Wednesday, April 26, 2017

Health Insurance For Me But Not for Thee? - How Legislators Tried to Rig the Repeal of the ACA to Keep Their Own Health Insurance Affordable

The turmoil swirling around the new Trump administration has flushed into the open some things that the public heretofore was probably not meant to see....

We have been writing a lot lately about how the insiders who run large health care organizations, and benefit mightily therefrom, try very hard to control the health care policy discourse, and keep us distracted from their wizardry behind the curtain.  Again, these days the curtain is likely to get blown away.

Sarah Kliff just reported in Vox about a provision newly inserted into the proposed American Health Care Act

Wednesday night, text leaked of a new Republican amendment to the party’s health care bill, the American Health Care Act, which was part of an ongoing effort to revive the bill in the House.

The amendment would allow states to opt out of some politically popular Obamacare provisions, like the requirement to charge sick people the same prices as healthy people, or to cover a core set of benefits.

Health law expert Tim Jost called me when he noticed something surprising on the sixth page of the amendment: an exemption for the health insurance of legislators and their staff. This means that members of Congress and their aides would be guaranteed access to Obamacare provisions that constituents could lose.

I wrote about it. It caused a stir. Twelve hours later, Republican legislators appear to be split — but not over the exemption policy itself. Instead, they have disputed whether it even exists.

This morning alone, legislators have claimed that the exemption never existed, that it does exist and was inserted by senators, and that it used to exist but has been removed. 

So, to recap, the amendment would have let individual states allow insurance companies to bill patients with pre-existing conditions at higher rates than healthy people.  That would negate the essential function of health care - to pool costs among large populations so that care is affordable for the sick.  Thus many people with pre-existing conditions would have to forego health insurance because of the cost.  However, legislators and their staffs would have had special privileges allowing them to get insurance at the low rate for healthy people even if they were to have pre-existing conditions.  For the legislators and their staffs, health care for me but not for thee.

This is conceptually like other special health care deals that insiders and the wealthy can get now, like "VIP care" at hospitals (look here, here, and here), or executive health plans for top corporate managers (look here).  Such privileges allow the American version of the nomenklatura to get better health care than the little people get (just like Soviet apparatchiks could get much better care than the proletariat, and now like Putin and his cronies will have access to a special health clinic, according to Reuters, via Business Insider.) 

It is likely that the persistence of health care dysfunction in the US has been driven in part by the ability of the rich and insiders to bypass the current system.  And this ability may have been in turn driven by how insiders have been able to manipulate the public discussion of health care policy to conceal such unpleasant truths (as noted here and here).

To ever achieve true health care reform, we need an honest discussion of what is wrong with health care, and especially of how the system has been rigged to protect the insiders who currently benefit the most from the status quo. 


Monday, April 17, 2017

Pontifications About Health Care Reform Written by Insiders Who Benefit from the Status Quo - Worse Than We Think

Perceptions that the US health care system is dysfunctional and needs major reform go way back.  A timeline from the Tampa Bay Times noted President Theodore Roosevelt's proposal for a national health service in 1912.  Nonetheless, as we have discussed endlessly, most attempts at reform failed, and health care dysfunction seems to be getting worse.

One big problem may be that we don't understand how much discussion of health care reform is driven by those who benefit from the status quo. 

A Personal Anecdote

When I began my academic career in 1983, I was often in the audience for talks about how to fix health care by people billed as experts.  Often these talks seemed oddly disconnected from the realities on the ground for a junior assistant professor with a lot of clinical and teaching responsbilities.  Worse, many of the solutions they offered seemed to entail greater burdens for health care professionals, with no obvious compensation other than the warm feeling that we would be benefiting society.  Who else these solutions might benefit was not discussed. 

One talk given a bit later stands out in my memory. On November 29, 2001, one Dr John W Rowe gave the prestigious Levinger Lecture at Brown University entitled "Good Health: Can we Afford It?" (referenced here, see items for 11/14 and 11/16)  As I recall, Dr Rowe spent considerable time scolding us hard working physicians for overuse of medical interventions leading to endless increases in health care costs, and promising more burdensome bureaucratic interventions to rein in our follies.  While promising more burdens on physicians, Dr Rowe did not dwell on how the resulting cost savings might benefit him in his role as CEO and Chairman of Aetna Inc.  Aetna had purchased the notoriously physician-unfriendly US Healthcare, and thus had become a big for-profit health care insurer already known for imposing bureaucratic burdens on physicians in hopes of decreasing their utilization, while increasing the company's revenues (look here).  Were Dr Rowe's pontifications really about improving health care for all Americans, or about justifying his previous management behavior, and perhaps supporting the price of his shares in Aetna? Why was Aetna's public relations given the patina of an academic lecture?

These days, health care professionals continue to be exhorted about health care reform.  Many such pontifications may be not so much about true health care reform as about preserving the fundamental status quo which has benefited and enriched so many insiders. The interests of the pontificators are often less obvious than those of Dr Rowe.  Maybe that is so why there has been so little real reform, and what little reform there has been seems to be under continuous attack.

Two Examples of How Hard It Is to Discover the Interests of Health Care Policy Pontificators

In the last few weeks I posted about two recent ostensibly authoritative pontifications.  One was about ways to address the worsening problem of physician burn-out (see this post). It was written by the CEOs of large, non-profit hospital systems, joined by the CEO of the American Medical Association.  The other was about a health care reform proposal from the prestigious National Academy of Medicine (see this post).  A rather uncritical article in the Washington Post hailed it as a "radical idea" because it was written by "doctors." In both cases, I was skeptical, mainly because many of the proponents had conflicts of interest, mostly undisclosed, that suggested they were already benefiting mightily from the current system.

However, it gets worse.  While I thought my posts were based on reasonable efforts to find undisclosed conflicts of interest affecting the authors of these exhortations, within a few weeks I realized I had missed one important item affecting each.  The lesson is that the web of conflicts of interest that ensnares the insiders who run most of US health care is even more complex and adherent than any of us realizes.

Dr John Noseworthy, Author of the Health Affairs Post on Reducing Physician Burnout: CEO of the Mayo Clinic, But Also Now Nominated to be a Director of Merck

Dr Noseworthy, CEO of the Mayo Clinic, was the lead author of a post in HealthAffairs about reducing physician burnout.  (Oddly enough, none of the proposed action items seemed to involve increasing physician autonomy by reducing the power of managers over health care professionals.)

Two weeks after Noseworthy and colleagues' post appeared, an article on the Minnesota Public Radio website reported that Dr Noseworthy has just been nominated to a seat on the Merck board of directors.  Presumably the possibility of this nomination had been known at the time the post was published.

I had previously written that two of the authors of the Health Affairs post were on corporate boards.  One, Dr Paul Rothman, was already on the board of Merck.  As corporate directors, they have fiduciary responsibilties to promote the revenues of their corporations.  Now it turns out there were at least three such board members among the health system CEOs who had pontificated to physicians about how to reduce their burn-out.

Yet the power of such health care systems, whose management is often mission-hostile, and who often put revenue ahead of physicians' professional values (per the shareholder value theory), is arguably a major cause of physician burnout.  Furthermore, Merck, in particular, has had its share of management misbehavior as demonstrated by a recent $830 million settlement for deceiving shareholders, a mere $5.9 million 2015 settlement for deceptive marketing, and multiple setttlements, cumulatively totaling more than $1 billion, plus one guilty plea for the historic deceptive marketing of Vioxx (see this post).

So to what extent are the authors of this pontification about reducing physician burnout (without really giving physicians much new autonomy) insiders benefiting from the status quo in health care?  It may be more than what we think, even now.

