Friday, June 22, 2018

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

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

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

Dr Gu Fired

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

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

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

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

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

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

VUMC denied that:

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

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

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

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

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

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

Also, he noted that

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

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

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

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

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

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


Discussion

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

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

As we wrote in February,

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

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

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

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

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

Musical Interlude

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

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





Tuesday, June 12, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday, June 05, 2018

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

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

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

Introduction: CVS Health and the Promotion of Social Responsibility

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




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

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

CVS claims to act socially responsible by making charitable contributions for

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

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

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

CNN reported on June 1, 2018, that 

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


The details were,

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

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

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

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

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

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

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

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

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

But wait, there is more.


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

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

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

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

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

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


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

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

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

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

But wait, there is more...

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

A Political Agenda from the Start

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

improving health and health care nationwide.

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

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

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

In addition,

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

Was it about improving health and health care?

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

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

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

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

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

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

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

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

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

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

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

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

 Also,

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

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

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

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

America First Policies' Founders Included Shady Characters

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

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

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

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

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

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

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

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

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

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

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

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

Discussion

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

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

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

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

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

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

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

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

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

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

Friday, June 01, 2018

The Stealth Shutdown of the US Agency for Healthcare Quality and Research (AHRQ) National Guideline Clearinghouse

The Quiet Announcement of the Shut Down

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

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

There was no further explanation.

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

The Importance of the National Guideline Clearinghouse

The shutdown is significant because the Clearinghouse was an important source of information on diverse practice guidelines useful to clinicians, but also to medical and health care educators and researchers.

It is noteworthy that AHRQ has recently endeavored to assure the trustworthiness of the posted guidelines. While guidelines have been long and widely touted as a way to improve the quality of health care, there have been continuing questions about their validity and usefulness. In particular, there was accumulating evidence that many available guidelines were biased by conflicts of interest, based on an incomplete sample of available evidence, and were not necessarily informed by rigorous review of the available evidence, as we discussed here

In response, in 2011, the US Institute of Medicine (IOM) published standards for trustworthy guidelines (look here).  These standards were more rigorous and better justified than any prevous attempts to assure guideline quality.

The summary of the IOM report included:

Most guidelines used today suffer from shortcomings in development. Dubious trust in guidelines is the result of many factors, including failure to represent a variety of disciplines in guideline development groups, lack of transparency in how recommendations are derived and rated, and omission of a thorough external review process. To be trustworthy, clinical practice guidelines should:
• Be based on a systematic review of the existing evidence;
• Be developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups;
• Consider important patient subgroups and patient preferences, as appropriate;
Be based on an explicit and transparent process that minimizes distortions, biases, and conflicts of interest;
• Provide a clear explanation of the logical relationships between alternative care options and health outcomes, and provide ratings of both the quality of evidence and the strength of recommendations; and
• Be reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations.
Additionally, as reflected in the committee’s standards for developing trustworthy clinical practice guidelines, guideline development groups optimally comprise members without conflict of interest. The committee recognizes that in some circumstances, a guideline development group may not be able to perform its work without members who have conflicts of interest—for example, relevant clinical specialists who receive a substantial portion of their incomes from services pertinent to the guideline. Therefore, the committee specifies that members of the guideline development group who have a conflict of interest should not represent more than a minority of the group.
However reasonable these standards may have appeared, by 2012 the IOM standards were largely ignored (as discussed here).

Yet, in 2017, at least one study appeared suggesting that many guidelines in the Clearinghouse did not meet the IOM standards (look here).  That year the AHRQ proclaimed that it would start assessing guidelines' adherence to the IOM standards (look here).

This is noteworthy again considering that the standards have had otherwise unfortunately little impact.

And now it seems the AHRQ's worthwhile effort to disseminate guidelines whose trustworthiness can be assessed will end.

Discussion

So it seems that the report on clinical practice guidelines emphasized two issues highly relevant to Health Care Renewal, the need for transparency in guideline development, and the need to avoid conflicts of interest affecting the development process.

Perhaps more because than despite that, as we noted above, by 2012 the IOM standards were largely ignored (as discussed here).  We speculated that these standards may have discomfited many people.  They could have cost a lot of medical societies considerable commercial funding, and a lot of health care professionals on guideline panels considerable personal wealth.  These standards could probably also have cost a lot of companies whose products and services were addressed by guidelines to lose revenue.  Their implementation could have cost too many people who are financially benefiting from the status quo too much money.  And these people, that is, leaders of professional societies dependent on commercial outside funding, health care professionals and academic used to financial support from commercial interests, and health care corporations are good at making sure their interests are not ignored, even if their interests conflict with those of patients, the public, and well-intentioned health care professionals.


