Friday, February 22, 2019

The Revolving Door Spins Again: the Now Constant Coziness Between the Health Care Industry and US Government

Just because Washington DC is now crazy town does not mean the revolving door has stopped spinning.  We have been dutifully accumulating cases, so it is time to present our latest update.



I will divide this into two sections 1) the incoming revolving door, through which come people from the health care industry to enter US government positions in which they may influence health care regulation or policy relevant to their former positions; and 2) the outgoing revolving door, through which go people from US government positions in which they influenced health care regulation or policy to industry positions which were relevant to the scope of their government work.  In each section, we will list cases chronologically according to when they were made public.

Incoming Revolving Door Transitions

James Parker from Multiple Positions in For-Profit Health Insurance Companies to Director of DHHS Office of Health Reform

This was reported in Health Leaders Media in April, 2018:

Parker's profile on LinkedIn says he worked for Anthem from 1995 through 2004, serving more than four years as president of Anthem Blue Cross and Blue Shield of Maine.

Parker then worked about five years for WellPoint after it was acquired by Anthem, serving as president of federal employee benefits, then president of federal government solutions, then chief of staff to President and CEO Angela Braly.

Parker spent more than three years as an independent healthcare consultant before landing his job as president and CEO of provider-sponsored IU Health Plans in 2012. Last year, he was named president and CEO of MDwise, an Indianapolis-based Medicaid managed care organization.

Note that current Secretary of DHHS Alex Azar, who came to his job from a top management position in pharmaceutical giant Eli Lilly, rationalized Parker's appointment thus:

His knowledge and expertise will be vital to our work at HHS to ensure that Americans have access to insurance that meets their needs,
Funny, he did not seem at all worried about putting a long term leader of for-profit health insurance companies in charge of ... health care (but operationally largely health insurance) reform.

Andrew Smith from a Legal Firm for which he Represented Numerous Large Health Care Corporations to Head of Federal Trade Commission Consumer Protection Bureau

This was summarized in The Hill in December, 2018:

The top consumer protection official at the Federal Trade Commission (FTC) is barred from handling cases involving more than 100 different companies due to conflicts of interest from his prior work as a private sector attorney, according to documents obtained by the consumer group, Public Citizen.

Andrew Smith, who was tapped as the chief of the FTC’s Consumer Protection Bureau in May, listed 120 conflicts on a financial disclosure form that Public Citizen released on Thursday.

The Hill's reporting emphasized Smith's representation of financial and technology firms, but he also represented a number of big health care corporations, based on the disclosure form that Public Citizen obtained via a freedom of information act (FOIA) request.

These included Bioverativ (a Sanofi subsidiary), Cardinal Health, GlaxoSmithKline, and the Pharmaceutical Research and Manufacturers of America (PhRMA).

Lisa Gilbert, Public Citizen Vice President of Legislative Affairs, was quoted:

Even in an administration full of unprecedented conflicts of interests, Mr. Smith’s conflicts stand out from the pack

An article in GizModo noted

Senator Elizabeth Warren was another staunch critic of Smith’s hire who in May said the agency’s decision was 'outrageous' and added that the FTC 'should pick someone with a track record of protecting consumers, not companies that cheat people.'

Dr Amy Abernethy from Chief Medical Officer for Roche Subsidiary Flatiron Health to Principal Deputy Commissioner of the FDA

Per Matthew Herper writing for Forbes in December, 2018:

The Food and Drug Administration has named Amy Abernethy, currently the chief medical officer at Flatiron Health, a unit of the drug giant Roche, to one of its highest positions. She will start in a few months.

Abernethy, an oncologist who is credited with helping Flatiron transform data collected from electronic medical records into information that might become acceptable to FDA regulators, will be the Principal Deputy Commissioner for Food and Drugs. This is the highest position at the FDA that is not a political appointment. It cuts across all areas of the agency’s remit, overseeing initiatives that cut across offices that oversee the regulation of drugs, medical devices, tobacco and food. Flatiron was purchased by Roche at a valuation of $2.1 billion earlier this year.

Mr Herper did include this dry statement

That potential conflict of interest could be an issue for some outside the FDA.

Of course, the current FDA commissioner was rather blase about any conflict of interests Dr Abernethy might have:

In his memo to staff, Scott Gottlieb, the FDA commissioner, said that Abernethy’s ethics review is still pending. It will likely help that she is unlikely to own large amounts of stock in either Flatiron or Roche, because Roche paid for Flatiron in cash.

There was considerable discussion of  Dr Gottlieb's own conflicts of interest at the time of his appointment (see, for example, this article from the New York Times).  

Outgoing Revolving Door Transitions

Multiple High Ranking FDA Officials to Pharmaceutical Companies

This was reported in April, 2018 in the newsletter of the Regulatory Affairs Professional Society:

Twenty-year FDA veteran Badrul Chowdhury, most recently director of the Center for Drug Evaluation and Research’s (CDER) Division of Pulmonary, Allergy and Rheumatology Products, has taken a job this month as senior vice president at AstraZeneca.

FDA confirmed to Focus that Chowdury joined the agency in 1997 and left on 16 April. And Chowdury isn’t the only one to leave in recent months for an industry job, FDA said.

Sarah Pope Miksinski, former director of the Office of New Drug Products in FDA’s Office of Pharmaceutical Quality, left the agency in February, also for AstraZeneca. And last July, Geoffrey Kim, former director of FDA’s Division of Oncology Products moved to AstraZeneca to become its VP of oncology and head of oncology strategic combinations.

Meanwhile, Jean-Marc Guettier, former director of FDA’s Division of Metabolism and Endocrinology Products, left FDA in December 2017 for Sanofi, Niraj Mehta, former associate director for global regulatory policy at FDA moved over to Merck as a director in March 2018....
So where could former FDA officials get such well compensated, top positions outside the pharma industry?

Bruce Greenstein, Chief Technology Officer of DHHS to LHC Group (For-Profit Home Health Care Provider)

Reported in the Home Health Care News in May, 2018:

HHS CTO Bruce Greenstein will become LHC Group’s first chief innovation and technology officer in June, the home health, hospice and personal care services provider announced Tuesday.

Note that in 2017, we discussed how Greenstein had transited the incoming revolving door from a health care technology company to DHHS.

Once a revolving door transitioner, always a revolving door transitioner? 

Dr Tom Price, Former Secretary of DHHS to Jackson Healthcare

As reported in Health Leaders Media in January, 2019:

Tom Price, MD, the scandal-plagued former secretary for the Department of Health and Human Services, has been named to the advisory board of Jackson Healthcare.

A spokesperson for the Atlanta-based healthcare staffing firm said that the company is privately held and would not detail Price’s compensation.

It is interesting that Health Leaders Media inserted that phrase, "scandal-plagued," in such a prominent way.  Nonetheless, the leaders of Jackson Healthcare was effusive:

'Nobody has as profound an understanding of the national healthcare landscape as Dr. Price,' Richard L. Jackson, chairman and CEO of Jackson Healthcare, said in a media release. Tom has exhibited an unwavering commitment to preserving the patient-physician relationship. That mindset, along with his physician, business and policy experience, will make him an invaluable addition to our board.'

No scandals to see here, please move on. 

Courtney Price, Assistant Secretary for Legislative Affairs at DHHS to Cigna

In February, 2019, ProPublica published an article documenting the departure of 33 top  executive branch officials for lobbying positions.  These included:

Courtney Lawrence was a longtime aide for Reps. Bill Cassidy and Tom Price and a federal lobbyist for the insurance trade association America’s Health Insurance Plans before taking a job as assistant secretary for legislative affairs at Health and Human Services in March 2017, when Price briefly headed the agency. Lawrence stayed for 18 months before leaving in August 2018 for a director role at Cigna Corp., the health insurance conglomerate.