Mr Leonard Schaeffer, Author of National Academy of Medicine Article on Health Care Reform: Member of the Boards of Wahlgreen Boots, Quintiles, scPharmaceuticals, but Also Long-Term Director of Amgen

Mr Schaeffer was an author of the National Academy of Medicine article, now published online in JAMA, about health care reform.  (Oddly enough, none of the "vital directions issue areas" mentioned in the article involved real challenges to the power of large health care organizations, particularly for-profit corporations, or increased autonomy for health care professionals.)

The version of the article published online by the NAM did not include any explicit disclosures of conflicts of interest.  It did note that two authors were full-time employees of health care corporations, one was a consultant to health care corporations, one was a lobbyist for health care corporations, and one was on the boards of health care corporations.  The online JAMA version added more disclosures, but these were incomplete.  In my post, I noted that fully 13 of the 19 authors had major ties to large health care corporations, as employees, lobbyists, consultants or  board members.

In particular, Mr Leonard D Schaeffer was listed in the NAM version as simply affiliated with the University of Southern California, but I found was actually on the boards of Wahlgreens Boots Alliance, Quintiles Transnational, and scPharmaceuticals Inc.  That was still an incomplete picture of his conflicts of interest.

A ProPublica article from February, 2017 recounted how big pharmaceutical companies engaged Precision Health Economics to wage public relations campaigns to try to justify high pharmaceutical prices.  The article noted the following about Mr Schaeffer.  
Amgen has ties to all three founders of Precision Health Economics. Working for other firms, Philipson has twice testified as an expert witness for Amgen, defending the company’s rights to drug patents, according to his curriculum vitae. The other two founders, Goldman and Lakdawalla, are principals at the Leonard D. Schaeffer Center for Health Policy and Economics at USC, which received $500,000 in late 2016 from Amgen for an 'innovation initiative,' according to public disclosures. Goldman said the funds were unrestricted and could be used at the center’s discretion. Robert Bradway, the CEO and chair of Amgen, is on the advisory board of the university center, and Leonard Schaeffer, a professor at USC and the namesake of the center, sat on Amgen’s board of directors for nearly a decade.

With funding from Amgen, the Schaeffer Center hosted a forum in Washington, D.C., in October 2015 on the affordability of specialty drugs. Before a panel focused on the new cholesterol treatment, Goldman cautioned against lowering drug prices.

So Mr Schaeffer, in addition to his current board positions, turns out to have had a long relationship with Amgen.  Given that according to the 2013 Amgen proxy statement, Mr Schaeffer retired from the board with at least 28,277 shares of Amgen stock and options for 15,000 more, he may have current financial ties to the company. 

So once again, to what extent were the authors of the 2017 NAM report on health care reform (which did not challenge the influence of large health care corporations over the health of US citizens) insiders benefiting from the status quo in health care?  It may be more than what we think, even now.

Summary

Health care professionals, policy makers, and the public are constantly harangued by apparently unbaised experts about health care reform.  Yet many of these authorities are insiders who benefit from the status quo.  Many of their financial connections to the corporations that make the most money from the US commercialized health care system are not disclosed.  It may take considerable investigation to determine their involvement in a web of conflicts of interest that drapes over the US health care system.

Meanwhile, audiences should demand that those who lecture us about health care reform disclose all their financial conflicts of interest.  Any whiff of deception about their personal interests should suggest intense skepticism. 

True health care reform requires honest discussion of the issues.  Honesty in this case entails complete and detailed disclosure of the discussants' conflicts of interest. Until such honest is the rule, be very, very careful about taking sanctimonious spiels at face value. 

Monday, April 10, 2017

Pittsburgh Post-Gazette: "Medication errors in hospitals don’t disappear with new technology". Government: "It's the doctors' fault." I am cited.

The Pittsburgh Post-Gazette published an article on EHR problems yesterday entitled "Medication errors in hospitals don’t disappear with new technology."  It is based on a recent study by the Pennsylvania Patient Safety Authority, retrievable here:  http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2017/Mar;14(1)/Pages/01.aspx

I am cited.  Also cited is an HHS official, Dr. Andrew Gettinger, acting deputy national coordinator for health information technology in the U.S. Dept. of Health and Human Services, who disagreed with my views.  I am familiar with Dr. Gettinger's views.  More on that later.

Medication errors in hospitals don’t disappear with new technology
Steve Twedt
Pittsburgh Post-Gazette
http://www.post-gazette.com/business/healthcare-business/2017/04/10/medication-error-electronic-health-record-hospitals-patient-safety-authority/stories/201704090072

In the first six months of 2016, Pennsylvania hospitals reported 889 medication errors or close calls that were attributed, at least in part, to electronic health records and other technology used to monitor and record patients’ treatment.

A majority of the errors pertained to dosages — either missed dosages or an administration of the wrong dose. Of the 889 errors, nearly 70 percent reached the patient. Among those, eight patients were actually harmed, including three involving critical drugs such as insulin, anticoagulants and opioids.

The extent of the injuries was not detailed, although no deaths were recorded.  Those are the stark numbers in a new analysis by the Pennsylvania Patient Safety Authority, an independent state agency that looks at ways to reduce medical errors.

But interpretations of the report’s significance — and specifically the overall benefits and risks of information technology in a hospital setting — cross a wide spectrum.

The wide spectrum is the gap between those who believe in what might be called cybernetic supremacy (that is, the hyper-enthusiasts who ignore the real-world downsides of technology such as today's EMRs) versus those who promote what I call cybernetic sobriety (a more candid, mature attitude fostered by actual knowledge of the long history of cybernetic failures and the myriad causes of such failures).

Some view reports such as that of the Pennsylvania Patient Safety Authority (PPSA) in a reasonably patient rights-oriented manner, including the PPSA itself:

“This is the classic ‘tip of the iceberg,’” said pharmacist Matthew Grissinger, manager of medication safety analysis for the Patient Safety Authority in Harrisburg and co-author of the analysis with fellow pharmacist Staley Lawes. “We know for a ton of reasons not every error is reported.”

I've written extensively at HC Renewal on the "tip of the iceberg" issue, a phrase also used in the past by the FDA CDER (Center for Devices & Radiological Health) director Jeffrey Shuren MD JD and others.  See for example my February 28, 2010 post "FDA on Health IT Adverse Consequences: 44 Reported Injuries And 6 Deaths In Two Years, Probably Just 'Tip of Iceberg'" at  http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html as well as my January 8, 2016 post "Yet another observation that known health IT-caused injuries and deaths are 'the tip of the iceberg'" at http://hcrenewal.blogspot.com/2016/01/yet-another-observation-that-known.html.

Of course, a PPSA disclaimer was issued, in my view perhaps to placate the health IT industry:

...Mr. Grissinger cautioned that the findings are “absolutely not” an indicator that patients are less safe, as hospitals have moved from paper to electronic records incorporating health information technology...the authors did conclude that technology meant to improve patient safety “has led to new, often unforeseen types of errors” due to system problems or user mistakes.

A more correct statement might have been that "these most current findings are yet another red flag that patients could be less safe with bad health IT, but since there are a 'ton of reasons' not every error is reported, we just don't know - and we truly need to devote a great deal of effort towards filling the gaps in our limited knowledge."

I've written on the issue of not jumping to health IT safety conclusions, one way or another, based on current data, especially when that data is admittedly limited.  For example, see my April 9, 2014 post "FDA on health IT risk:  "We don't know the magnitude of the risk, and what we do know is the tip of the iceberg, but health IT is of 'sufficiently low risk' that we don't need to regulate it" at http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html.

In that post I noted that a secret 2010 FDA internal report on health IT risk (marked "not for public use") unearthed by investigative reporter Fred Schulte stated that "...In summary, the results of this data review suggest significant clinical implications and public safety issues surrounding Health Information Technology...The absence of mandatory reporting enforcement of H-IT safety issues limits the number of relevant MDRs [device reports] and impedes a more comprehensive understanding of the actual problems and implications."

