, the organization advocates for

a wall to stop illegal immigration and drug smuggling; putting an end to sanctuary cities; and deporting illegal aliens with criminal records.

These issues seem to have nothing directly to do with health care, or with the company's stated reasons for charitable giving.  Many people might argue that these objectives could harm the health care, at least of some immmigrant groups.

So far, it is not clear why CVS Health really chose to donate to America First Policies.

But wait, there is more...

America First Policies Appears to be a Partisan Political Operation of Dubious Legality

A Political Agenda from the Start

A few more minutes of Google searching reveals that America First Policies has an advocacy agenda that seems in direct conflict with the CVS committment to social responsibility, and that America First Policies does not in the least resemble the sort of charitable organization that CVS says it intends to fund.   Recall that CVS says that the purposes of its charitable giving are

improving health and health care nationwide.

We support programs that improve access to health care services, provide chronic disease management and promote smoking cessation and prevention.

Yet when America First Policies was started, initial coverage, like this AP report from January, 2017, per WJLA, said it was a political operation.

Six of President Donald Trump's top campaign aides have banded together to start a nonprofit called 'America First Policies' to back the White House agenda.

In addition,

'Some of the same like-minded individuals who put their energy into getting Mr. Trump elected are now going to be part of a grassroots group to go out there and help with the agenda, help the White House be successful,' [former Trump campaign digital director Brad] Parscale said.

Was it about improving health and health care?

America First Policies will conduct research into public policies and promote Trump's favored causes, such as dismantling and replacing President Barack Obama's health care law and changing immigration policies.
Again, many would argue such actions could harm health and health care.

For a Non-Profit "Social Welfare Organization," Doing Political Polling May be Illegal

In March, 2018, CNBC did a long investigative article on America First Policies political polling operation.

Last summer, America First Policies took an unprecedented step for a politically allied nonprofit: It started using three top polling firms from Trump's 2016 presidential campaign to produce a steady stream of Trump-focused polls, strategy memos and reports that continue to this day. The three firms initially put their own logos on the polling they did for the group, but over time the America First Policies logo gradually replaced theirs on some of the documents.

CNBC reviewed many of the polls it conducted. One example of an obviously political poll was

A September poll showed that America First Policies was exploring ways to defeat Arizona Republican Sen. Jeff Flake in a primary, a month before Flake, a Trump critic, announced his retirement.

Note that America First Policies worked closely with a political polling firm which was founded by a close Trump associate who now works in the White House, but somehow obtained an ethics waiver  allowing her to continue working with this firm.

The America First Policies polling effort operates as a network of coordinated groups, with two lesser-known firms, National Research Inc. and Baselice & Associates, working alongside a well-known Washington firm, The Polling Company, which was founded by former Trump campaign manager-turned-White House counselor, Kellyanne Conway.

When Conway sold her firm in September 2017, The Polling Company had already been working for America First Policies for more than two months, judging from the company's logo on polls that it conducted for the group in June and July.

Conway was granted a special ethics waiver last June so she could engage in 'communications and meetings' with former clients of The Polling Company without violating Trump's two-year ban on communications with former employers or clients. Conway has been called the 'Trump whisperer' for her ability to influence the often mercurial president. In a 2016 interview with MSNBC, she described herself as a 'discreet advisor' to Trump who was expected to use her data and strategy experience to help Trump craft his message.

CNBC interviewed ethics experts on the legality of what America First Policies was doing.

'AFP is doing the type of polling that would typically be done by a presidential campaign or a major party committee like the RNC or the DNC,' said Brendan Fischer, an election law expert at the nonprofit Campaign Legal Center. 'So even though they claim to be committed to a set of issues, the available evidence here indicates that they're operating as a polling shop for the president.'

 Also,

Stephen Spaulding, a former special counsel at the Federal Election Commission and now director of strategy for the nonpartisan watchdog group Common Cause, agreed. 'There are ample grounds here to investigate whether America First Policies has been raising money that's subject to limits and disclosure requirements because it's being used for political purposes,' he said.

Finally, the article suggested that America First Policies was a way for wealthy donors, who could be individuals or corporations, to fund Trump's political agenda while hiding their identities and circumventing legal limits on direct political contributions.

'So you have a situation where large donors are contributing to America First Policies with the understanding that their secret donations are going to be seen as valuable by the president, because this group appears to work so closely with the White House,' said Campaign Legal Center's Fischer. 'And because these donors are secret, the public and Congress will never know if the White House later took action to advance a donor's interests.'