Lawrence registered as a lobbyist with Cigna in October. Her disclosure forms state that she was working on proposed changes to Medicare, the Affordable Care Act and prescription drug rebates. Federal lobbying disclosures show that Lawrence was one of several lobbyists to communicate with federal agencies and the White House, and not just members of Congress. In a statement, Cigna asserted that the lobbying disclosure — which was prepared by the company — is inaccurate. Cigna blamed a 'formatting issue.' The statement said Lawrence 'does not and will not lobby the Executive Branch.' The company said it would correct her lobbying disclosure form.
So where will she lobby instead?

Alex Campau, White House Health Policy Aide to Cozen O'Connor

ProPublica also briefly noted

Alex Campau, a White House health policy aide now running the health lobbying team at Cozen O’Connor

That should do it for now.

Summary

With so many crises appearing during the Trump regime, the issue of the revolving door seems to get lost in the fray.  However, the Trump regime has supercharged a chronic problem, especially in its proclivity to hire people direct from industry to regulate and set policy that affect their old employers.  As we have said again and again, that is three times in 2018,  

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 from industry to the Trump regime 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.


Thursday, February 14, 2019

How Stupid Do They Think We Are? - Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo

In the early 21st century, the debate about health care reform in the US ramped up.  The result ultimately was the Patient Protection and Affordable Care Act (PPACA, ACA, "Obamacare"), which arguably improved access to health care, made some reforms in the regulation of health care insurance, but did not affect the fundamental reliance of the US on employer-paid, for-profit health care insurance to finance health care for many patients.  Nor did it really affect the issues we discuss on Health Care Renewal (look here for details).

After the tumultuous election of President Donald Trump, the debate started up again with his and his party's attempt to "repeal and replace" Obamacare.  Arguably, Obamacare ended up damaged but not repealed.  Once again, the issues we discuss on Health Care Renewal were ignored, including threats ot the integrity of the clinical evidence base, deceptive marketing, distortion of health care regulation and policy making, bad leadership and governance, concentration of power, abandonment of health care as a calling, perverse incentives, the cult of leadership, managerialism, impunity enabling corrupt leadership, and taboos, or the anechoic effect.  (Look here for a detailed discussion. )

It is time once again to discuss health care reform in the US.  Now the push is from the Democrats and the left, with the stated goals of making care more universal, and perhaps decreasing or even ending the role of for-profit commercial health care insurance companies.

It is no surprise that those who benefit the most from the current system (even as modified by Obamacare) are rushing to its defense. 

Dark Money to Defend Commercial Health Insurance

We already discussed  how large health care corporations, including pharmaceutical and biotechnology companies, have been using dark money to funnel money for distinctly partisan purposes, to defeat whom they perceive as too left-leaning politicians, almost all Democrats.  They seem to fear such politicians might promote health care reform efforts that would be based on "anti-free-market, anti-business ideology," that is efforts to decrease the role of commercial, for-profit health insurance in financing health care.

More recently, the focus has shifted to Democratic proposals for government run single-payer, or "Medicare for all" health insurance. In early January, 2019, the Hill reported

Thomas Donohue, the president and CEO of the Chamber of Commerce, on Thursday vowed to use all of the Chamber's resources to fight single-payer health care proposals.

'We also have to respond to calls for government-run, single-payer health care, because it just doesn't work,' Donohue said during his annual 'State of American Business' address.

The US Chamber of Commerce historically has had many executives of big health care corporations on its board.  We listed 10 such members in 2015.   It also historically has received financial support from some corporations.  We listed 17 in 2018.


Then later in January, The Hill reported that a group called Partnership for America's Health Future started digital ads attacking "Medicare for All."  The Hill stated its

members include major industry players such as America’s Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America
So here we have the leaders of big health care corporations funneling corporate money into propaganda campaigns to defeat government run single payer health insurance, an old policy idea that suddenly is looking politically credible.  Current US regulation and practice allows them to hide the exact amounts spent on such campaigns by processing them through dark money organizations.

Such stealth health policy advocacy is now not new.  What is surprising now is how some top leaders are willing to jump into the debate themselves, rather than just trying to manipulate public opinion through public relations/ propaganda proxies.  Here are some telling examples. in chronological order.

Quest Diagnostics CEO Attacks "Medicare-for-All" Using an Appeal to Authority, an Argument by Gibberish, the Non Sequitur Fallacy, (and an Incomplete Comparison) 

On January 24, 2019, Yahoo Finance reported

A top health care CEO is sounding the alarm on 'Medicare for All,' an idea gaining steam in political circles, including from newly-elected Rep. Alexandria Ocasio-Cortez (D-NY).

'Most people don’t understand the basics of health-care economics in the United States,' said Steve Rusckowski, chairman & CEO Quest Diagnostics (DGX), in an interview with Yahoo Finance editor-in-chief Andy Serwer at the World Economic Forum in Davos, Switzerland....

Mr Rusckowski implied that he knows a lot more about health care economics than most people, so most people should listen to him.  Thus, he began with an implied logical fallacy, the appeal to authority.

He then presented the justification for his argument.

'The majority of people get their health care from their employers, and the majority of healthcare costs are paid by employers and employees,' he said. 'If you look at the $3.5 trillion spent on healthcare costs, that portion is actually funding the Medicare and Medicaid programs throughout this country.'

The syntax was fractured, and so this was incoherent and confusing. In particular, it was not clear to what "this portion" referred.  $3.5 trillion? Health care costs paid by employers and employees?

The context of  his use of that phrase did not help.  Note that US total health spending was reported to be approximately $3.5 trillion in 2017 by the US Center for Medicare and Medicaid Services (CMS).  However, that was total health spending, not just the amount spent by Medicare and Medicaid.  Furthermore, Medicare and Medicaid are funded by sources other than employers and their employees.  While employers and employees pay tax on employee income to fund Medicare, general funds from the federal government, and from state governments funds Medicaid. Furthermore, many employers pay parts of their employees' private health insurance premiums, while the employees make up the difference in premiums. Self-employed people may may for their own insurance, etc, etc.


Mr Ruskcowski, not to put to fine a point on it, seemed to speaking gibberish, and would use this gibberish to justify his next point.  So in formal terms, he used the logical fallacy of an argument by gibberish.

When incomprehensible jargon or plain incoherent gibberish is used to give the appearance of a strong argument, in place of evidence or valid reasons to accept the argument.

In any case, Mr Rusckowski went on to argue that he

remained skeptical of a Medicare-for-all plan funded by corporations and employees. 'I don’t think [corporations and employees] can afford to provide that access as described.'
However, not only were his earlier statement gibberish, they were not clearly arguments in support of his contention that corporations and employees cannot "afford to provide that access as described."  So this appeared to be an example of the logical fallacy of the non-sequitur.

Mr Rusckowski's total compensation as CEO of Quest was over $10 million in 2017, as estimated by Bloomberg News.  So it is perhaps not surprising that is self-interest in preserving the status quo was strong enough to motivate him to jump into the debate.  One would think, however, that someone who managed to become a rich CEO of a medical diagnostic company could manage to be a bit more logical.

Anyway, he has some strange bed-fellows in this cause, including two billionaires who are not directly involved in health care corporations, but who have obviously benefited from the current economic status quo.

Michael Bloomberg and Howard Schultz Used the Incomplete Comparison Fallacy

Two billionaires provided striking examples of one logical fallacy. 