We don't know what we don't know, but to date the efforts to robustly learn the truth has been milquetoast to non-existent.  "Proof (of safety) by lack of evidence" - in an area where we admit the evidence is likely severely deficient - seems to be the default industry go-to position.  "Proof by lack of evidence", of course, is a logical fallacy.

Back to the Pittsburgh Post-Gazette:


... Frustration with the technology
In January 2015, 35 physician groups — including the American Medical Association, the American Academy of Family Physicians and the American Society of Anesthesiologists — sent a nine-page letter about electronic health records to the national coordinator for health information at the U.S. Department of Health and Human Services.

Their purpose was to convey their “growing frustration with the way EHRs are performing,” the letter stated.

“Many physicians find these systems cumbersome, do not meet their workflow needs, decrease efficiency, and have limited, if any, interoperability. Most importantly, certified EHR technology can present safety concerns for patients.”

That Jan. 2015 letter is at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf and speaks for itself.  Kudos to the Post-Gazette for citing it; the public is largely unaware of its existence.

I am then cited in the Gazette article:

Physician Scot Silverstein, a Philadelphia-based consultant and independent expert in electronic health records and vocal critic of such systems, calls the software “legible gibberish” better designed for handling warehouse inventory than managing and monitoring patient care in a clinical setting.

“Electronic health records are a massively complex computer application, far too complex than is needed for a clinic taking care of patients,” he said in a phone interview. “EHRs need to be toned down, be less complex, and be used less.”

Opportunities for mistakes are numerous, he said, as a physician may have to scroll through multiple screens, while each screen with a dozen or more columns plus an array of drop down menus. Some systems, he said, allow doctors to keep screens on multiple patients open simultaneously, increasing the chances of a medication mix-up.

“The software needs to be designed better.”

I am a vocal critic of bad health IT, and actually called the output of the systems to be "legible gibberish" as at my Feb. 27, 2011 post "Two weeks, two reams" at http://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html, but the quote is close enough.

Indeed, today's EHRs seem more designed for mercantile, manufacturing and management settings, and "calm, solitary office environments" (channeling Joan Ash) rather than the incredibly complex, poorly bounded and unpredictable environment of clinical medicine.

I am quoted accurately on the complexity and overuse issue, although the issue of preventing  physicians from having multiple patient screens open was actually a short term workaround known to me to have been put in effect some years back.  This was done when a major EHR was unpredictably transposing orders into wrong charts when multiple patient's screens were open (creating two potential patients at risk).

The software indeed needs to be designed better, to meet clinical needs.


Dr. Silverstein, who says his mother’s death was precipitated by a heart medication mix-up involving her electronic health record, cites federal initiatives giving hospitals financial incentive to implement electronic health systems as pushing the programs without sufficient vetting.

“The thinking was, ‘Computers plus doctors equals better medicine,’ period. But the technology was not and is still not ready for that kind of push.”

Indeed it was not ready, being experimental technology. Further, vetting in real-world settings via robust premarket surveillance, and postmarket surveillance of any rigor were, in fact, absent when massive incentives (and penalties) were announced as part of the so-called Economic Recovery Act and its "HITECH" component.

Instead, he recommends some combination of paper, with paper imaging capability so records are accessible, and electronic systems. “I don’t think paper should or ever will go away completely,” he said.

On this issue, and for a highly successful real-world example, see my August 6, 2016 post "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html.

I note with some irony about the above linked post (regarding a highly successful EMR that protected clinicians from oppressive clerical burdens) that the newly-appointed Director of the Office of the National Coordinator for Health IT (ONC), Dr. Donald Rucker (http://www.healthcareitnews.com/news/donald-rucker-named-new-national-coordinator-onc), was formerly the Chief Medical Officer of Shared Medical Systems, a hospital infrastructure IT provider.  He then became CMO of the failed Siemens Healthcare EMR effort after SMS was bought out ca. 2000.  Siemens Healthcare officials told me ca. 2007 that the real-world, highly successful invasive cardiology information system I'd developed as shown in the aformentioned Aug. 2016 post was "impractical" for commercial emulation.

Back to the Post-Gazette article.  In it, a government health IT official blames the doctors, a line I've heard dating back to the early 1990s when I was a postdoctoral informatics fellow at Yale:

A need for better training

Anesthesiologist Andrew Gettinger, acting deputy national coordinator for health information technology in the U.S. Dept. of Health and Human Services, disagrees with Dr. Silverstein.

He identified three key components to a successful electronic health record system — good design and implementation and the users’ good understanding of the system.

I have no disagreement there, only on the route to achieve those goals.

“What we find is that many clinicians who complain vociferously about the software and how many clicks it takes, and how user unfriendly it is, have not actually taken the time to understand the system,” he said.

This seems the "blame the physicians, they're just complainers and Luddites" canard I've written about for almost 20 years now.

Gettinger seems to ignore the issue of bad health IT and use error:

  • Bad Health IT is health 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, lacking in evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.   (S. Silverstein and J. Patrick).
  • Use error (as opposed to user error) is defined by another U.S. government agency, the National Institute of Standards and Technology (NIST) as follows: "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).

No amount of "training" can compensate for those issues.  Further, physicians and nurses just don't have abundant time for such training about mega-complex systems, on which they're already spending 50% or more of their time.  They especially don't have the time to learn multiple EHR's, a situation that exists for clinicians who work on more than one hospital.  I possess the physician and nurse user guides for a number of EHRs though my forensics work.  A manual for an EHR is as complex as a manual for an office suite like MS Office, or an OS such as Windows.

There's also the fact that physicians and nurses are not reimbursed for the hours they spend feeding the payers and other profit-makers the data, for free.

“Quite frankly, doctors are not always the best at signing up for training and taking the training...

Blaming the doctors again.

... , and some of the training is not always the best.”

Not that, as mentioned previously, "training" is at the root of the EHR problem.


He allowed that the usability criticism “is a very legitimate thing to look at”... 

How kind of Dr. Gettinger to acknowledge what has been known in the IT world for decades about poor usability, e.g., this mid 1980's wisdom written for the U.S. Air Force on user interfaces:



GUIDELINES FOR DESIGNING USER INTERFACE SOFTWARE
ESD-TR-86-278
August 1986
Sidney L. Smith and Jane N. Mosier
The MITRE Corporation
Bedford, Massachusetts, USA
Prepared for Deputy Commander for Development Plans and Support Systems, Electronic Systems Division, AFSC,
United States Air Force, Hanscom Air Force Base, Massachusetts.
Approved for public release; distribution unlimited.
SIGNIFICANCE OF THE USER INTERFACE

The design of user interface software is not only expensive and time-consuming, but it is also critical for effective system performance. To be sure, users can sometimes compensate for poor design with extra effort. Probably no single user interface design flaw, in itself, will cause system failure. But there is a limit to how well users can adapt to a poorly designed interface. As one deficiency is added to another, the cumulative negative effects may eventually result in system failure, poor performance, and/or user complaints.

Outright system failure can be seen in systems that are underused, where use is optional, or are abandoned entirely. There may be retention of (or reversion to) manual data handling procedures, with little use of automated capabilities. When a system fails in this way, the result is disrupted operation, wasted time, effort and money, and failure to achieve the potential benefits of automated information handling.

In a constrained environment, such as that of many military and commercial information systems, users may have little choice but to make do with whatever interface design is provided. There the symptoms of poor user interface design may appear in degraded performance. Frequent and/or serious errors in data handling may result from confusing user interface design [in medicine, this often translates to reduced safety and reduced care quality - ed.] Tedious user procedures may slow data processing, resulting in longer queues at the checkout counter, the teller's window, the visa office, the truck dock, [the hospital floor or doctor's office - ed.] or any other workplace where the potential benefits of computer support are outweighed by an unintended increase in human effort.