The Trump regime has exhibited great coziness with those who lead large corporations, including health care corporations, and other such plutocrats (look here).  The Trump regime appointed a person who was a manager of commercial information technology firms, not a health care professional or researcher, as head of the AHRQ (look here).  So it should come as no surprise that the AHRQ leadership under that regime was unable to maintain a Guideline Clearinghouse that attempted to uphold such standards of guideline trustworthiness.

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

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

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

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

Musical Interlude - Donovan, Try and Catch the Wind, 1973





Friday, May 25, 2018

The March of Legal Settlements Made by Pharmaceutical Companies is Diminishing - Presaging Even Less Accountablity for Top Health Care Organizational Leaders?

Introduction

We have long been discussing the legal settlements made by health care organizations of alllegations like fraud, bribery, and kickbacks.  Despite the unsavory nature of the behaviors revealed by most settlements, which often appeared to risk patient harms, the companies involved usually have had to pay fines that were tiny relative to their multi-billion dollar revenues.  They companies only seldom have had to admit responsibility, and almost never did a settlement cause company managers and leaders to  suffer any negative consequences for enabling, authorizing, directing or implementing the bad behavior.

So these settlements also provided a window onto the impunity of top leaders of health care organizations.  Lack of deterrence caused by such impunity appears to be a major cause of  the epidemic of continuing unethical behavior, crime and corruption on the part of large health care organizations.

However, at least these settlements seemed to be useful markers of the such bad behavior apparently sanctioned by the leadership of these organizations.  But now even these markers seem to be fading away. 

We had an ongoing enterprise trying to discuss what appeared to be the most interesting and significant legal settlements by major health organizations.  This year, however, things have seemed slow. Our last major wrap-up of recent legal settlements appeared on October 1, 2017.  On December 3, 2017, we did comment on a significant but barely noticed settlement by Pfizer of allegations of fraud done to prevent generic competition.  But since then it has seemed very quiet.

A new settlement by Pfizer was just announced yesterday.  This inspired me to review the files I had lying around, which did include a few US settlements by pharmaceutical companies from 2017 which I had not discussed.  However, I found nothing from 2018.  Fortuitously while I considered all this, I found a new article that corroborates my perception that things are changing, probably not for the better.  That I will discuss below. 

But first I will review the latest single entry in the march of legal settlements,   (Note that the missed 2017 cases appear at the end of this post in an Appendix.)

Pfizer Settled Charges of Giving Kickbacks to Patients Through Disease Advocacy Organization to Mask the Prices of Its Drugs

On May 24, 2018, Bloomberg reported a rather unusual case involving a company that has often provided grist for our mill,

Pfizer Inc. used a 'purportedly independent' charity to help it sharply raise the price of a heart drug, shielding patients from the increase while Medicare picked up the higher costs, the U.S. Justice Department said Thursday in a civil settlement announcement.

Pfizer will pay about $24 million in the anti-kickback settlement, the government said in a statement. It’s the latest agreement in a long-running U.S. investigation into drugmaker ties to patient charities. Pfizer will also enter into a five-year monitoring agreement with the Department of Health and Human Services Office of Inspector General.

In particular,

The Pfizer settlement is focused on three drugs: Sutent and Inlyta for kidney cancer, and the heart-rhythm drug Tikosyn. Sutent had U.S. sales of $374 million last year, while Inlyta sold $126 million. Tikosyn sold $153 million in 2016, according to the company.

In the case of the heart rhythm drug, Pfizer worked with the Patient Access Network Foundation to finance a fund for heart patients at the same time it was taking a huge price increase. The drugmaker raised the price of Tikosyn -- by 44 percent during the last three months of 2015, according to the government.

'Pfizer coordinated the timing of the opening of the fund for these patients with the implementation of a Tikosyn price increase,' the government said. For the next nine months, patients on the drug accounted for virtually all the beneficiaries of the charitable fund, the Justice Department said.

In 2015, Pfizer gave more than $10 million to the Patient Access Network Foundation, according to a summary by the drugmaker. It doesn’t specify how much of that went to the heart drug fund.