First, from the New York Times, January 29, 2019:

Mr. Bloomberg, the former New York City mayor who is considering a 2020 bid on a centrist Democratic platform, rejected the idea of 'Medicare for all,' which has been gaining traction among Democrats.

'I think you could never afford that. You’re talking about trillions of dollars,' Mr. Bloomberg said during a political swing in New Hampshire, which holds the nation’s first primary in 2020.

'I think you can have ‘Medicare for all’ for people that are uncovered,' he added, 'but to replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time.'

Second, from CNN on January 30, 2019:

'Why do you think Medicare-for-all, in your words, is not American?' CNN's Poppy Harlow asked Schultz on Tuesday.

'It's not that it's not American,' Schultz said. 'It's unaffordable.'

'What I believe is that every American has the right to affordable health care as a statement,' Schultz said, lauding the Affordable Care Act, otherwise known as Obamacare, as 'the right thing to do.'

He added, 'But now that we look back on it, the premiums have skyrocketed and we need to go back to the Affordable Care Act, refine it and fix it.'

He argued that the Democratic progressive platform of providing Medicare, free college education and jobs for everyone is costly and as 'false as President Trump telling the American people when he was running for president that the Mexicans were going to pay for the wall.'

So both billionaire Bloomberg and billionaire Schultz stated that Medicare-for-all would cost too much.  Yet neither addressed how much our current health care system costs.  However, as a subsequent op-ed in the Washington Post by Paul Waldman pointed out, it only makes sense to talk about affordability in the context of a comparison with a reasonable alternative, say, the current health care system:

there is one thing you absolutely, positively must do whenever you talk about the cost of a universal system — and that journalists almost never do when they’re asking questions. You have to compare what a universal system would cost to what we’re paying now.

there have been some recent attempts to estimate what it would cost to implement, for instance, the single-payer system that Sen. Bernie Sanders (I-Vt.) advocates; one widely cited study, from a source not favorably inclined toward government solutions to complex problems, came up with a figure of $32.6 trillion over 10 years.

That’s a lot of money. But you can’t understand what it means until you realize that last year we spent about $3.5 trillion on health care, and under current projections, if we keep the system as it is now, we’ll spend $50 trillion over the next decade.

Again, you can criticize any particular universal plan on any number of grounds. But if it costs less than $50 trillion over 10 years — which every universal plan does — you can’t say it’s 'unaffordable' or it would 'bankrupt' us, because the truth is just the opposite.

These are text-book examples of the fallacy of incomplete comparison.

By the way, buried amongst his use of gibberish and non-sequiturs, Quest Diagnostics CEO Rusckowski also opined that Medicare-for-all would be unaffordable without any reference to the costs of the status quo, and hence also provided an example of an incomplete comparison.

The Waldman op-ed noted

The fact that these two highly successful businessmen — whose understanding of investments, costs and benefits helped them become billionaires — can say something so completely mistaken and even idiotic is a tribute to the human capacity to take our ideological biases and convince ourselves that they’re not biases at all but are instead inescapable rationality.

Maybe.  However, it may also be a tribute to their arrogance bred by decades of public relations (which Bernays thought sounded better than "propaganda") and disinformation meant to soften up the minds of the public so that they will follow the lead of the rich and powerful.  

Schultz Also Added an Appeal to Tradition (or to Common Practice)

Also on January 29, the Washington Post reported that

Schultz referred to a town hall hosted Monday night by CNN in which Harris embraced a 'Medicare-for-all' single-payer health insurance system and said she would be willing to end private insurance to make it happen.

'That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

'That’s not correct. That’s not American,' Schultz said on CBS. 'What’s next? What industry are we going to abolish next? The coffee industry?'

Presumably, by saying "that's not American," Schultz means that is not what we have always done, that is not what has been traditional American practice, begging the question of whether that practice could be ill-advised.  Thus Schultz appeared to ladle on an appeal to common practice, otherwise known as an appeal to tradition

As an aside, the quote also suggests that Schultz's real concern is not with the affordability of Medicare-for-all, particularly in comparison with that of the current system, but with the financial health of the insurance industry.  But that is for another day....

Summary

So, to protect against the dread "Medicare for all," that is, proposals for a government single-payer health insurance system to replace our current practice of financing health care through large, mainly for-profit  insurance companies, we see an acceleration of public relations/ propaganda paid by undisclosed donors, that is, via dark money.  We also see prominent multi-millionaire and billionaire executives laying down a barrage of logical fallacies to support the status quo.


It is hard to believe that the defenders of the current system are not mostly self-interested.  That status quo has made some people very rich.  

It is also hard to believe they are stupid.  However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

In 2011, we wrote,

Wendell Potter, author of Deadly Spin, has provided a chilling picture of health care corporate disinformation campaigns and the tactics used therein.

In particular,

Mr Potter recounted how deceptive PR campaigns subverted the health care reform plans of US President Bill Clinton, reduced the impact of Michael Moore's movie, 'Sicko,' and helped to remodel the recent health care reform bill to reduce its threat to commercial health insurers.  He further noted how PR distracted public attention from the growing faults of a health care system based on commercial health insurance, and how practical and legal safeguards against abuses by insurance companies were eroded.

Furthermore, Mr Potter

described 'charm offensives;' the deliberate creation of distractions, including the planting of memes for short-term goals that went on to have long-term adverse effects; fear mongering; the use of front groups, including 'astroturf,' (faux disease advocacy and/or grass roots organizations), public policy advocacy groups, and tame (and conflicted) scientific/professional groups; and intelligence gathering.  He provided some practical advice for detecting such tactics. For example, be very suspicious of policy advocacy by groups with no apparent address or an address identical to that of a PR firm, or with anonymous leaders and/or anonymous financial backing.

Now it is 2019, once again health care reform is in the air, and once again the defenders of the status quo are hard at work.  Now, they are even wealthier than they were 10 years ago, and have even more sophisticated tools, like social media and its hacks, at their disposal.  Still, however, their arguments are ultimately built on sand.

As I did in 2011, it makes sense to quote Wendell Potter

onslaught drastically weakened health-care reform and how it plays an insidious and often invisible role in our political process anywhere that corporate profits are at stake, from climate change to defense policy.
[Potter, Huffington Post]
So,
The onslaughts of spin will not stop, the distortions will not diminish, and the spin will not slow down. To the contrary, spin begets spin, as the successes of corporate PR functionaries increase the revenues of their employers, further funding their employers' efforts to create a more hospitable climate for their business interests. Americans are thus being faced with increasingly subtle but effective assaults on their beliefs and perceptions. Their best defense right now is to understand and to recognize the sophisticated tactics of the spinners trying to manipulate them.

Most important is a singular mandate: Be skeptical.
[Potter, Huffington Post]

I still hope that summarizing some of Mr Potter's amazing points will help us all to be much more skeptical.

You heard it here first.

ADDENDUM (22 February, 2019) - This post was re-posted on Naked Capitalism.  See the comments section for a quite interesting discusison. 



Wednesday, January 30, 2019

Watching the Detectives: Logical Fallacies and Unsubstantiated Claims to Denigrate Investigations of Leaders' Conflicts of Interest and Alleged Corruption

Introduction: Logical Fallacies and Unsubstantiated Claims in Defense of Conflicts of Interest in Health Care

We have long been concerned about deceptive marketing to sell health care products, and deceptive public relations to push policy positions favorable to health care organizations' leaders.  Deceptive marketing and public relations may morph into stealth marketing and stealth advocacy, and then  outright propaganda and disinformation.

At the same time, we have long been concerned about how leaders have become unaccountable for the conflicts of interest generated and outright criminal and corrupt behaviors by their organizations.  They have thus exhibted impunity.

