Saturday, October 19, 2019

Government Increasingly Promoting Sectarianism-Based Health Policy

Traditionally, physicians and other health care professionals are taught to put the care of the individual patient first.  Patients deserve care according to their own values as best they can be realized.  Physicians whenever possible should avoid substituting their own values for those of the patient.  In particular, they should avoid imposing their own religious beliefs on those of patients.

In the US, we live under a Constitution whose First Amendment states "Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof."

Thus it is concerning that under the Trump administration we have seen efforts apparently meant to orient government agencies involved with health care and public health to a particular set of religious beliefs.  We summarized here instances in which appointments to government agencies seemed to be based on appointees' religious view, and/or in which appointees seemed to be promoting health policies based on their personal religious beliefs.  These included instances of appointees arguing against the adoption of children, and making assertions that "intersex patients do not exist, that contraception causes cancer and violent death, that pornography is a major public health hazard."

This year, we have seen more evidence that the administration has been appointing people to health care or public health related leadership positions based on their religious views, and promoting sectarianism-based health care and public health.

More Appointments Apparently Based on Religious Views Rather than Health Care or Public Health Expertise

In May, Reuters published an article entitled "the foot soldiers in the Trump-Pence religious health movement."  Its introduction stated

With Donald Trump’s election in 2016, Vice President Mike Pence emerged as a force in reshaping American health policy. Aligning the policy with Pence’s evangelical Christian principles, the administration stocked the Department of Health and Human Services and other federal agencies with a cadre of pro-life staff members.

The implication is that the appointments were made according to the appointees' religious beliefs, rather than their knowledge of or experience in relevant health care or public health spheres.

It included capsule biographies of several people heretofore unknown to me.

ANDREW BREMBERG

Position: Former head of Domestic Policy Council; now nominated as ambassador to the United Nations mission in Geneva.

Background: Bremberg, a health policy expert, served as co-chair of the HHS transition team that stocked the agency with religious conservatives before serving as chief of the White House policy operation. He drafted the expanded Mexico City policy that imposes anti-abortion rules on billions in U.S. health aid.

MAGGIE WYNNE

Position: HHS, Counselor for Human Services Policy

Background: A former HHS official under the Obama administration and director of the U.S. House Pro-Life Caucus, Wynne worked for the Knights of Columbus, a Catholic service organization, before rejoining HHS. She served on the transition team, helped bring in other anti-abortion activists and participated in attempts to prevent pregnant immigrant girls from obtaining abortions.

STEVEN VALENTINE

Position: Chief of Staff, Office of the Assistant Secretary for Health

Background: A former interim legislative director at Susan B. Anthony List, an anti-abortion group, Valentine helps supervise the Title X grant program. With other anti-abortion advocates in the office, he tried to end the Teen Pregnancy Prevention Program, [more about contraception than abortion] a move blocked by the courts.

VALERIE HUBER

Position: Senior policy advisor, HHS Office of Global Affairs

Background: The former president of a Washington group that championed 'sexual risk avoidance,' or abstinence as an alternative for birth control, Huber wrote a paper that said Christians should promote 'God’s sexual guidelines to life' in sex education and public health policy. Huber worked on the attempt to kill the Teen Pregnancy Program, and now works on international health policy.

MARCH BELL

Position: Chief of Staff, Office for Civil Rights

Background: An abortion opponent and former Justice Department attorney, Bell was staff director for a House panel that investigated Planned Parenthood [which provides contraception services, cancer screening, and other health services in addition to providing abortions] for selling baby parts, an inquiry that grew out of a controversial video sting operation.

MATTHEW BOWMAN

Position: Deputy general counsel, HHS

Background: As senior counsel at the Alliance Defending Freedom, an organization that defends religious conservatives, Bowman was part of a 'life litigation project,' working on cases against the contraception mandate in Obamacare. He himself has been arrested for demonstrating outside abortion clinics.

Note that these appointees advocacy of religious beliefs about health care were not limited to their views on the highly controversial topic of abortion, but also were directed against, for example, provision of contraception and other family planning services.

