The global financial melt-down, or great recession, or whatever it will be called was a big surprise in September, 2008, to those of us not immersed in finance. A year later there is an opportunity to at least better understand the events leading up to it. I have managed to read two focused books on aspects of the melt-down, (House of Cards, by William D Cohan, and Fool's Gold by Gillian Tett) and am in the midst of what may be the best general narrative of it published to date, The Sellout, by Charles Gasparino.
Reading the recent history of the meltdown makes me uncomfortably aware of parallels between these events and the current dysfunction of the health care system. In his discussion of the run-up to the crash, Mr Gasparino emphasized a number of issues which I will catalog along with their health care parallels.
Prices Always Go Up
The prices in question were those of real-estate, and the notion that they would always go up helped to fuel would an explosion of mortgage loans made to people who had little chance of fully repaying them. When housing prices reached an unsustainable level and started to fall, the melt-down began.
- It is a cliche that overall health care costs in the US have been going up much faster than inflation for as long as most of us can remember (at least since the 1970s), creating the expectation that they always will go up.
Products were Over-Rated by the Apparent Experts
Mortgages made to people who were unlikely to be able to pay them back were sold by irresponsible originators, and then packaged into financial derivatives by finance firms. Many of these derivatives were rated "AAA" by trusted rating firms, even though they contained multiple individually risky mortages. The rating firms boasted of expertise, and used complex mathematical models supposedly based on evidence to make their ratings.
- In health care, we have come to trust expert professionals' assessments of products (like drugs and devices) and services based on their expertise and clinical research evidence.
Evidence Used to Rate Products was Suspect
The mathematical models used to predict risk were based on limited data and assumptions. In particular, they did not account for the possibility that real-estate prices might go down, or that particular circumstances might cause multiple home-owners to default on their mortgages at the same time. The increasing level of defaults, signaling that the derivatives based on the mortgages might be riskier and less valuable than previously thought, caused the melt-down to accelerate.
- We have discussed how the clinical evidence may be manipulated by those with vested interests in selling products or services. When manipulation does not yield the result desired by the marketers, the results of the research may be entirely suppressed. One particularly telling example was the suppression of research unfavorable to new anti-depressant medications as documented in part by Erick Turner et al. When all suppressed research was taken into account, the drugs appeared much less effective than was previously believed.
The Experts were Conflicted
The rating agencies were paid by the finance firms which sold the derivatives. Ratings agencies that did not deliver sufficiently good ratings were likely to lose business. "By 2005 triple-A ratings were being handed out like candy: underwriters could nearly demand they wanted on a deal and did."
- We have discussed how physicians and medical academics frequently have conflicts of interest due to their financial ties to pharmaceutical/ biotechnology/ device and other health care companies. August academic medical institutions have come to depend on money from industry to support research and education. Distinguished academics are often paid key opinion leaders for drug and device marketers.
Per The Sellout, "On Wall Street, complexity isn't something to be avoided - it allows smooth-talking salesmen to obscure simple concepts like risk and losses."
- We have written again and again about deceptive marketing practices, how marketing is disguised as medical education, the use of stealth marketing, etc to promote often overpriced tests and treatments that are often less effective and/or more hazardous than they are advertised to be.
Politicians Pushed Access without Regard to Consequences
US politicians from both parties pushed ever more accessible mortgages for the laudable goal of making better housing available to the less advantaged, but seemed unconcerned about how they would eventually pay back the loans.
- The driving motivation for most current health care reforms efforts in the US seems to be to provide "access," now redefined as some sort of health insurance, without much attention to the reasons health care has become so inaccessible in the first place.
Major Organizations Lead by the Clueless
The Sellout provided some notable vignettes, including those about Jimmy Cayne, the CEO of Bear Stearns, who did not understand the complex derivatives his firm bought and sold, or the level of risk the firm was assuming; Stan O'Neal, the CEO of Merrill Lynch, whose tenure was "one of the strangest, most volatile, and ultimately most disastrous that Wall Street had ever seen;" and Charles Prince, the CEO of Citigroup, who apparently was a good lawyer, but had "little experience running a business," much less one as complex as Citigroup.