These concerns have sometimes merged.  We have occasionally written posts about how prominent figures in health care, thought leaders, or as health care marketers like to call them, key opinion leaders with impressive credentials, have used questionable data and logical fallacies to defend their and other health care leaders' conflicts of interest.  For example, most recently, in 2015, I discussed a commenary in the prestigious New England Journal of Medicine defending conflicts of interest affecting health care academics.  At the time, I wrote:

It was more surprising, given the reach of this journal, that these articles featured a catalog of logical fallacies in support of their arguments.  We have noted that logical fallacies have been a stock in trade of those who actively defend laissez faire policies about conflicts of interest, and other kinds of interactions among health professionals and industry.  However, I would not have believed that the New England Journal of Medicine would go along with this sort of thing.

The logical fallacies I cited were burden of proof, appeal to authority, ad hominem, appeal to pity, and the straw man fallacy.

I concluded with:

The series of articles about conflicts of interest that just appeared in the New England Journal, while ostensibly scholarly, published by the journal's "national correspondent" in the Medicine and Society section, appear to be polemical.  They deployed a substantial number of logical fallacies to make the point that medicine and society have gotten too tough on conflicts of interest.  They are notably short on logical, dispassionate discussion of the evidence.  Thus, they seem more like posts on a very opinionated blog site rather than commentaries in a scholarly medical journal.

I had written similarly in 2012 on logical fallacies employed in a report by the European Society of Cardiology defending, again, conflicts of interest, and again on logical fallacies employed by the new Chancellor of UCSF in the Wall Street Journal, again to defend conflicts of interest affecting academic medicine.

Now, in 2019, we stil see academics with impressive credentials making arguments in national media based on poor data and logical fallacies, but now to defend the highest leaders of our country from charges of conflicts of interest and corruption.

Victor Davis Hanson's Nationally Syndicated Challenge to the Postulated Over-Investigation of the Trump Administration


Here is one recent, vivid, widely published example.  An op-ed appeared in my local newspaper, the Providence Journal, an abbreviated version of a commentary by Victor Davis Hanson which appeared in the National Review, and was syndicated to numerous other right-wing or conservative publications, such as RealClear Politics, TownHall, and in syndication to multiple news media.  Per the ProJo version, Hanson professes to be "a classicist and historian at the Hoover Institution, at Stanford University."  His official Hoover Institute biograpshy states "Victor Davis Hanson is the Martin and Illie Anderson Senior Fellow at the Hoover Institution; his focus is classics and military history."  It claims he has received multiple awards, and has hundreds of publications.  Thus Hanson claims to be a public intellectual, not a polemicist, and may well fit the definition of a thought leader.

Hanson's main point was that President Donald Trump was being unfairly investigated.  He started with quoting the famous question, "who will watch the watchers," and then goes on to suggest that Trump's watchers (auditors, investigators) need to be reined in, implying that it was unreasonable that the Trump administration " has become the most investigated, the most audited, and the most closely examined presidency in history."

I my humble opinion, in support of his contention, Hanson offered arguments were often illogical, and lacked any substantiating evidence.  Therefore, his piece appeared to be propaganda.   Let me first list some of its illogic.

Hanson's Logical Fallacies


Logical Fallacy: Affirming the Consequent

Hanson's main assertion was:

Given President Trump’s unconventional background, his wheeler-dealer past, and the hatred he incurs from the left, few ever give him the benefit of the doubt.

The paradoxical result is that his tenure in just two years has become the most investigated, the most audited, and the most closely examined presidency in history.

Note that the superlative claims, that is those about the "most investigated," "audited," and "closely examined" presidency, are not substantiated.  These are the essence of  Hanson's argument is that Trump has been scrutinized for (morally) bad reasons, e.g., "hatred from the left."  Hanson is arguing this based on the truth of the result, that his presidency is the most scrutinized.  Yet even if it is, that does not prove the reasons were "hatred from the left," etc.  Thus, this is an example of the logical fallacy of affirming the consequent, presenting an argument in an if p, then q format, but then stating that if q is true, p must have true as well. 


Another example of this fallacy was a little way down the page:

his most frequent accusers — the media — have set themselves up as the country’s moral paragon. Journalists now see themselves as social-justice warriors who are immune from the scrutiny to which they subject others.

The result of such self-righteous moral exemption has led to journalism’s nadir, with an unprecedented lack of public confidence in the media. 'Fake news' now abounds, from CNN to BuzzFeed.

The argument here is a caustive one: if journalists are "immune" "social-justice warriors, then the result is "journalism's nadir," and "fake news."

Again, even if it is true that journalism is at its nadir, that does not mean Hanson's postulated cause, journalists as immune social-justice warriors, is true.  However, Hanson's argument, that the investigations are unreasonable, and the auditors need to be audited, arises from his claim that the original auditors, the journalists, are "immune from scrutiny" and need to be reined in.  Again, he states if p, then q, but then argues that because q, then p.

Logical Fallacy: Hasty Generalization

Trying strengthen his case that journalism as at a "nadir," with "fake news" abounding, Hanson then cited the case of a recent BuzzFeed article:

Recently, BuzzFeed (which first published the unsubstantiated Steele dossier) alleged that there was proof that Trump had ordered his erstwhile lawyer, convicted felon Michael Cohen, to lie.

Furthermore,

the BuzzFeed yarn drew a rare rebuke from Special Counsel Robert Mueller’s team, which disputed the veracity of the story.

That was one case, one anecdote.  Hanson did not cite any other examples of faulty journalism in his commenatry.  So this appears to be a version of the logical fallacy of hasty generalization, also known as an argument from small numbers, or anecdotal reasoning.  Citing an anecdote of a particular pheonomenon means that the phoenomenon is possible, but obviously does not mean that the pheonomenon is common, or important.

Again, Hanson made his argument that the investigations of Trump by law enforcement are alos excessive,


The Department of Justice and the FBI are supposed to be our preeminent guardians of justice. But former director James Comey, former deputy director Andrew McCabe, former general counsel James Baker, and several other top FBI officials have either resigned, retired, or been fired — and some may soon be facing indictments themselves.

Setting aside whether resignations, retirements, or even firingsd under these circumstance indicate excessive zeal or criminal behaviore, and whether Hanson's speculation about indictments are valid, he cited only a few cases to imply that investigation of Trump has been excessive.  So this is another case of reasoning from a small number of anecdotes, thus hasty generalization.

Base Rate Fallacy

Hanson went on to embellish his descriptions of the alleged misbehavior by a few Department of Justice personnel.  In particular, he noted

On 245 occasions in sworn testimony before Congress, Comey answered that he either did not know the answers to questions or could not remember the details of events. Had any private citizen tried such stonewalling in an investigation, he or she would likely end up in jail.

He here was no longer citing one or a few anecdotes.  245 occasions seem to be a lot.  However, Hanson's citation of it omits mentioning the numerator.  Setting aside again the notion that people may go to jail for responding to questions under oath by claiming faulty memory or lack of knowledge, Hanson failed to state either how many questions Comey was asked  Without knowing this, one cannot tell whether the Comey's behavior was frequent or rare.  Thus, Hanson's implication that Comey committed some sort of crime, and that doing so discredits his investigation of Trump, was based on the base rate fallacy.  He focused on the number of times an event occurred, while ignoring how many times it did not.

 Logical Fallacy: Incomplete Comparison

Consider again the two sentences written by Hanson above.  Not only did Hanson not establish the rate Hanson claimed faulty memory or ignorance, he did not address how often "private citizens" make such claims.  Thus, even if we knew the rate of Comey made these claims, we do not know the rate private citizens do so.  This thus appears to be an example of the logical fallacy of incomplete comparison, described as "an incomplete assertion that cannot possibly be refuted. This is popular in advertising."   