So it appears that CVS Health was one of those wealthy corporate donors who was secretly giving to a obviously political operation, possibly to be seen as "valuable to the president," which may be a way of saying to bribe the president?

America First Policies' Founders Included Shady Characters

The early AP article about the founding of America First Policies stated that the people involved included,

The group includes Trump's digital and data director Brad Parscale, onetime deputy campaign manager Rick Gates and two campaign advisers to Vice President Mike Pence, Nick Ayers and Marty Obst.

As the New York Times reported in February, 2018, Rick Gates pleaded guilty to the federal crimes of financial fraud and lying to investigators,

A former top adviser to Donald J. Trump’s presidential campaign has agreed to cooperate with the special counsel inquiry into Russia’s interference in the 2016 election after pleading guilty on Friday to financial fraud and lying to investigators.

The adviser, Rick Gates, is a longtime political consultant who once served as Mr. Trump’s deputy campaign chairman

Note that Mr Gates had previously been charged with many more crimes,

The deal came as the special counsel, Robert S. Mueller III, has been raising pressure on Mr. Gates and Mr. Manafort with dozens of new charges of money laundering and bank fraud unsealed on Thursday. Both men were first indicted in October and pleaded not guilty.

By that time, it was likely that Mr Gates was increasingly involved in America First Policies.  As of March, 2017, an article in Politico noted that,

Rick Gates, a former Trump aide who served as Paul Manafort’s deputy, is increasingly involved day-to-day [in America First Policies].
Also, Brad Parscale, the 2016 Trump campaign digital director, was involved with Cambridge Analytica's highly questionable operations on behalf of the campaign.  Per a New York Times article of March 17, 2018

Under the guidance of Brad Parscale, Mr. Trump’s digital director in 2016 and now the campaign manager for his 2020 re-election effort, Cambridge performed a variety of services, former campaign officials said. That included designing target audiences for digital ads and fund-raising appeals, modeling voter turnout, buying $5 million in television ads and determining where Mr. Trump should travel to best drum up support.

A New Yorker article published on March 21, 2018 stated,

Cambridge Analytica contractors worked with Trump’s digital team, headed by Brad Parscale and Jared Kushner. Alongside all of them were Facebook employees who were embedded with the Trump campaign to help them use Facebook’s various tools most effectively—including the so-called 'dark posts,' used to dissuade African-Americans from showing up to vote. Did any of them know that the data that Cambridge Analytica was using to target voters, craft ads and blog posts, and determine Trump’s travel schedule came from millions of American Facebook members whose data had been taken without consent and sold for a million dollars—what Cadwalladr is calling a massive data “breach”? 

Discussion

CVS Health says it donates to charity to improve health and health care, and that it has a social responsibility agenda to again improve health and keep the planet in balance.  Yet it secretly donated to a "social welfare" organization that explicitly was devoted to upholding the Trump agenda, founded by former Trump campaign officials, at least two with questionable ethics, one of which  pleaded guilty to federal crimes, and which ran a political polling operation that may have been illegal.  When its donation was discovered, and the racist sayings of two, and apparently pro-Nazi sayings of another of the organization's leaders were exposed, CVS then said it would not donate further. 

Why did CVS Health donate to America Health Policies in the first place?

Given what transpired, at least CVS Health should immediately explain the reasons for this donation, and why it was made despite its obvious conflicts with CVS Health's stated policies and mission.

CVS Health should also disclose whether it has made any similar donations in the past, and what its policy on donations will be in the future.

Until such disclosures are made, we are left with further, exceedingly troubling questions.

Was this merely a case of severe and mission-hostile (mis)management?  However, it is difficult to believe that CVS Health managers did not know what the purpose of America First Policies was, and who its leaders were.

Was the donation to America First Policies an effort to cozy up to the Trump regime, arguably the most conflicted and corrupt presidential administration (look here), in hope of securing economic favors for CVS Health and/or its managers?

Did the donation somehow otherwise support top CVS Health managers' self-interest?  Given that President Trump has failed to condemn white supremicists and neo-Nazis (look here), and has recently proclaimed he is above the law, and thus called by editorialists a president who would be a king (e.g., here in the New York Times), are CVS Health managers closet monarchists, authoritarians or fascists?

Is this case unique?  Are other corporations that proclaim their social responsibility secretly funding groups like America First Policies?  Are these corporations thus covertly undermining not only patients' and the public's health, but the foundations of the American republic? 

The frogs must figure out how to get out of the pot of now boiling water.