- We have repeatedly discussed how large health care organizations are now often mismanaged, at times by people with little knowledge of or experience in the health care context.
Overpaid, Isolated, Arrogant, Imperial CEOs
The Sellout provided more notable vignettes. Jimmy Cayne (see above), was at one point worth more than US $1 billion. He spent more and more time playing bridge, and less managing his company. Stan O'Neal (see above), would often vanish to play golf. The leadership of Richard Fuld, the CEO of Lehman Brothers, "was more like that of a cult leader than even that of an imperial CEO."
- We have repeatedly discussed how large health care organizations' leaders may be overpaid (some making nearly as much as the leaders of some financial firms before the collapse), arrogant imperial CEOs, some aspiring to be members of the superclass. One striking example was the former CEO of UnitedHealth, Dr William McGuire, who was once worth more than US $1 billion before it became apparent that some of his fortune was based on back-dated stock options.
Sycophantic Cronies as "Stewards"
The Sellout discussed how members of the boards of directors of financial firms were mostly chosen by the CEOs they were supposed to supervise. For example, Jimmy Cayne, who had "a firm grip over his board of directors," noting "my board is my board."
- We have often discussed poor governance of health care organizations, and specifically how boards of directors or trustees of health care organizations are similarly unlikely to challenge the CEOs they are supposed to supervise. We also have noted how health care organizations' are often lead by the same Masters of the Universe who brought us the global financial collapse. For example, Cornell's Weill Medical School was named after former trustee Sanford Weill, who constructed the giant conglomerate Citegroup, but did not figure out how to make its pieces fit together, and was forced "to step down as CEO as the research scandal [investigation] initiated by [former New York state Attorney General] Spitzer snared its highest-profile target, Weill himself." (from The Sellout, p. 187.)
Suppression of Dissent
The Sellout noted how increasingly arrogant leaders of financial firms ignored advice of more conservative or risk-adverse employees. Dissenters were often afraid to speak out, and some were fired. For example, at Bear Stearns, Jimmy Cayne increasingly marginalized "Ace" Greenberg, who was wary of excess risk. At Lehman Brothers, the cult of personality that surrounded Fuld suppressed dissent and debate.
- We have discussed the anechoic effect, the lack of discussion surrounding important health care issues, seemingly enabled by the sense that one simply does not talk about such issues. Whistle-blowers are often ostracized, or worse, and academic freedom and free speech may be frankly threatened.
Ineffective, or Captured Regulators
From the 1980s onward, deregulation of the financial industry advanced. The Sellout discussed how the Federal Reserve, lead by Allan Greenspan, enabled if not cheer-lead for the bubble. The Securities and Exchange Commission (SEC) was often ineffectual at best.
- We have discussed how the FDA got conflicted advice and often seemed to feel that drug and device manufacturers, rather than the public were its clients. We just noted that one version of health care reform would put control of a comparative effectiveness research institute in the hands of industry, and would empower its leaders to suppress research which offends them.
We have discussed the impetus to make physicians give up their professionalism ostensibly to increase competition (see post here), and to then hand over control of health care to managers ostensibly to reduce costs. Since the 1980s, health care has increasingly been dominated by large organizations run as businesses by business managers. It should therefore be no surprise that the ethos of health care management has come to resemble the ethos of business management in general. Thus, maybe the parallels between some of the issues related to the global financial meltdown and the issues related to current health care dysfunction should not be surprising.
A few other bloggers and business writers have referred to a health care bubble in the last few years. Notably, Dr Wes advanced the concept in 2008. Dr Rich spoke out in early 2009, and Dr George Lundberg added to it later in 2009.
So I make a fearless assertion and prediction. Health care dysfunction has lead to a health care bubble, which is likely to burst soon with considerable adverse consequences. Perhaps a controlled deflation of the bubble would be possible, but would require more courage and clear thinking than most of our political and health care leaders have exhibited so far. We have repeatedly noted how current efforts to reform health care have ignored most of the issues discussed above and documented repeatedly on Health Care Renewal. If one of the currently proposed versions of health care reform becomes law, it may postpone for a while the popping of the bubble. However, the longer the bubble grows, the nastier the bursting of it.
Do not say we did not warn you.
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