Hanson's Unsubstantiated Claims of Fact

I found the following relevant examples of claims about frequency or prevalence without any supporting data.

Half the country apparently believes Trump cannot be trusted.

everything he says and does is the object of pushback, opposition, and audit.

'Fake news' now abounds,

I found the following relevant examples of claims about causation without substantiation.

The sexual-abuse crises within the contemporary Catholic Church arose from the de facto exemptions from the law given to priests.

Too many assumed that men of faith were exempt from prosecution because as holy men they would be the last to violate the trust of minors


I found the following relevant unsubstantiated claims about peoples' intent or state of mind.

They all apparently believed that their loud liberal credentials gave them immunity from being held accountable for their harassment.

They apparently assumed that as supposed victims, they could not be viewed as being sympathetic to victimizers.

Journalists now see themselves as social-justice warriors who are immune from the scrutiny to which they subject others.

Weissmann apparently didn’t mind that the dossier was used by his colleagues to deceive the Foreign Intelligence Surveillance Court into granting a warrant to spy on an American citizen.

Credible Allegations of Trump's and Cronies' Conflicts of Interest and Corruption

While spinning his web of logical fallacies and unsubstantiated claims, Hanson ignored the rationale for the multitude of investigations of President Trump and associates.  In fact, there is voluminous documentation of evidence suggesting he has numerous conflicts of interest and he and his regime are corrupt.  We summarized some of the most recent data here, in October, 2018.  As I said then, up to October, 2018...

In January, 2018, we first raised the question about how health care corruption could be pursued under a corrupt regime.  We noted sources that summarized Trump's. the Trump family's, and the Trump administration's corruption..  These included 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," categorized Mr Trump's conflicted and corrupt behavior.  A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

In July, 2018, we addressed the Trump regime's corruption again  By then, more summaries of Trump et al corruption had appeared.   In April, 2018, New York Magazine published "501 Days in Swampland," a time-line of  starting just after the 2016 presidential election. 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. Meanwhile, Public Citizen released a report on money spent at Trump's hospitality properties.

In October, we summarized the lengthy Tracking Corruption and Conflicts of Interest in the Trump Administration. It broke down Trump and cronies' behavior into the following four categories: 1) US government payments to the Trump Organization; 2) use of the power of the presidency to promote Trump brands; 3)    U.S. government regulatory and policy decisions that benefit the business interests of the Trump family and senior advisors; and 4) private and foreign interests seeking to influence the Trump administration through dealings with Trump businesses.  The lists of specific instances in each category go on for pages, and have grown since October through weekly updates.

Most recently, Citizens for Responsibility and Ethics in Washington (CREW) published a report that listed the following concerning Trump's first two years in office:

CREW has identified 12 foreign governments that have made payments to Trump properties during his first two years in office, each of which is likely a violation of the Constitution’s foreign emoluments clause....

Instead of pushing back on President Trump’s refusal to divest from his business, allies in Congress have embraced the arrangement. 53 U.S. senators and representatives made more than 90 visits to Trump properties during his second year in office, up from 47 visits by 36 members the prior year, and similarly, at least 33 state-level government officials visited Trump properties, likely resulting in taxpayer funds going into Trump’s coffers.

More than 150 political committees, including campaigns and party committees, have spent nearly $5 million at Trump businesses since he became president. In Trump’s second year in office, CREW tracked 33 political events held at Trump properties—13 of which Trump himself attended, meeting and speaking with wealthy donors.

Special interests held at least 20 events at Trump properties during the president’s second year in office. Since Trump took office, at least 13 special interest groups have lobbied the White House, some for the first time, around the same time they patronized a Trump property, suggesting that making large payments to Trump’s businesses is viewed as a way to stay in his administration’s good graces.

Over the past year, President Trump made 118 visits to properties he still profits from in office, bringing his two-year total to 281 visits. CREW also identified 119 federal officials and employees who visited Trump properties over the past year, up from 70 the prior year.
In addition to making frequent visits to his properties, President Trump and other White House staff have promoted Trump businesses on at least 87 occasions. Trump himself mentioned or referred to his company 68 times during his second year in office, more than double the 33 times he did so the prior year.

Paying members at Trump’s resorts and clubs have received benefits beyond getting occasional face time with the President. Four Mar-a-Lago members have been considered for ambassadorships since his election, and three other members—with no federal government experience—acted as unelected, non-Senate-confirmed shadow officials in Trump’s Veterans Administration.
As an aside, in response to Hanson's claim that few have ever given Trump "benefit of a doubt," we discussed here all the credible allegations of misbehavior by Trump prior to his presidency that were investigated minimally, if at all, and which never led to any serious consequences for him.  Trump had been accused of lying to investigators about his Mafia connections; accepting kickbacks; violating fiduciary duties and at least two instances of fraud; failing to disclose he was under grand jury investigation in a casino license application; and perjury.  Also, his casino was found to have committed numerous violations of state regulations, and violating regulations regarding money laundering, but Trump paid no personal penalties.

Hanson ignored all that. 

Discussion

So here is one example, one anecdote, showing, in my humble opinion, an extreme case of illogical, unsupported argumentation in defense of our current president against multiple credible allegations of conflicts of interest and corruption.  These allegations should concern anyone who cares about conflicts of interest and corruption in health care, because the presidency sets the tone for the whole country, and up to now, the executive branch of the US government provided the most and best resources for preventing and challenging conflicts of interest in health care.  Obviously, these allegations should also concern anyone who cares about the state or representative democracy in the US.

This case is notable because of the academic credentials of the person whose argumentation was so illogical and unsubstantiated.  Someone with such a prestigious academic position ought to know better, I think.

The case was also notable for how this widely published article seems to have inspired no criticism to date.  Of course, note that analyzing a short article filled with logical fallacies and unsubantiated claims likely takes much longer than writing said article.  Furthermore, note that the criticism takes much more space than the article itself.  This makes it hard to do criticism that is likely to be noticed much or have much effect.


So in conclusion let me take something I wrote about bad arguments in support of conflicts of interest in medicine in 2015, and edit it for a 2019 audience [additions in brackets]

it is most disappointing that conflicts of interest are now being uncritically and illogically publicly defended by people in positions to exert so much influence on health care [and the greater political economy, and all of society].


Then

True ... reform requires such substantive reform of the financial arrangements among corporations  ... and others who make decisions about patients' or the public's health [and about the health of the political economy and the greater society].  To decide how to accomplish such reform, we need a better discussion informed by logic and evidence, sans logical fallacies. Those who lead health care [the political economy, and the greater society] ought to be able to participate in this discussion under these conditions.


Musical Interlude

To lighten things up a bit, here is a 1978 video of Elvis Costello live performing Watching the Detectives




Tuesday, January 29, 2019

Retaliation against physicians reporting EHR flaws that cause use errors? Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks

It appears that way to my eye.  First, on use errors (as opposed to user errors from carelessness):

“Use error” is a term used very specifically by NIST to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging, misuse of color-coding conventions, omission of information, etc. From "NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records." It is available at http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf (PDF).

Now this:

Becker's Hospital Review
Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks
Jessica Kim Cohen
January 25, 2019
https://www.beckershospitalreview.com/legal-regulatory-issues/physicians-subpoenaed-in-rhode-island-allegedly-after-reporting-ehr-risks.html

The Rhode Island Department of Health reportedly has served at least four emergency room physicians at Providence-based Rhode Island Hospital with subpoenas, according to the Politico Morning eHealth newsletter.