SCOTT LLOYD

Position: Former head of the Office of Refugee Resettlement, now senior advisor at the Center of Faith and Opportunity Initiatives

Background: When Lloyd ran the office responsible for caring for young migrants, he tried to block some of the underage women from having abortions, sparking court battles. A lawyer, Lloyd helped found a firm that worked on cases based on Catholic doctrine on birth control and abortion. 'The law is pagan territory,' he has written. 'Look no further than no fault divorce, legalized abortion on demand, and gay marriage as confirmation.'

I can find no information suggesting that any of the people above has direct experience or training in biomedical science, medicine, other health professions, or public health.  Note that in previous posts we had mentioned several of the people appearing in this article: Katy Taalento, Diane Foley, and Roger Severino. Others we had noted as apparently unqualified members of the Trump "beach head teams," but without knowledge of their sectarian focus.

More Administration Action Promoting Sectarianism-Based Health Policies

Several relevant articles have appeared this year.  In March, the Washington Post reported on efforts to promote policies oriented specifically to evangelical Christian and Catholic beliefs.   In summary,

In the first year of the Trump administration, Christian social conservatives placed in high-level jobs — [Valerie] Huber [see above] among them — focused mostly on U.S. policy. They were highly successful, pushing through a religious exemption to the Affordable Care Act’s birth-control mandate, prioritizing abstinence-only sex education and imposing what critics call 'gag rules' on family planning groups receiving $286 million in the United States and up to $7.4 billion around the world that prohibit them from referring for abortions.

Now, they are seeking to spread those views to the rest of the world by building a coalition of nations that would wield clout beyond the Trump administration.

In May, another Reuters article noted

the quiet, behind-the-scenes influence of Vice President Mike Pence, who has been driven throughout his political career by his evangelical Christian beliefs to restrict abortion and prioritize the rights of religious conservatives.

So,

Under the direction of two secretaries recommended by Pence, the Department of Health and Human Services has moved to slash funds from teen pregnancy-prevention programs, curb abortion both in the United States and abroad and strip civil protections for transgender patients.

The administration has emphasized abstinence programs, led by appointees who believe contraception harms women, and pushed to cut government funds for Planned Parenthood – a longtime cause for Pence while he was in Congress. Planned Parenthood, a national network of healthcare providers, offers infertility services, contraception and abortions.

Again, the focus goes way beyond the controversial abortion issue:

In Kenya, services are already being reduced, said Jedidah Maina, director of the Trust for Indigenous Culture and Health, which offers programs on sexual and reproductive health and operates a health services hotline. One partner organization no longer provides free healthcare for the impoverished, and another was forced to reduce HIV services, she said.

In Peru, the reproductive-rights advocacy group PromSex said it was unable to apply for a grant to combat human trafficking from the U.S. Agency for International Development because it fights for access to abortion. In a November 2017 email obtained by Reuters, a USAID contracting officer said if the group 'were carrying out activities or planning to carry out any activity related to family planning methods, it could not commit itself with the Government of the United States.'

Also,

Christine Dehlendorf, director of the Person-Centered Reproductive Health Program at the University of California, San Francisco, said HHS cancelled two grants for ongoing research into contraception. One was restored through litigation.

Dehlendorf said she lost about $800,000 in funding for a study of how well medical providers meet women’s contraception preferences, which included natural family planning methods favored by some conservatives. There was 'no reason to eliminate it other than a lack of a general desire to meet women’s reproductive health needs,' Dehlendorf said.

Top Administration Leaders Advocating Government Establishment of Religion

Recently, two top Cabinet Secretaries gave speeches in their official capacities advocating government oriented to particular religious beliefs, conservative Christian principles.  One was Attorney General William Barr, as reported by Mother Jones on October 12, 2019, decried the influence of people who do not believe in organized religion

'This is not decay,' Barr said. 'This is organized destruction. Secularists and their allies have marshaled all the forces of mass communication, popular culture, the entertainment industry, and academia in an unremitting assault on religion & traditional values.'