In situations where degradation in system performance is not so easily measured, symptoms of poor user interface design may appear as user complaints. The system may be described as hard to learn, or clumsy, tiring and slow to use [often heard in medicine, but too often blamed on "physician resistance" - ed.] The users' view of a system is conditioned chiefly by experience with its interface. If the user interface is unsatisfactory, the users' view of the system will be negative regardless of any niceties of internal computer processing.

Back to Dr. Gettinger for a somewhat non-sequitur 'BUT' disclaimer:

... BUT he defended the federal incentives, saying they defrayed the cost to hospitals while encouraging vendors to develop better systems.

I would say the incentives, just like the spectacularly failed subprime mortgage market a decade ago, just incented the health industry to waste hundreds of billions of dollars on half-baked, experimental technology, alienating physicians and nurses (cf.: the 2015 Medical Societies letter mentioned above).  The incented effort even put some organizations in financial jeopardy, e.g.,

 "MD Anderson to cut about 1,000 jobs due to 'financial downfall officials largely attributed to its EPIC EHR implementation project'
" at
http://hcrenewal.blogspot.com/2017/01/heath-it-mismanagement-md-anderson-to.html

"What is more important in healthcare, computers, or nurses and other human beings? Southcoast Health cutting dozens of jobs on heels of expensive IT upgrade" at http://hcrenewal.blogspot.com/2016/04/what-is-more-important-in-healthcare.html

"Lahey Health: hospital jobs lost, but computer vendors prosper" at http://hcrenewal.blogspot.com/2015/05/lahey-health-hospital-jobs-lost-but.html,

"Monetary losses and layoffs from EHR expenses and EHR mismanagement" (http://hcrenewal.blogspot.com/2013/06/monetary-losses-and-layoffs-from-ehr.html),

"Financial woes at Maine Medical Center: Reading this blog might have saved them millions of dollars, and prevented massive 'cost saving initiatives'" (http://hcrenewal.blogspot.com/2013/05/financial-woes-at-maine-medical-center.html),

and "In Fixing Those 9,553 EHR "Issues", Southern Arizona’s Largest Health Network is $28.5 Million In The Red" (http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html)

I also believe the easy money disincented the vendors from improving the techology, instead selling what they had on hand and acting to discourage innovation and competition to maximize their profits, e.g., see my April 16, 2010 post "Healthcare IT Corporate Ethics 101: 'A Strategy for Cerner Corporation to Address the HIT Stimulus Plan'" at
http://hcrenewal.blogspot.com/2010/04/healthcare-it-corporate-ethics-101.html and my August 31, 2012 post "Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists - Did ONC Ignore This?" at http://hcrenewal.blogspot.com/2012/08/health-it-vendor-epic-uses-clients-as.html.

Finally, I regrettably note that Gettinger seems to possess a rather hard-nosed attitude about health IT harms.  I have contributed, of course, to articles about EHR's in other publications, including, among many others, Politico.  Arthur Allen at Politico wrote me this in 2015 regarding my opposition to the toothless "Health IT safety center" concept, and my promotion of a need for true HIT regulation:


On Wed, Jun 17, 2015 at 1:13 PM, Arthur Allen <aallen@politico.com> wrote:
I’m putting together a piece on the safety center with some notes from an interview I did with Andy Gettinger a few weeks ago. I asked him whether he though the RTI panel (which RTI named, apparently) would have come to the same consensus – that the safety center should be a safe harbor, not an investigatory agency – if you [i.e., me - Scot  - ed.] had been on the panel.

He said,
“he [i.e., me - Scot - ed.] may have heard what we were intending and been able to step back from specific things relative to his mother’s care and gotten to a space to see that this initiative has the potential of making real change in the EHRs used throughout the country. I would have loved to have Scot at the table.”

Any response?


In other words, if only I was able to "step back" from my mother's severe injury, year's worth of horrible suffering as a cripple before she died as a mentally-impaired vegetable, and my lovely mother being taken away from my home in a body bag as a result of a health IT mishap, I'd be able to see just how wonderful a toothless HIT safety center would be.  (Also, I was never asked to be "at the table".)

What a kind comment that was. 

In conclusion:

While I wish the Pittsburgh Post-Gazette article was longer, in its limited space its author did touch upon the major relevant issues well regarding the PA Patient Safety Authority study and its implications towards national Health IT policy.

ONC's Dr. Andrew Gettinger's responses, however, seems to reflect an unwillingness of he and the government to acknowledge Bad Health IT.  His repsonses also appear to show a lack of appreciation of the complaints about EMRs from nearly 40 medical societies.  "It's the doctors fault" for not training enough.

He does acknowledge that better IT would be a good thing, but to date the best HHS could come up with to achieve that goal is a toothless Safety Center. Healthcare IT would be the only healthcare device sector afforded that extraordinary regulatory accommodation.

The notion that all that is needed to solve EMR problems is clerical training of (resistant) physicians seems that of a computing dilettante, and/or a health IT hyperenthusiast.  Such a view ignores decades of knowledge of bad IT, and in multiple sectors.

The blaming of physicians is also decidedly unhelpful towards the reputation of the technology and its enthusiasts in government.  Bad enough that physicians are already spending 50% or more of their time at computers, distracting from patient care.  Gettinger's "solution" also fails to acknowledge that physicians often work in multiple hospitals with different EHRs. They don't have the time to become clerical experts in multiple mega-complex systems.

Claiming the national incentives promoted the vendors to make better health it is also absurd. It actually promoted them to sell the bad health IT they had on hand, and lessened any motivation to improve the technology.

What the issues really boil down to is a conflict between those who believe in cybernetic supremacy (the hyperenthusiasts who ignore the real-world downsides) versus those who promote what I call cybernetic sobriety (a more candid, mature attitude fostered by actual knowledge of the long history of cybernetic failures and the myriad causes of such failures).

-- SS

Friday, April 07, 2017

"A Radical Idea for Health-Care Reform: Listen to the Doctors" - Oops, I Mean Listen to the Corporate Executives, Directors, and Lobbyists

It has been the season for health care reform in the US since at least the Nixon administration.  We have endlessly discussed the unholy triad of health care dysfunction: rising costs, declining access, and stagnant quality.

These days, with all the furor over whether Obamacare should be repealed and replaced, let alone, or improved, it is still the season for health care reform.  Last week an article by David Ignatius in the Washington Post entitled "A Radical Idea for Health Care Reform: Listen to the Doctors," appeared.   Since on Health Care Renewal we are all about trying to uphold physicians' professional values, I thought this deserved a closer look, with the hope that it would provide some down-to-earth wisdom from physicians in the real clinical world.

Background - Doctors Views on the Causes of Health Care Dysfunction


As we recently discussed, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes.  Our first crude qualitative research(1) suggested  that physicians' angst was due to perceived threats to their core values, and in turn that these threats arose from the issues this blog discusses: concentration and abuse of power, health care leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and health care governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting these proposed causes of health care dysfunction. 

Other research provided some corroboration.  Written comments from a 2001 survey of Massachusetts physicians made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line.  Taken over by large corporations.  Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(2)  Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(3)  (Also, see our comments on this paper.)(4)  Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(5)   We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(6)

The Latest Attempt to Listen to the Doctors about Health Care Reform


Ignatius' WaPo article was based on the pre-publication version of a new report by the National Academy of Medicine, (formerly the Institute of Medicine) made available on its website, entitled, Vital Directions for Health and Health Care.  According to Ignatius' interpretation, the basic problem health care reformers need to address is that America "squanders money on the wrong things - expensive procedures and tests rather than preventive care and social programs."  His summary of the supposed doctor recommended cures for this problem were: 

First, providers should be paid for value — for patient outcomes, not for the volume of procedures. Second, incentives should empower people to take better care of themselves through wellness programs or lifestyle changes. Third, better connectivity is needed among doctors, patients and others to encourage data-driven advances. Finally, the Academy argues for community strategies that target the highest-need patients, who are also most costly to treat.