The subpoenas allege the physicians participated in behaviors that fall under the umbrella of medical misconduct, on account of mistakes the physicians reported themselves. The mistakes, which didn't injure any patients, reportedly were meant to draw attention to risks associated with the hospital's EHR.

This is outrageous if accurate, especially considering the issues I raised in my Nov. 4, 2011 post "Lifespan (Rhode Island): Yet another health IT 'glitch' affecting thousands - that, of course, caused no patient harm that they know of - yet" at https://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html.

The RI Dept. of Health owes the public an explanation.

The subpoenas primarily relate to medical scans, such as X-rays, which were mistakenly ordered by the physicians. EHR experts who spoke with Politico said these errors are common because it's easy to click on the wrong icon or patient name in complex system interfaces.

That is classic "use error" and results from poorly-designed, mission-hostile user interfaces of bad health IT as defined by myself and Australian informatics expert Dr. Jon Patrick at at http://cci.drexel.edu/faculty/ssilverstein/cases/:

Bad health IT is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy, lacks evidentiary soundness permitting concealment of alterations, or otherwise demonstrates suboptimal design and/or implementation. 

I covered the issue of 'mission-hostile health IT' at a 10-part series in 2009 at http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html

Physicians and EHR safety researchers have raised concerns over the subpoenas, suggesting that the department's response could discourage future clinicians from voluntarily reporting medical errors.

Not "could." 

Will
, and likely by design in my opinion.  The ultimate motive for the subpoenas and those behind them, which may extend outside the DOH, needs to be determined.

"Anyone punishing individual providers for these events is punishing the wrong thing," Jason Adelman, MD, chief patient safety officer at NewYork-Presbyterian Hospital in New York City, told Politico. "These are system issues, not the provider being reckless. The focus should be on things like EHR usability and safety."

I am aware of patient injuries and deaths as a result of mis-clicks due to mission-hostile user interfaces that confuse users and lack appropriate safety alerts and notifications.  This includes ER mistakes.

The corporate response followed the expected boilerplate:

When asked about the subpoenas Jan. 25, Rhode Island Hospital spokesperson David Levesque [Director of Media Relations, Lifespan, https://www.lifespan.org/news-events/news/media-contacts] provided the following statement to Becker's Hospital Review:

"Rhode Island Hospital is deeply committed to the safety of our patients and the continual improvement of our healthcare environment, including the processes our caregivers and staff follow. Furthermore, the hospital's culture of transparency remains a point of pride and is unwavering. Rhode Island Hospital supports our world-class physicians, nurses and other staff and appreciate their tirelessly work in providing world-class healthcare."

As one colleague of mine observed, "the hospital's culture of transparency remains a point of pride" seems to mean that "you can prosecute staff for being transparent, and it is not a contradiction."

I wrote Mr. Levesque regarding this story:

From: S Silverstein
Date: Tue, Jan 29, 2019 at 10:07 AM

Subject: Re: Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks

"Rhode Island Hospital is deeply committed to the safety of our patients and the continual improvement of our healthcare environment, including the processes our caregivers and staff follow. Furthermore, the hospital's culture of transparency remains a point of pride and is unwavering. Rhode Island Hospital supports our world-class physicians, nurses and other staff and appreciate their tirelessly work in providing world-class healthcare."

Really? 

After the debacle I documented at https://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html , I think this is an outrage.

I am passing this story on to trial lawyers who will likely pass it to the national trial lawyer's listserv.  I believe these actions are retaliation against the physicians.

I am aware of patient injuries and deaths following "wrong clicks" in ER's.

Sincerely,

Scot Silverstein MD

The stated source of the subpoenas, DOH, seems odd.  The hospital should strongly defend its doctors against DOH if the DOH was the sole source of the subpoenas and accusations of medical misconduct, not just provide boilerplate.  If DOH was influenced by some other party to take this action, that needs to be revealed.

I hope I am wrong about the retaliation issue, and that this has all been a misunderstanding.  Perhaps Mr. Levesque will clarify.  Perhaps the subpoenas against the physicians who reported the EHR use error issue were issued by the DOH to gain more information about the alleged EHR problems.  If not, I hope they will be summarily dropped. 

If not, I hope the matter gets wider attention, especially at a time when bad health IT is contributing considerably to clinician burnout per numerous studies and reports (see for instance my Jan. 23, 2019 post at https://hcrenewal.blogspot.com/2019/01/experts-declare-physician-burnout.html).  Burnout increases risk of medical error for everyone.

Supposed accusations of any type of "professional misconduct" are outrageous, and will have a chilling effect on other like-minded, candid clinicians (including nurses) confronting bad health IT.

-- SS

Friday, January 25, 2019

More Than Just Dander

First, a sort of meta-comment in the form of a shout-out to HCRenewal's intrepid editor, Dr. Roy Poses, for his just-published analysis of what we might call "blogging: rise and fall." He sees decline reflected in publications long  devoted to health and health policy, yet now flaking off.

Methinks, however, despite the usefulness of his overview of recent decades, Dr. P need not fret excessively. Water spilling out of the barrel's lip will slow down once folks come along and punch a whole bunch of little mid-section tweet-holes in it. Information still flows. (Sort of.)  In any case, surely there's overlap between blogs' and tweets' readerships. Surely well-researched and -reasoned long form still has its place. Unfortunately, hard to know for sure: it's hard to measure. Nobody's polling these folks and to my knowledge information scientists haven't published much--a quick search inside Google Scholar bears this out--that's of a quantitative nature.

So we're left with admittedly rather unsatisfactory anecdotal reports on people who need blogs like ours and find their way to it. Congressional staffers you know who you are. Rightly or wrongly, I'm hopeful. Maybe we shade this a little by the suspicion that many younger social media users share with me a short attention span. Hence they come to rely more and more on quick hits. In any case, let's hope this is evolution and diversification, not just entropy and a race to the bottom.

Now to my theme of the day. Yet again the dander hath risen for I've lost count how many times around what ails our health delivery systems. And so is my lunch: the gorge, too, hath risen. The miscreants' very relentlessness is nauseating. More, then, on two of them that keep cropping up here like those small burrowing insectivores in this tedious yet oddly riveting game of Whack-A-Mole.

A. Chicanery at the VA: looking back and looking forward.

On balance, and despite its many flaws, VA health's operation in all its enormity is not itself a miscreant. Different story for those folks trying to destroy it from within, on the dubious premise that lest we privatize it it's irredeemable. Search this blog on "VA Cetona" for detail on such matters.

Why does this even happen? We've described the VA's Shadow Rulers (search here on that as well) in these pages. The SR's fall in the 0.1%. Why do they need or want the headache of trying, in what's fated to be a futile effort, to upend and hollow out the health lifeline extended for nearly a century to patriots returning from the military?

When the left gets power it tries to expand and improve government. (Of course the efforts can unfortunately go awry, viz. Hillarycare in the 1990s, and cast shade on future attempts.) When the right gets power, at least in the two generations since an actor became president in 1980, government is seen as "not the solution but the problem." The response may be to try to rejigger and downsize. "Drown the baby in the bath." Or, perhaps far more likely, something else now happening in the VA and throughout the Trump kakistocracy.

Namely, don't seize power to return it to the people. Seize it in order to use it in a third-dimensional play to drain resources. As for the first two dimensions, don't even try to improve--David Shulkin's mistake (see below)--or eliminate (despite Mick Mulvaney's baby drowning proclivities, hugely unpopular) care provided by the VA. Not when there's a third way: divert those resources. In fact, from the earliest instances of frontier exploitation to the newest frontier we have--our heretofore private personal information--despoliation has been the watchword, the core motive, the secret sauce: don't ameliorate. Don't eliminate. (Honestly: viz., Shrub's expansion of guvmint.) Despoliate.