Then,

In his address Friday, Barr thundered against what he described as a 'moral upheaval.' 'Virtually every measure of social pathology continues to gain ground,' he said. 'Along with the wreckage of the family we are seeing record levels of depression and mental illness, dispirited young people, soaring suicide rates, increasing numbers of alienated young males, an increase in senseless violence and the deadly drug epidemic.'

So he seemed to imply that the cure for depression, mental illness, and drug abuse is ... conservative Christian religion.  Again, here is sectarianism-, not evidence-based health policy.  Note that the article also stated,

Barr’s depiction of a war between the non-religious and people of faith shocked legal experts, who saw Barr’s defense of religious freedom as an assault on the First Amendment’s protection against the government’s establishment of any religion.

In an editorial in the NY Times, Paul Krugman wrote in reference to Barr's speech

how inappropriate it is for Barr, of all people, to have given such a speech. The Constitution guarantees freedom of religion; the nation’s chief law enforcement officer has no business denouncing those who exercise that freedom by choosing not to endorse any religion.

Furthermore,

And he didn’t just declare that secularism is bad; he declared that the damage it does is intentional: 'This is not decay. It is organized destruction.' If that kind of talk doesn’t scare you, it should; it’s the language of witch hunts and pogroms.

Meanwhile, Secretary of State Mike Pompeo was even more explicit about how he deliberately establishes his religion in his government work, as reported by the Times of Israel also on October 12,

In his official capacity as America’s top diplomat, US Secretary of State Mike Pompeo delivered a speech on Friday on 'what it means to be a Christian leader' during a State Department event, prompting criticism that he crossed the line denoting the separation of church and state.

Addressing the American Association of Christian Counselors in Nashville, Tennessee, Pompeo emphasized what he deemed the main components of Christian leadership.

'I want to use my time today to think about what it means to be a Christian leader, a Christian leader in three areas,' he said. 'First is disposition. How is it that one carries oneself in the world? The second is dialogue, talking. How is it that we engage with others around the world? And third is decisions, decisions that we make.'

By the way, just to underline that this was an official speech, not just Pompeo speaking personally about his religious beliefs, the transcript of the speech is now on the official US State Department website here.

The Times of Israel quoted

Aaron Keyak, the former head of the National Jewish Democratic Council, questioned the propriety of Pompeo’s using his platform to promote a particular religion.

'There’s obviously no issue with the secretary of state being a leader, nor his being a proud Christian,' Keyak told The Times of Israel. 'But it’s a problem that Secretary Pompeo thinks it’s appropriate to put those two words together and hold an official State Department event on being a Christian leader.'

'He’s an American leader, who is also a practicing Christian,' Keyak went on. 'Him talking as a Christian leader and billing it as such is an affront to our separation of church and state.'

Summary

As we said before, basing health care and public health decisions on political ideology or religious belief seems worse than just basing them on money, which had become prevalent in the dysfunctional US health care system. In some cases, the resulting mission-hostility seems to translate into violations of the US constitution.  For example, making health care decisions based on a particular religion's beliefs could be harmful for patients or citizens who do not share these beliefs, plus violate the Constitution's guarantee of freedom of a government establishment of religion.

For years, I thought that health care dysfunction was primarily about individuals and private organizations, including but not limited to pharmaceutical, biotechnology and device companies; hospitals and hospital systems; insurance companies, academic medical institutions; physicians and their practices; etc, etc, etc.  Consequently, I thought these individuals and organizations needed better awareness of health care dysfunction to provoke them to improve matters.  I thought of the government as being involved, but mainly because of well-intentioned, sometimes bumbling government actions and policies that often had unintended effects, and sometimes excess coziness with the health care industry.  While I knew that the government was subject to regulatory capture and various leadership problems, its role in health care dysfunction, at least in the US, seemed almost secondary.

But in the Trump era, there is a new (ab)normal.  All the trends we have seen since our last discussion of health care reform are towards tremendous government dysfunction, some of it overtly malignant, especially in terms of corruption of government leadership of unprecedented scope and at the highest levels, and overt influence of government-favored political ideology and religious beliefs on health care policy and other policies and actions.