It sounded good at first, but I quickly thought of questions: Does it make sense to pay for patients' outcomes, when those outcomes may occur regardless of what doctors do? What sort of incentives would be needed to make patients who are not taking good care of themselves change their ways?  Why would connectivity help when health care dyfunction has gotten worse as the world has become more connected?  How to you find patients with highest need, and how would you target such patients?  And above all, how would these cures, assuming one could figure out what they mean, prevent squandering money on the wrong things?

I left the Ignatius piece confused.  Perhaps the NAM publication on which Ignatrius' WaPo article was based would provide enlightenment.

What the National Academy of Medicine Wrought


So my next step was to quickly read the underlying report.  But that did not lessen the confusion.

The report did begin with sort of a definition of health care dysfunction

Health care today is marked by structural inefficiencies, unprecedented costs, and fragmented care delivery.

However it did not go on to providing an organized list of possible causes of these problems, with justifications for these diagnoses.  At best, it sort of alluded to the following as possible causes:

- the "rapidly aging population;"
- "persisting care fragmentation and discontinuity;"
- "costs associated with unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed prevention opportunities, and fraud;" and
- "constrained innovation" due to "outdated regulatory, education and training models," particularly "uncertaintly and unpredictability around approval" of drugs and devices; and payment models that might place "excessive burden on manufacturers to demonstrate the value of their products."

"Rapidly again population" often appears as a postulated caused of health care dysfunction.  On Health Care Renewal we frequently discuss the problem of outright criminality and corruption in health care, including fraud; and the take over of health care by managers, which can result in "excess administrative costs."  However many of the other items were either too vaguely described to assess, or did not appear with clear justification. 


Furthermore, this list also raised some obvious questions.  For example, why are US costs so much higher than those of European countries whose populations are also aging?  Who sets criteria for how "high" prices should be?  What causes prices to be excessively high? Whose uncertainty and what unpredictability affect drug and device approvals?  How is the burden on manufacturers excessive?

Here was more confusion.  More was to follow. 

The bulk of the report is about "Vital Directions Issue Areas," again sort of a list of cures for health care dysfunction     

Vital Directions Issue Areas
Better health and well-being
Systems strategies for better health throughout the life course
Addressing social determinants of health and health disparities
Preparing for better health and health care for an aging population
Chronic disease prevention: tobacco, physical activity, and nutrition for a healthy start
Improving access to effective care for people who have mental health and substance use disorders
Advancing the health of communities and populations
 High-value health care
Benefit design to promote effective, efficient, and affordable care
Payment reform for better value and medical innovation
Competencies and tools to shift payments from volume to value
Tailoring complex care management, coordination, and integration for high-need, high-cost patients
Realizing the full potential of precision medicine in health and health care
Fostering transparency in outcomes, quality, safety, and costs
The democratization of health care
Workforce for 21st century health and health care
 Strong science and technology
Information technology interoperability and use for better care and evidence
Data acquisition, curation, and use for a continuously learning health system
Innovation in development, regulatory review, and use of clinical advances
Targeted research: brain disorders as an example
Training the workforce for 21st century science

However these apparent action items were not clearly associated with the causes of health care dysfunction they were supposed to address.  The discussions of these items raised yet more questions.  For example, the report discussed how to "drive health care payment innovation providing incentives for outcomes and value," presumably related to "payment reform" in the above list.  New payment and delivery models would have the "aim to reduce waste, increase value, and improve outcomes."  What was the evidence that they would be able to do so?  The next item was to "help clinicians develop the core competencies required for new payment models."  Would physicians be willing to accept a new payment system that would not work without subjecting the same busy clinicians to extensive new training? Etc, etc, etc

So in summary, the ful report did not give a clear definiton of the health care dysfunction, did not discuss the causes of the problem, and did not provide solutions keyed to either.  Furthermore, the report does did not provide clear justification for the action items it suggested.

Instead of a clear common-sense set of reforms, the new report just muddied the waters. Listening to the doctors was not helping at all. 


Listening to Not So Much Doctors as Health Care Corporate Executives, Directors and Lobbyists

The reason may be that the National Academy of Medicine report was written more by health care corporate executives, members of health care corporations' boards of directors, and lobbyists for health care corporations than by doctos.  The report's author list appeared thus on the NAM website:

Victor J. Dzau, National Academy of Medicine; Mark McClellan, Duke University; Sheila Burke, Harvard Kennedy School; Molly J. Coye, AVIA; The Honorable Thomas A. Daschle, The Daschle Group; Angela Diaz, Icahn School of Medicine at Mount Sinai; The Honorable William H. Frist, Vanderbilt University; Martha E. Gaines, University of Wisconsin Law School; Margaret A. Hamburg, National Academy of Medicine; Jane E. Henney, National Academy of Medicine; Shiriki Kumanyika, University of Pennsylvania Perelman School of Medicine; The Honorable Michael O. Leavitt, Leavitt Partners; J. Michael McGinnis, National Academy of Medicine; Ruth Parker, Emory University School of Medicine; Lewis G. Sandy, UnitedHealth Group; Leonard D. Schaeffer, University of Southern California; Glenn D. Steele, xG Health Solutions; Pamela Thompson, American Organization of Nurse Executives; Elias Zerhouni, Sanofi


Thus two physician authors were obviously employees of large health care corporations. Both in fact were high ranking executives. Dr Lewis G Sandy, is Senior Vice President, Advancement, for UnitedHealth Group; and Dr Elias Zerhouni, is President, Global Research and Development, for Sanofi.  Also, The Honorable Michael O Leavitt was the founder of Leavitt Partners, a business consulting group, whose clients include companies in the "pharmaceuticals and biopharmaceuticals, medtech and medical devices, health IT, diagnostics" and "commercial [health care insurance] plans," according to its website.

The author information provided at the end of this version of the article also stated that "the Honorable Thomas A Daschle is Founder and CEO of The Daschle Group, a Public Policy Advisory of Baker Donelson.'  Note that Baker Donelson is a Washington, DC lobbying firm.  Furthermore the author information included the fact that The Honorable Willaim Frist is "chairman of the Executive Board of the health service private equity firm Cressey & Company." Finally, Leonard D Schaeffer was identified as "the founding Chairman & CEO of Wellpoint."

While most of the other authors were listed as affiliated with academic organizations, some searching reveals that most of them had major financial relationships with for-profit health care corporations, including some of the largest.  Many, in fact, had come to the attention of Health Care Renewal in the past because of their important conflicts of interest. 

When Dr Victor Dzau was proclaimed the new president of the then Institute of Medicine, there was little initial discussion of his major conflicts of interest.  At the time of the announcement, he was on the boards of directors of Alnylam Pharmaceuticals, device maker Medtronic, and sugary drink maker Pepsico (see our 2014 blog post).  At the time of the announcement, he owned millions of dollars of shares or share equivalents of the three companies.  In 2010, Duke University students had protested his multi-million dollar salary as Chancellor for Health Affairs (see our blog post).

We discussed in a 2013 blog post how Dr Mark McClellan transited the revolving door from his position as head of the Center for Medicare and Medicaid Services (CMS) in the Bush administration to positions as special advisor to private equity firm General Atlantic LLC, strategic advisory committee member for private equity firm Capital Royalty LP, on the advisory board for Castlight Health, and on the boards of directors of AvivReit and Johnson and Johnson.  In 2016 we discussed how Dr McClellan pretended to be an independent scholar for the Brooking Institution while he was still on the board of Johnson and Johnson.