It is, as Shrub used to say (maybe), one of our country's most basic pieces of strategery.

Such a strategy was discussed (and surely it's as old as the hills) by Times tech reporter Steve Lohr in a recent piece on, of all things, artificial intelligence. ("Elixir of prosperity [or] job killer"?) Lohr makes clear that what's old is new again, linking the asset of private data to all the other assets that've been strip-mined. "In the American model," notes Lohr, "coming from Silicon Valley in California, a handful of Internet companies become big winners and society is treated as a data-generating resource to be strip mined."

As Buffy the Vampire Slayer once said, "can you spell 'duh'?"

Strip mining started with the earliest settlers, and now ... data, the final frontier. Same deal, though. The American model, and economic maldistribution, and so much of our plight is bound up with this baked-in trait, which seems to've seeped into society's DNA. Or else originated there. Find a mine. Strip it. Let others pick up the pieces.

But let's go back to that last credible VA Secretary. How do we know that Shulkin pissed off the strip-miners? Why, just read what he himself wrote in a scholarly publication just a few months ago in the prestigious New England Journal. In a piece entitled "why the VA needs more competition," he and closely-associated Michigan colleague Kyle Sheetz first declared, unequivocally and repetitiously, competition: good!!! Emphasis in the original through repetition. Clever. After reassuring their audience how much they liked competition they let the cat out of the bag in the final paragraph of a long-ish article: "Privatizing the VA by offering unregulated access to private-sector providers is probably not feasible, necessary, or the best way to care for veterans."

That's exactly what the quietly-undermining, unelected Trumpsters pushing for strip-mining veterans' health care didn't want to hear. We know (see below) how that came out.

Similar in emphasis is a piece just out (January 2019) in the equally prestigious Annals of Internal Medicine, by (no pun intended) veteran federal health official Carolyn Clancy and her own VA/AHRQ colleagues. I'm perplexed at the way Clancy herself has hung in there (and yet she persisted) at the federal agencies to which she's contributed greatly over recent decades. I'm perplexed about how, within these agencies,she's been bounced around, most recently landing as the VA's "Deputy Under Secretary for Discovery, Education and Affiliate Networks." (That top's spinning so fast what I just wrote may already be superannuated news.)

In any case Clancy et al. put their shoulders to Shulkin's wheel extolling the May 2018 federal MISSION legislation streamlining VA and non-VA care, and the ostensible role their new Center for Innovation might play in such an effort. They pointed out all the right innovation-cum-research caveats about the need for adequate data: "paying for value could backfire without accurate measurement of costs and outcomes." In this case they were certainly correct: privatizers in this particular world aren't interested in evidence-based anything. They're profiteers. (See: "Department of Education." See: "Department of the Interior." See: Environmental Protection Agency.)

Shulkin's words saw the light of day about a month after the MISSION legislation, in the final days of June, 2018. But here's why I put Shulkin having "liked competition" in the past tense. By the time his NEJM piece appeared Shulkin, also accused of what I still deem to've been truly flimsy ethics violations, was already gone from his organization. By the end of March the Orange Man had already fired him. As a personal fiasco this was unseemly, since the VA secretary was a rare bird who both consented to be a hold-over from early administrations, yet managed early on to be a current POTUS favorite. Surprising? In this White House?

In none of these events was there ever put forward any really compelling justification either for privatizing VA care or for starting with the assumptions that outside "leaders" and outside doctors could do a better job than--what with all their flaws--VA medical staff. Suzanne Gordon, a distinguished journalist and author, admittedly parti pris as a fellow of the Oakland-based 501(c)3 Veterans Healthcare Policy Institute, has just published an American Prospect piece on "Trump’s under-the-radar push to dismantle veterans' health care." Her central thesis is worth quoting in extenso.
[The Republican] strategy will not only erase what has been the most successful American experiment in government-delivered health care, but will also send veterans out into a private system that is more expensive, less accountable, and unable to meet their particular needs. The key notion underpinning the Mission Act, that the private sector can offer comparable care to the VHA, is deeply flawed. Study after study (after study) has found that the VHA generally outperforms the private sector on key quality metrics, and that private providers are woefully unprepared to treat the often unique and difficult veteran patient population. The most recent evidence came in a Dartmouth College study published in December, which compared performance between VHA and private hospitals in 121 regions across the country. The results: In 14 out of 15 measures, government care fared “significantly better” than private hospitals.

Gordon also has a new book out on this subject, as most supporters of the traditional VA system already know. Worth a look. Meanwhile the Senate and White House and those advising them clearly never really cared about quaint ideas such as "studies," "evidence," or "data." They cherry-pick a few quotes about the brusqueness of some VA care, which often is admittedly more bureaucratic than today's "consumer-facing" and endlessly-polling private-care organizations. You can find those quotes as well as I can--any search engine known to man will do the trick.

Recent events on the larger political canvas make it abundantly clear, in the meantime. It's not about quality. It never was. It's about callously starting with a dismissive attitude toward government workers, then back-solving from there. Having worked for years at the VA, I can vouch for its quality as well as its struggle to assist the really needy patients who depend upon it. In fact, this new study shows quite rigorously that the VA was already dramatically reducing wait-times within multiple VA installations, right down to private-sector levels. So this branch of government has listened and successfully striven to achieve a performance level that's not just high-science but also high-touch, as medicine's "customers" (yechhh) have come to expect.

The present furlough of federal employees proves the point. If you can dismiss someone as human collateral-damage, you don't start first by examining the good things they've done for you. You're an elephant poacher. Take the spoils and leave the carcass to rot.


B. More on the Opiate Eaters Who Eat Very Well.

Speaking of despoliators, Dr. Poses and I both wrote here recently on how, in the world of dangerous narcotics, this single family of mostly physicians, the Sacklers, garnered a much more grand market share than they like to let on. Time to add to that and earlier reporting with a few updates.

When, in a different venue than the VA I was providing front line medical care to privately-insured patients, I noticed an arresting change. I saw more and more folks arrive in my office in shop-till-you-drop mode seeing opiate renewals. Always OxyContin, Percocet or Vicodin. If I didn't provide the "fill" they'd go next door. The demand built and built. The drug makers kept assuring they were safe and effective. At free dinners they paid an army of fellow physicians to regale us with the same message.

Then those patients started to die on me. OD courtesy of "safe" Purdue (and others') product.

Then in the past very few years, and I honestly should've seen it coming but didn't, the crisis spilled over from doctors' exam rooms into the political arena. It's actually something, unlike the VA, that's garnering a certain timid degree of nonpartisan interest in finding practical solutions, call it consensus even, starting with decriminalizing measures. But I find it gorge-raising to see the usual suspects continuously fighting the notion that as a society, we blew it with opiates. We blew it. With their help.

I've spent a fair amount of time looking at similar medico-legal crises, including the far-reaching tobacco and environmental lead poisoning matters, as well as narrower ones such as evolving surgical and pharmacological approaches to certain diseases. In every case our tort system, combined with the deep pockets of those who are (allegedly) truly guilty, conspire to perpetuate Bleak House-style court battles over culpability. Strip miners seem to believe--or want us to swallow whole the absurdist notion--that they leave the world a better place. In the case of Purdue, this false consciousness is undoubtedly propped up by the Sacklers' prowess as culturati: one can hardly turn around, as I recently did at the Met in New York, without finding their name plastered on this gallery or that institution of higher learning. But the motive, be it within the strip miners' organization or that of a cultural organization, comes down to the same thing: "we need the money." Allegedly.