I hope that our update above will add to the urgency pointing health care and public health professionals, patients, and all citizens towards a much more vigorous response.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways.  We do not have much time to act.

If not now, when?

If not us, who? 

Friday, October 11, 2019

The Rise of the Suits - First Hints of Managerialism in Health Care

Tom Mueller just published a monumental work on whistleblowing, Crisis of Conscience - Whistleblowing the an Age of Fraud



The introductory chapter starts with the TMAP/ Risperdal/ Johnson and Johnson case.  We first posted on this case in 2006 here.  Briefly, as revealed by whistleblower Allen Jones, Johnson and Johnson subsidiary Janssen was accused of conducting a campaign of deception, which we labeled a systematic stealth marketing campaign, to push use of the  anti-psychotic drug Risperdal (risperidone).

Crisis of Conscience includes a substantial amount of material on whistleblowing in health care, drawn from interview with many in the field, including Steven Aftergood, Elliot Aronson, Elin Baklid-Kunz, Alison Bass, Max Bazerman, Sara Miron Bloom, Donna Boehm, Lori Brown, Diane Burton, Richard Condit, Daniel Fessler, Skip Freedman, Adrian Furnham, Susan Gouinlock, Mark Greenberg, Eric Havian, Jim Helmer, Marianne Jennings, Erika Kelton, Don Kettl, Brian Knutson, Steve Kohn, Sheldon Krimsky, Jeanne Lenzer, Harry Lewis, Harry Litman, Iain McGilchrist, Cheryl Eckard Mead, Tom Melsheimer, Russell Mokhiber, Mickey Nardo, Cliff Palefsky, Robert Prentice, Jim Ratley, Lesley Ann Skillen, Lynn Stout, Skyler Swisher, Paul Thacker, Janine Wedel, Marlan Wilbanks, Scott Withrow and Lin Wood.  It also includes material supplied by yours truly.

I am taking this opportunity to provide brief excerpts showing the very earliest beginning of my realizations that health care professionals were losing control of medicine, and health care.

The Early Days of Managerialism

1978, during my internship, from the haze of sleep deprivation, remembered with emotion

In October 1978, Dr. Roy Poses, an intern at the University Hospital in Boston’s South End, the teaching hospital of Boston University, had just completed the first twenty-five hours of another brutal, sleepless shift. 'People were horrendously overworked,' Poses remembers. 'You walked in at seven a.m. and worked to seven p.m. the next day, with about two hours of sleep— no night floats, no day floats, no hours restrictions.' Waiting for an elevator, eyes glazed and head bowed with fatigue, he wondered how he’d get through the day. When the elevator finally arrived, he stepped on, and found himself surrounded by men and women whose perfumes and colognes contrasted with the alcohol and disinfectant of the ward he’d just left, much as their tailored business suits contrasted with his body fluid–flecked, sweat-soaked scrubs. Conversation ceased. The well-groomed visitors were all watching him.

'It took me a while to figure out who they were,' Poses remembers. 'They certainly weren’t doctors or patients. They were too well-dressed to be vendors. I thought they might be bankers.' Eventually he understood: these were the hospital’s financial executives, just arriving for their day’s work in the management suite on the top floor. 'I felt like rubbing up against them and saying, ‘Go ahead, folks, take a whiff! I’m the guy you’re paying minimum wage to keep this f***in’ place running.’ 

Sorry, but to this day, it inspires anger.  As Mueller later noted

This was Poses’s first encounter with managerialism, which has seen financial managers take control of major hospital chains and other healthcare providers. He initially believed that the problem was limited to Boston University. 'I just assumed that the chief of medicine and the chief of surgery ran most hospitals, and that the business people worked for them, to keep the finances straight.' In fact, at that point CEOs, CFOs and COOs were a rarity at hospitals. 'There might have been an ‘executive director’ or a ‘hospital superintendent,’'  Poses remembers, 'but he was a retired doctor, and his office wasn’t too grand. There were ‘hospital administrators,’ but you’d only contact them if the lights went out or there were no linens on the beds.' However, as he moved to other posts at university medical centers in Pennsylvania, New Jersey and Virginia, before ending up at Brown University medical school in 1994, he found the same widening gulf between the values of medicine and the methods of hospital leaders, most of whom were skilled in capital rather than health.