Sheila Burke is a strategic advisor to Baker Donelson, the Washington, DC lobbying firm for which Mr Daschle also works. 

Dr Molly J Coye is currently on the boards of directors of health insurance company Aetna, and chairwoman of the board of Prosetta Biosciences Inc.

Former US Senator Thomas A Daschle's firm is actually a lobbying firm, and was officially registered as a lobbyist for Aetna in 2016 (per Politico).  His firm is now part of Baker Donelson, a larger Washington, DC lobbying firm (as noted above).

Former US Senate Majority Leader Dr William H Frist was a founder of the Hospital Corporation of America (HCA) and likely holds millions of shares of related stock (per Wikipedia), and currently serves on the boards of directors of Teledoc, and "publicly held companies Select Medical and AECOM. In addition, he serves as a board member for several of Cressey & Company’s privately-held portfolio companies." He had been on the board of the controversial diagnostic testing company Theranos (per this news release).

After Dr Margaret Hamburg was confirmed commissioner of the US Food and Drug Administration (FDA) in 2009 in the Obama administration, we discussed how she had to divest herself of shares of medical supply company Henry Schein Inc, on whose board of directors she formerly sat, and how she and her husband, a top hedge fund manager, had to divest themselves of various other holdings that entailed conflicts of interest.

We first discussed Dr Jane E Henney's multiple conflicts of interest in 2006.  Currently, she is on the board of directors of global pharmaceutical distributor AmeriSourceBergen and giant health insurance company Cigna. Recently, she had been on the boards of pharmaceutical companies AstraZeneca (through 2011), and Cubist (through 2014).

In 2011, we discussed how Michael D Leavitt, former US Secretary of Health and Human Services  under the Bush administration, transited the revolving door to a position on the board of directors of Medtronic.

Leonard D Schaeffer serves on the boards of Walgreens Boots Alliance, Quintiles Transnational Holdings, Inc. and scPharmaceuticals Inc

Dr Glenn D. Steele is on the boards of directors for medical app developer Ingenious Med; Director, PTC Therapeutics; Director, Stratus Video; biotechnology company Synaptive Medical; and again large for-profit health insurance company Wellcare Health Plans Inc (look here).

By the way, in 2010, we discussed how Dr Elias Zerhouni, former Director of the National Institutes of Health (NIH) in the Bush administration, transited the revolving door to positions on the board of directors of biotechnology company Actelion and of Danaher, which makes, among other things, medical devices, and then to a full-time position with global pharmaceutical company Sanofi.  In 2005 we discussed how Dr Zerhouni, as NIH director, lead a not very vigorous response to a series of scandals involving conflicts of interest at that august institution, after relevant government rules had been relaxed in the Clinton administration (see also this post and links backward).

Just to add to the confusion, while none of these relationships were noted in the version of the report on the NAM website, a few were listed in an online published version in JAMA.(7)  The JAMA version omitted those of Dr Dzau; all of the relationships of Dr McClellan, save an admission that he "received personal fees from Johnson & Johnson"; Ms Burke's position with Baker Donelson; Dr Coye's position on the board of Aetna; Mr Daschle's position as lobbyist for Aetna; Dr Frist's positions on the boards of Select Medical and AECOM, and former position on the board of Theranos, although the JAMA version added a position on the board of Aspire Health; Mr Leavitt's board membership; Mr Schaeffer's membership on the boards of Quintiles and scPharmaceuticals; and all of Dr Steele's board memberships.

By my count, a majority, 13 of 19 authors had major financial ties to large for-profit health care corporations.  The authors included three who worked for Washington, DC lobbying and consulting firms with major health care industry clients, including one who explicitly lobbied for for Aetna.  The authors included  top executives of UnitedHealth and Sanofi.  The authors included current or recent members of the boards of directors of Alnylam Pharmaceuticals, Medtronic(2), Castlight Health, AvivReit, Johnson and Johnson, Aetna, Prosetta Biosciences, Teledoc, Select Medical, AECOM, Theranos, Aspire Health,  AmeriSourceBergen, Cigna, AstraZeneca, Cubist, Walgreens Boots Alliance, Quintiles Transnational Holdings, scPharmaceuticals Inc, Ingenious Med, PTC Therapeutics, Synaptive Medical, and Wellcare.

The Washington Post article would better have been sub-titled, "Listen to Health Care Corporate Eexecutives, Directors, and Lobbyists." 

Summary

A recent report by the prestigious National Academy of Medicine, now published electronically in JAMA,  and an accompanying newspaper article promised common sense ideas for health care reform suggested by physicians.  On its website, the Academy did not disclose most of the multitudinous and serious conflicts of interest of its authors.  A version electronically published by JAMA disclosed a few more, but was still very incomplete.  Relationships that were not disclosed included positions on the boards of directors of for-profit health care corporations, from start-ups to some of the biggest such corporations in the US.  In my humble opinion, such incomplete and inconsistent disclosures was dishonest and deceptive.

The prevalence of health care corporate board members as authors of this report is particularly concerning.  In 2006, we first blogged about a "new species of conflict of interest" which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care.  We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]  So it should be no surprise that the NAM report did not really suggest any radical ideas for health care reform, despite Mr Ignatius' title.  Most of its authors were in a position to benefit from the status quo in health care.

Furthermore, it is no wonder the NAM report was confusing and muddled.  As Joe Collier  observed, "people who have conflicts of interest often find giving clear advice (or opinions) particularly difficult."(8)

In my humble opinion, the NAM report represents the sort of obfuscation that has been befogging discussion of health care policy for a long time.  Wendell Potter described how years of debate on health care policy that started during the Clinton administration was defined by concepts developed by for-profit insurance company public relations departments to steer debate away from ideas would threaten their profits.  In his book Deadly Spin, (p 64) he described a the AHIP (America's Health Insurance Plans, an insurance industry lobbying group) Strategic Communications Committee discourse on

the approach the industry would be taking when the reform debate heated up.  The goal would be to divert the public's and the media's attention from the uninsured and toward problems the insurers coudl insist were beyond their control.  The industry's spin, in other words, was going to be something like this: Health care costs are out of control because new treatments and technologies are more expensive than ever, the population's getting older and sicker, too many people are seeking care they don't really need, and health care professionals and providers are all too willing to provide the care that people don't need.

These putative causes of health care dysfunction, derived from an insurance industry organized public relations effort, have become the accepted wisdom.  Note that there were vestiges of them ("rapidly aging population") among the somewhat disorganized presentation of causes of health care dysfunction in the NAM report.  That there were not more of them may reflect the fact that the NAM report was not written just by people tied to the insurance industry.  It also included many people tied to biotechnology, drug, device, etc companies.  


Now during an era in which "fake news," propaganda and disinformation are in the headlines, we still see the terms of debate seemingly engineered by powerful health care organizations.

Physicians, other health care professionals, journalists, policy makers and the public at large should be extremely skeptical of apparently authoritative pronouncements on health care reform, especially when it is not clear what financial interests the authors of the pronouncements have, or when it is clear that the authors have important financial ties to large health care organizations, particularly large for-profit health care corporations.

At a minimum, media and certainly scholarly articles on health care reform and related policy issues should have at least as rigorous disclosure of conflicts of interests as clinical research articles.  

Real health care reform would start with honest debate in which the contestants at least make clear their underlying financial interests. 