Recent disclosures from "sources," including internal Purdue emails, clarify all this. Fortunately for us it turns out the founder's (Raymond's) son Richard was an early adopter--relatively so--of email. Both were physicians, but Richard was of the first generation to be granted an American MD. Email was barely used at all in 1995 when Microsoft first added a TCP/IP stack to its operating system, with the introduction of Windows 95. Then email really took off, by 2001 having a fair amount of penetration in the business world. So maybe we shouldn't be so surprised that Purdue Pharma was squirreling away some of Richard's pronouncements in an archival time capsule for our delectation nearly a generation later.

According to a new court filing recently revealed in the NY Times, Richard Sackler said some, um, fairly incriminating things to say in these internal emails. Still earning his spurs as head of daddy's (and Uncle Mortimer's) company after a couple of years or so in the saddle, and undoubtedly aware of the dramatic uptick in addiction issues that I saw in my own clinic in those turn-of-the-century years, he allegedly blasted everyone else in sight--except, of course, his own ever-so-cultured family.

"[T]he launch of OxyContin tablets will be followed by a blizzard of prescriptions that will bury the competition. The prescription blizzard will be so deep, dense, and white...." said Sackler fils. Based on no evidence reps were told to claim a “less than one percent" risk of addiction. As for that small subset of patients who did find themselves hopelessly addicted, the claim was to be made that “We have to hammer on abusers in every way possible.... They are the culprits and the problem. They are reckless criminals.”

Now, hot off the press in 2019, the Guardian reports how this overall attitude has been replicated within the lobbyist-influenced government of Messrs. Trump and Azar. Since 2015 (pre-Trump! pre-Azar!) chair of the FDA's own Anesthetic and Analgesic Drug Products Advisory Committee, Kentucky anesthesiology professor Raeford Brown has bravely characterized the rift that now mires down the FDA in tackling this crisis seriously. Admittedly with cover from many in Congress, Brown said this to interviewers.
I think that the FDA has learned nothing. The modus operandi of the agency is that they talk a good game and then nothing happens. Working directly with the agency for the last five years, as I sit and listen to them in meetings, all I can think about is the clock ticking and how many people are dying every moment that they’re not doing anything. The lack of insight that continues to be exhibited by the agency is in many ways a willful blindness that borders on the criminal.
Scott Gottlieb, who's tying your hands? Is it this guy? The FDA seems to be replete with such interlocking-directorate staff, all trying to assure  the "level playing field." And what is that playing field? Who are the players? We can answer this. Talk to the drug reps (I have). Except of course those who wake up and see what they're really doing, burn out and bail out. Talk to the lobbyists and the investors (I have). The watchword is not "safe and effective." It's blame-the-victim and lucrative. Let's get our motives straight here. You can do that just fine without listening to us at Health Care Renewal. Just listen to Richard Sackler in a time capsule from 2001.

Ever wonder why the strip-miners need so much of our patients' loot? Well, take a little trip to Davos, Switzerland, where the rich and rich go to rub shoulders and tell each other how smart they are: YouTube offers a hint here.

B'bye--too much dander, got to go take a bath.

Wednesday, January 23, 2019

Experts declare physician burnout ‘a public health crisis’ - and health IT a significant pathogen

I'm certain when the information technology hyperenthusiasts and non-clinical management information systems "experts" and pundits get the technology all figured out, this burnout crisis will end.


It will be about the same time as Zefram Cochrane invents the warp drive in Bozeman, Montana just prior to first contact by the Vulcans. That is in 2063 or so.


Experts declare physician burnout ‘a public health crisis’
January 22, 2019
https://www.healio.com/psychiatry/practice-management/news/online/%7B7f2124e2-d72e-4e3e-be53-6fbe41986186%7D/experts-declare-physician-burnout-a-public-health-crisis

Experts from leading U.S. health organizations deemed physician burnout “a public health crisis” in a recent report.

Physician burnout has received some attention in recent years, but not enough. As a result, it is both poorly understood and getting worse,” Andrew R. Iliff, MA, JD, lead writer and program manager at Harvard Global Health Institute, told Healio Psychiatry.

“Like the blind man describing an elephant, people have described the challenges in front of them, including unhelpful electronic health records and a looming physician shortage,” he continued. “We believe it is important to frame this as a systems problem, requiring systemic solutions in order to avoid further adding to ballooning health care costs and undermining the provision of care.”

In their paper, experts from Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society and the Massachusetts Health and Hospital Association recommended ways to address the prevalence of burnout among physicians and other health care providers. Recommendations included:
  • appointing an executive-level chief wellness officer (CWO) at every major health care organization;
  • providing support for those experiencing burnout; and
  • improving the efficiency of EHRs.

More on that third Pavlovian, formulaic, hackneyed, health IT amateur-proffered bullet point in a moment.

... The usability of EHRs must be addressed through reform of certification standards by the federal government; improved interoperability; use of application programming interfaces by vendors; and increased physician engagement in the records’ design, implementation and customization, according to the report.

"Certification" standards are useless towards the stated ends.  Interoperability via API's is not the major issue, either; fundamental operability and, ultimately, clinician burden is.

It is also far too late in the game for "physician engagement" to make any difference.   People in my specialty, myself included dating back to the 1990's - and me on this blog starting ca. 2004 - had been calling for clinician (and especially Medical Informatics) leadership (not merely "engagement") of health IT. 

I note that the original title for my health IT academic site, still residing here, was "Preventing Medical Errors: Medical Informatics and Leadership of Clinical Computing."  The original ca. 1999 site is partially archived at http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/index_org.htm.

Little has changed, and the worst predictions I'd been making about the healthcare IT bubble/experiment (see query search https://hcrenewal.blogspot.com/search/label/Healthcare%20IT%20experiment) seem to be reaching unfortunate fruition.

Regarding the "efficiency" bullet point above:  quite seriously, from the perspective of this trained-by-the-pioneers Medical Informatics specialist, the "efficiency of EHRs" can only marginally be "improved."  This is due to both technical and political reasons.  The systems are far too complex, with far too many templates, widgets, options, "tricks", "gotchas" etc.  (with user manuals hundreds of pages long for each, that cause even my eyes to glaze over), too embedded, too protected by the industry, especially those involving legacy code, and too entrenched by politics - to name just some of the issues making major reform of the systems themselves impractical.

The situation should never have gotten this far, predicted as far back as 1969 by EHR pioneer Dr. Donald A.B. Lindberg (http://www.nlm.nih.gov/od/roster/lindberg.html), who wrote that an effect of the "over sell" even occurring then has been "the feeling that logic compels us to build total hospital information systems like military command-and-control systems ... and other grotesque concepts too numerous to mention."
  

Lindberg in 1969.  From Collen, "A History of Medical Informatics in the United States: 1950 to 1990"

What is needed is a significant downgrading of required clinician (physician/nurse) interaction with these "command-and-control systems", including data entry, and the use of clericals to perform those functions.  See my August 2016 essay "More on uncoupling clinicians from EHR clerical oppression" at https://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html

More generally, see my numerous posts on this issue at https://hcrenewal.blogspot.com/search?q=oppression

One last quote from the Healio article:
... Burnout not only causes physicians suffering, it also can adversely impact patients. Prior research has shown that burnout may does increase the risk for medical errors.  [Fixed the academic equivocation - ed.]

Put more simply, physician and nurse burnout can kill you.

If a healthcare organization cannot afford the appropriate clerical help to avoid clinician burnout, then they cannot afford an EHR.

Finally:

Can I now say "I told you so?" without the health IT industry sockpuppets coming out of the woodwork? (http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html)

-- SS