Recap: Managerialism

Since we started Health Care Renewal, we have discussed the rise of generic managers, which later we realized has been called managerialism, quite a bit. Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations' work.  Managerialism has become an ascendant value in health care over the last 30 years.  The majority of hospital CEOs are now management trained, but lacking in experience and training inmedicine, direct health care, biomedical science, or public health.  And managerialism is now ascendant in the US government.  Our president, and many of his top-level appointees, are former business managers without political experience or government experience.

We noted an important article in the June, 2015 issue of the Medical Journal of Australia(1) that made these points:
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals


Generic or managerialist managers by definition do not know much about health care, or about biomedical science, medicine, or public health.  They are prototypical ill-informed leadership, and hence may blunder into actual incompetence.  They are trained that they have a right to lead any sort of organization, which breeds arrogance.  These managers are not taught about the values of health care professionals.  Worse, they are taught in their business style training about the shareholder value dogma, which states that the main objective of any organization is to increase revenue.  Thus, they often end up hostile to the fundamental mission of health care, to put care of the patient and the health of the population ahead of all other concerns, which we have called mission-hostile management.  Finally, arrogance and worship of revenue allows self-interested and conflicted, and even sometimes corrupt leadership. 

Managerialists may be convinced that they are working for the greater good.  However, I am convinced that our health care system would be a lot less dysfunctional if it were led by people who actually know something about biomedical science, health care, and public health, and who understand and uphold the values of health care and public health professionals - even if that would cost a lot of very well paid managerialists their jobs.

 Reference

1.  Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM.  The scourge of managerialism and the Royal Australasian College of Physicians.  Med J Aust 2015; 202: 519- 521.  Link here.

Thursday, October 03, 2019

Marketers Want Even More Control Over Hospitals

Once, a long time ago, in a galaxy far away, doctors and hospitals did no marketing, and pharmaceutical marketing was restricted to health care professional audiences.  Now, in the US, we have  often seen the negative effects of exuberant  marketing, often deceptive, on the health care system.

A Marketer Pushes More Marketing Influence on Hospital Management

Yet, in a post in the Marketing Insider section of MediaPost, a writer lamented that marketing does not have enough influence within hospitals.

About 10% of hospital budgets are designated for marketing. It’s been that way for years, with stagnant year-on-year growth.

That is in contrast to ... Amazon, of course:

Amazon reported record profits in 2018, earning $10.1 billion in net income compared with just $3 billion the prior year. Amazon ranked as the nation's fourth-largest advertiser in 2017, spending an estimated $3.4 billion in U.S. advertising and promotions.

It goes beyond Amazon, though:

Amazon is not the only company appropriately valuing marketing. Many modern consumer-focused enterprises are moving from seeking maximum ROI to actually transforming the marketing value chain.

IMHO, this shows how managers who run, or at least pontificate about running hospitals do not seem to have an idea what hospitals actually do.  How does a hospital, the locus for providing care to sick and injured people, care provided by highly trained health care professionals sworn to put patients' values ahead of all other concerns, compare to a web-based retailer, or to most "consumer-focused enterprises?"

Furthermore, the post pushes the value of marketing beyond just raising awareness of or promoting a product,

Part of the reason hospital systems are starting to spend more on marketing is that the function is broadening. Marketing teams are being asked to take on more strategic tasks, from managing the hospital’s brand and reputation to operationalizing patient engagement.

Traditionally, patient experience falls under the purview of quality or safety. But in the last decade, health systems have seen the marketing department’s impact on the patent experience, even going so far as to have marketing report to the chief patient experience officer.

One might think that the typical patient who comes to a hospital wants to experience an improvement in their condition, their symptoms, their function, reduction of their pain, or sometimes the remission or even cure of their problem.  I do not see how any rational person seeking a fun experience would choose to go to a hospital.  What marketing has to do with health care quality or safety completely escapes me.