References

1. Poses MD. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130. Link here.
2. Massachusetts Medical Society. Physician satisfaction survey (2001). Link here.
3.Pololi L, Kern DE, Carr P, et al. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med 2009; 24: 1289-95. Link here.
4. Poses RM, Smith WR. Faculty values. J Gen Intern Med 2010; 25: 646. Link here.
5. Pololi L, Ash A, Krupat E. Faculty values in the culture of academic medicine: findings of a national faculty survey. Link here.
6. Poses RM, Baier-Manwell L, Mundt M, Linzer M. Perceived leadership integrity and physicians’ stress, burnout, and intention to leave practice. J Gen Intern Med 2005; 20: S182. Link here.
7. Dzau DJ et al.  Vital directions for health and health care: priorities from a National Academy of Medicine initiative.  JAMA 2017; doi:10.1001/jama.2017.1964.  Link here.
8.  Collier J. The price of independence. Br Med J 2006; 332: 1447-9.  Link here

Sunday, April 02, 2017

Part of the Solution, or Part of the Problem? - Health Care Corporate CEOs on Physician Burnout

Physician burnout is in the news again.  Late in 2015, an article by Shaneyfelt and colleagues in the Mayo Clinic Proceedings showed an increase in the proportion of physicians reporting at least one symptom of burnout to 54.4% in 2014(1), up from the 45.5% they reported in 2012(2).  A March 28, 2017, post in the Health Affairs blog based on the latest article warning about burnout and suggesting how to address it got considerable attention.

Background - Physician Burnout

However, physician burnout is hardly new.  As we wrote in 2012 about the predecessor the 2012 Shaneyfelt article, this is just the latest in a long series of studies showing physicians' growing angst, dissatisfaction, burnout, or whatever one calls it. In 1987, in an AMA survey of physicians over 40, 44% replied that were they given chances to do it all over again, they would not go into medicine.(3)  In a 2001 survey of Massachusetts physicians, 62.3% were dissatisfied with the practice environment.(4)  In 2002, a national survey by the Kaiser Family Foundation showed that 45% of physicians would not recommend that a young person should go into medicine.(5)   In a survey of primary care physicians in 2007, 38.7% were somewhat or very dissatisfied.(6)  I have a 6 inch thick set of paper files containing articles on the subject, although it is remarkable how many research studies reported only average scores on instruments, and hence did not report proportions of physicians who were burned out or dissatisfied. Yet the 2017 Health Affairs post garnered headlines  declaring physician burnout to now be a crisis.

Whether the current attention to burnout will lead to any real improvements is doubtful.  In particular, I am concerned that the Health Affairs blog post that sparked all the attention was at best misdirected. It avoided discussing more than a few of the most immediate, proximate causes of burnout.  It seemed more motivated more by concerns about money than about patients and the physicians that try to serve them.  It read like a top down diktat uninfomed by the concerns of physicians or patients, maybe because all of its authors were CEOs of large health care organizations, all but one large hospital systems.

I will venture to go through the issues point by point in the hope of sparking a discussion more focused on the physicians subject to or at risk of burnout, and ultimately the effects of their burnout on their patients.


For the Love of Money


While the blog post began with a nod towards improving the quality of, lowering the cost of, and improving access to health care, there was a subtext.  Consider some quotes, first, stating that one cause of burnout is,
profound inefficiencies in the practice environment

Also,

The experience from Atrius Health suggests that replacing a physician who retires early or leaves to pursue other career opportunities can cost between $500,000 and $1 million due to recruitment, training, and lost revenue during this time.

Also,

Professional satisfaction for physicians is primarily driven by the ability to provide high-quality care to patients in an efficient manner.

Also,

As leaders, we must recognize burnout in physicians and other health care workers as a serious problem and respond vigorously. This is especially true if we want to maximize the effectiveness, productivity, and longevity of clinicians.

Also,

More than words are needed. Leaders of health care delivery organizations must embrace physician well-being as a critical factor in the long-term clinical and financial success of our organizations. We must make both the prevention of burnout and the restoration of the joy of a career in medicine core priorities, and address this issue with the same urgent methods we would use to solve any other important business problem: commit to measurement, develop strategy and tactics, and allocate the resources necessary to achieve success.

To interpret these passages, note that the authors of the blog post were John Noseworthy, James Madara, Delos Cosgrove, Mitchell Edgeworth, Ed Ellison, Sarah Krevans, Paul Rothman, Kevin Sowers, Steven Strongwater, David Torchiana, and Dean Harrison (links are those supplied by the post.)  All but Dr Madara are CEOs of large, nominally non-profit corporate hospital systems.  Dr Madara is the CEO of the American Medical Association (AMA). 

I would suggest that to a business CEO, efficiency refers to a state in which goods and services are produced with a minimum of costs.  Furthermore, many business managers follow the business dogma first called the shareholder value theory, which seems mainly to be interpreted to mean managers should maximize short-term revenue as their first priority (look here).  This is part of the larger financialization of all spheres of life, including hospital systems.

The focus on relentless revenue maximization may be reinforced by large incentives for top managers, particularly CEOs, based on revenue and other financial, not clinical outcomes.  Such perverse incentives have resulted in huge increases in executive compensation for hospital CEOs.  For example, as we recently discussed,  author Dr John Noseworthy, CEO of the Mayo Clinic, received more than $2.3 million in total compensation in 2013, and was just reported to have received more than $2.5 million in 2015. Author Dr Delos (Toby) Cosgrove, CEO of the Cleveland Clinic, received more than $4.8 million in 2015 (look here). 

Thus, too a hospital CEO, efficiency might mean the ability to provide services as cheaply as possible, and such efficiency is likely to be a top priority.  The quotes above suggest that hospital CEOs mainly want to combat burnout to increase efficiency.  One quote above refers directly to the monetary costs, again presumably to the hospital, of losing physicians to burnout. One quote refers to burnout as hampering physician productivity, which to a hospital CEO might mean the ability to produce maximum billing, that is revenue, in the minimum amount of time.  Finally, one quote suggests that to the authors, burnout is a business problem, not a human problem, or a clinical problem.

Even stranger, two quotes suggest that the CEO authors believe  inefficiency might cause burnout. That would appear very strange to employed physicians who may be increasingly pressured by top management to be more efficient, and thus to increase revenue.  I would guess that many employed physicians would attribute their burnout to this relentless push for productivity and efficiency by top management. 


So reading not between the lines, but the lines themselves suggests that the CEO authors might be more interested in reducing burnout to increase hospital revenues, and thus their total compensation, rather  than to make physicians happier or more fulfilled, much to less improve patient care.  Such a focus on revenue might not be reassuring to burned out physicians, especially those who feel forced to shortchange time spent with individual patients to fuel revenue.  The repetitive discussion of efficiency and productivity in the Health Affairs blog post should worry any physician who feels his or her first responsbility is to take the best care of each individual patient. 


Hear No Evil,...

Proximal Versus Organizational, Leadership and Governance Causes of Burnout

Here is what the blog post said about the causes of burnout:

The spike in reported burnout is directly attributable to loss of control over work, increased performance measurement (quality, cost, patient experience), the increasing complexity of medical care, the implementation of electronic health records (EHRs), and profound inefficiencies in the practice environment, all of which have altered work flows and patient interactions.
We dealt with the curious citation of inefficiencies as a cause of burnout above.
 
The rest of the items seem more plausible.  However absent from the post is consideration of why physicians lost control over work, have been subject to performance measurement (often without good evidence that it improves performance, and particularly patients' outcomes), and have been forced to use often badly designed, poorly implemented EHRs.  Particularly absent was any consideration of whether the nature or actions of large organizations, such as those led by the authors of the blog post, could have had anything to do with physician burnout.

Contrast this discusion with how we on Health Care Renewal have discussed burnout in the past. In 2012, we noted the first report on burnout by Shanefelt et al(2).  At that time we observed that the already voluminous literature on burnout often did not attend to the external forces and influences on physicians that are likely to be producing burnout. Instead, burnout etc has been addressed as if it were lack of resilience, or even some sort of psychiatric disease of physicians. 