The Rationale: a Misinterpretation of  the Social Determinants of Health

The rationalization for involving marketers in patients' experiences was:

Leaders are seeing that the care they provide accounts for just 20% of patients’ optimal outcomes. The rest is attributable to factors like social determinants of health. Today, if hospital systems want to keep patients healthy, they have to influence experiences patients have outside the hospital walls.

The notion that marketing by a hospital would be an optimal way to positively influence social determinants of health is bizarre, to use a polite term.  To quote an article entitled "Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity" published by the Kaiser Family Foundation,

Social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care.
What could hospital marketing do to affect such factors?  Instead, the writer explained:

Hospitals and health systems are moving beyond simple outreach and using the principles of marketing — such as segmentation, personalization and meeting consumers where they are — to engage patients in changing behavior and getting them invested in their own well-being.

Health systems must ensure that every time a patient interacts with their brand, that interaction keeps patients engaged and satisfied and delivers on the fundamental promise that they make to their patients: making and keeping them well.

Again, what has that to do with socioeconomic status, education, neighborhood and physical environment, employment, and social support networks? Rather than talking about social factors, the writer appears to be talking about some efforts to change individual patients' behavior.

However, the KFF article made a clear distinction between social determinants of health and individual health behaviors, while asserting that social determinants of health may influence individual behaviors, but not necessarily the other way around:

While there is currently no consensus in the research on the magnitude of the relative contributions of each of these factors to health, studies suggest that health behaviors, such as smoking, diet, and exercise, and social and economic factors are the primary drivers of health outcomes, and social and economic factors can shape individuals’ health behaviors. For example, children born to parents who have not completed high school are more likely to live in an environment that poses barriers to health such as lack of safety, exposed garbage, and substandard housing. They also are less likely to have access to sidewalks, parks or playgrounds, recreation centers, or a library.4 Further, evidence shows that stress negatively affects health across the lifespan5 and that environmental factors may have multi-generational impacts.

Thus, to argue that hospital marketing could influence individual patient behaviors and thus positively affect social determinants of health makes no sense.

Summary: Managerialism, Again

I applaud the writer's implication that

hospital systems want to keep patients healthy

(As an aside though, hospitals cannot want anything, but the people who work in them can.)

But however well intended, or at least rationalized, marketers pushing their greater involvement in patient experience, even if it is not self-serving, seems like just another push for the managerialism that already haunts health care. 

Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations' work.  Managerialism has become an ascendant value in health care over the last 30 years.  The majority of hospital CEOs are now management trained, but lacking in experience and training inmedicine, direct health care, biomedical science, or public health.  And managerialism is now ascendant in the US government.  Our president, and many of his top-level appointees, are former business managers without political experience or government experience.

We noted an important article that in the June, 2015 issue of the Medical Journal of Australia(1) that made these points about managerialism:
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals

Managerialism may be a major cause of  mission-hostile management. In non-profit hospitals, mission-hostile management threatens care of vulnerable patients, particularly by prioritizing hospital revenues, and the financial self-interest of management over patient care. Note that the rise of the manager-leader occurred at a time when management schools increasingly preached the dogma that maximizing shareholder value, usually equivalent to maximizing short-term revenue, should be the first, if not the only goal of all managers (look here).  For example, an article on the miseducation of Sheryl Sandberg, Facebook's chief operating officer, asserted that


Harvard Business School, like much of the M.B.A. universe in which Sandberg was reared, has always cared less about moral leadership than career advancement and financial performance.


Managerialists may be convinced that they are working for the greater good.  However, I am convinced that our health care system would be a lot less dysfunctional if it were led by people who actually know something about biomedical science, health care, and public health, and who understand and uphold the values of health care and public health professionals - even if that would cost a lot of very well paid managerialists their jobs.

 Reference

1.  Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM.  The scourge of managerialism and the Royal Australasian College of Physicians.  Med J Aust 2015; 202: 519- 521.  Link here.