In fact, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes.  Our first crude qualitative research(8) suggested  hypotheses that physicians' angst was due to perceived threats to their core values, and that these threats arose from the issues this blog discusses: concentration and abuse of power, leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting this viewpoint.

We found some corroboration of these hypotheses from other research.  Written comments from the 2001 Massachusetts survey made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line.  Taken over by large corporations.  Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(4)  Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(9)  (Also, see our comments on this paper.)(10)  Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(11)   We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(12)

Yet at best most studies of physicians' burnout, angst, or dissatisfaction only vaguely allude to "system factors" and not greedy, money-focused, preversely incentivized, self-interested, or corrupt leadership, etc as its causes. "System factors" such as bad EHRs and performance measures suggested by the Health Affairs bloggers were more likely to have been imposed on physicians by bad organizational leadership than by the physicians themselves.  Of course, the CEO authors of the post likely would be made very uncomfortable with the notion that  bad health care leadership, including of hospital systems like their own, might be a major cause of burnout.

Furthermore, there clearly have been leadership problems at many of the blog post authors' institutions that could have made them more uncomfortable.  Cases involving some of the authors' institutions have appeared on Health Care Renewal.

Most recently we noted that Mayo Clinic CEO Dr Noseworthy had raised questions of mission-hostile management by suggesting that the Mayo Clinic should give some patients with commercial health care insurance priority over those with less well paying government health insurance (look here).   Not long ago we noted the controversy generated by Cleveland Clinic CEO Dr Cosgrove's lukewarm approach to the Trump administration's "Muslim ban," even though that ban had affected one of the Clinic's own house-staff, while the Clinic was planning a fund raising event at Mr Trump's Mar a Lago resort, raising yet more conflict of interest questions (look here).

We have also disccused issues occurring at the American Medical Assocation, and particularly its RBRVS Update Committee (RUC) (CEO Dr Madara), Sutter Health (CEO Ms Krevans), Johns Hopkins (CEO Dr Rothman),  Duke (CEO Mr Sowers), Partners (CEO Dr Torchiana), and Northwestern (CEO Mr Harrison).

Finally, several of the Health Affairs authors have "board level" conflicts of interest.  In 2006, we first blogged about a "new species of conflict of interest" which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care.  We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]

Two Health Affairs blog authors have such conflicts.  Dr Paul Rothman is on the boards of Merck and of Cancer Genetics, a biotechnology company specializing in DNA based testing. Dean M Harrison is on the board of Northern Trust, a wealth management firm. He was on the board of Ikaria Inc, a biotechnology company now part of Mallinckrodt, and incidentally is a special advisor to Merrick Ventures, a private equity firm (look here).

Thus, how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?


Corporate Employment as a Cause of Burnout

Finally, the Health Affairs post mention of "loss of control over work" deserves special attention.  It could represent a catch-all of more "system factors" as noted above.  However, the biggest cause of physicians' loss of control over work may be the rising power of large health care organizations, in particular the large hospital systems that now increasingly employ physicians, turning them into corporate physicians.

In the US, home of the most commercialized health care system among developed countries, physicians increasingly practice as employees of large organizations, usually hospitals and hospital systems, sometimes for-profit corporations.  The leaders of such systems meanwhile are now often generic managers, people trained as managers without specific training or experience in medicine or health care, and "managerialists" who apply generic management theory and dogma to medicine and health care just as it might be applied to building widgets or selling soap.

We have also frequently posted about what we have called generic management, the manager's coup d'etat, and mission-hostile management.  Managerialism wraps these concepts up into a single package.  The idea is that all organizations, including health care organizations, ought to be run people with generic management training and background, not necessarily by people with specific backgrounds or training in the organizations' areas of operation.  Thus, for example, hospitals ought to be run by MBAs, not doctors, nurses, or public health experts.  Furthermore, all organizations ought to be run according to the same basic principles of business management.  These principles in turn ought to be based on current neoliberal dogma, with the prime directive that short-term revenue is the primary goal.

Again, the authors of the Health Affaris post included some generic managers:  Mr Edgeworth, whose highest degree was an MBA, and who had a long career as a hospital manager; Ms Krevans, and MBA with an MPH, who also had a long career as a hospital manager; and Mr Harrison, an MBA, who also had a career in hospital management.  Doubtless all of the authors lead organizations whose upper management is frequently generic and managerialist.  It is likely that the hospital systems they lead increasingly employ physicians, who thus have become corporate.  So the Health Affairs blog authors might not be comfortable with the notion that a major cause of burnout may  physicians' new status as hired employees sometimes of their own hospital systems, rather than autonomous practitioners.

To repeat,  how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?


Summary

I am glad that physician burnout is getting less anechoic.  However, in my humble opinion, the last thing physicians at risk of or suffering burnout need is a top down diktat from CEOs of large health care organizations.  The CEOs who wrote the Health Affairs post may not have any personal responsibility for any particular physician's burnout.  However, the transformation of medical practice by the influence of large health care organizations run by the authors' fellow CEOs, particularly huge hospital systems, often resulting in physicians practicing as hired employees of such corporations likely is a major cause of burnout.  If the leaders of such large organizations really want to reduce burnout, they should first listen to their own physicians.  But this might lead them to realize that reducing burnout might require them to divest themselves of considerable authority, power, and hence remuneration.  True health care reform in this sphere will require the breakup of concentrations of power, and the transformation of leadership to make it well-informed, supportive of and willing to be accountable for the health care mission, honest and unconflicted.

Physicians need to join up with other health care professionals and concerned member  of the public to push for such reform, which may seem radical in our current era.  Such reform may be made more difficult because it clearly would threaten the financial status of some people who have gotten very rich from the status quo, and can use their wealth and power to resist reform.

Despite the fact that the current US president has stated he is for the "forgotten people" rather than the elites, do not expect such reform from him.  He has sought advice on health care policy from the same people who wrote the Health Affairs post, as per the Washington Post, December 28, 2016:

On Wednesday, his guests were health-care executives, many of whom represent companies or institutions that have a big stake in the outcome of Trump’s ambitions to dismantle the Affordable Care Act. According to a pool report, the group, all men, met with him at 11 a.m. at the Mar-a-Lago estate in Palm Beach, Fla. They included John Noseworthy of the Mayo Clinic, Paul Rothman of Johns Hopkins Medicine, David Torchiana of Partners HealthCare and Toby Cosgrove of the Cleveland Clinic.

We truly live in interesting times. 


References

1.  Shanafelt TD et al.   Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc 2015; 90: 1600-1613. Link here.
2.  Shanafelt TD, Boone S, Tan et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.  Arch Intern Med 2012; available online here
3.    cited in Schroeder SA. The troubled profession: is medicine's glass half full or half empty? Ann Intern Med 1992; 116:583-592.
4. Massachusetts Medical Society. Physician satisfaction survey (2001). Link here.
6.  Kaiser Family Foundation. National survey of physicians - part III: doctors' opinions about their profession.  Link here.
7.  Merritt Hawkins & Associates. 2007 survey of primary care physicians.  Link here.
8. Poses MD. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130. Link here.
9.Pololi L, Kern DE, Carr P, et al. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med 2009; 24: 1289-95. Link here.
10. Poses RM, Smith WR. Faculty values. J Gen Intern Med 2010; 25: 646. Link here.
11. Pololi L, Ash A, Krupat E. Faculty values in the culture of academic medicine: findings of a national faculty survey. Link here.
12. Poses RM, Baier-Manwell L, Mundt M, Linzer M. Perceived leadership integrity and physicians’ stress, burnout, and intention to leave practice. J Gen Intern Med 2005; 20: S182. Link here.

Musical Diversion

"For the Love of Money" by the O'Jays, used as the opening theme for (now President) Donald Trump's Celebrity Apprentice