In the case of the kidney cancer drugs, the New York-based drugmaker worked with a third-party pharmacy company to steer patients to the foundation for financial help, instead of giving out free drug. It tracked data from the pharmacy to confirm that some that Pfizer’s donations were going to patients on its products, according to the Justice Department.

As is usual in legal settlements made by big health care organizations,

Pfizer said the settlement isn’t an admission of liability. None of the company’s executives were charged or fined.

So the company got to say

This resolution reflects the company’s desire to put this legal matter behind it and focus on the needs of patients,...

And the impunity of managers of big health organizations continues.

Also, the amount of money involved in the settlement, $24 million, seems to be a drop in the bucket compared to the money Pfizer was making from the drugs involved, thus making it unlikely to deter future bad behavior by Pfizer or other organizations.  

The settlement doesn’t mention price increases for the cancer drugs, which can cost tens of thousands of dollars a year. Inlyta currently costs about $239 per 5-milligram tablet, or more $14,000 a month, according to data compiled by Bloomberg Intelligence. Sutent costs more than $600 for a 50-milligram capsule, or more than $17,000 for a six-week treatment cycle that includes four weeks on the drug and two off.

It also is an even tinier drop in the bucket compared to Pfizer's revenues,which were $52.5 billion in 2017, according to Pfizer.

Finally, the settlement did not seem informed by Pfizer's long track record of bad behavior, including settlements almost too numerous to count, and involving billions in fines.  For our most recent summary of this, look here.   

But the settlement at least provided some insight into the clever, if likely unethical ways pharmaceutical companies are now using to maintain the extremely high prices of drugs, an important reason US health care is the most expensive, if not the best in the world.

But why have there been so few settlements in 2018 besides this one?  


Drop in Law Enforcement Targeting White Collar Crime Under the Trump Administration

Today, I also noticed the report of a study that provides a bit of evidence that my perception of recent diminution of the march of legal settlements was not far off.  It suggests that there has been a recent drop-off not just in settlements, but in law enforcement efforts targeting white-collar crime in general.

As reported by Bloomberg, with the headline, "White-Collar Prosecutions Fall to 20-Year Low Under Trump," on May 25, 2018,

The number of white-collar prosecutions is on track to hit a 20-year low under President Donald Trump, after reaching a high in 2011 during the Barack Obama administration, according to a nonprofit research center that analyzes government data.

A total of 3,249 cases were brought during the first seven months of the U.S. government’s 2018 fiscal year, which runs from October 2017 to April 2018, according to a case-by-case analysis of government data by Syracuse University’s Transactional Records Access Clearinghouse, or TRAC.

That’s a 4.4 percent drop from the same period in 2017, a decline of 33.5 percent from five years ago, and 40.8 percent fewer cases than in 1998, according to the report. The analysis is of data obtained by TRAC under the Freedom of Information Act.

Discussion

So my perceptions that the number of the sorts of legal settlements of interest to us has likely been diminishing was accurate.  Unfortunately, rather than the decrease being due to better behavior, decresed reporting, or my laxity in case-finding, it now looks that US government efforts to combat bad behavior by big health care corporations and to hold top leaders of these organizations accountable is getting even more lax.

So once again, with feeling...  

We seem to be sliding backwards in efforts to make the leaders of large health care organizations accountable, and particularly to combat the worse manifestation of their lack of accountability, impunity. 

The system appears to be rigged to favor of leadership and management of large companies, as opposed to health professionals, and particularly as opposed to patients.  For years now we have discussed stories like this, which include allegations of severe misbehavior by large health care companies affirmed by legal settlements, but which only involve paltry financial penalties to the companies, and almost never any negative consequences to any humans. Furthermore, as in this case, these stories are often relatively anechoic, noted often only briefly in the media, and have inspired no real action by the US government. 
  

This adds to the evidence suggesting that US health care, at least, is rigged to benefit its top insiders and cronies, and as such, is part of a larger rigged system.  We have previously discussed how market fundamentalism (or neoliberalism) led to deregulation, which enabled deception, fraud, bribery, and intimidation to become standard business practices, and allowed increasing concentration of power by large corporations. Managerialism allowed the top leaders of these corporations and their insider cronies to amass increasing power and money. Everyone else, other employees, stockholders of public corporations, customers, vendors and suppliers, and the public at large lost out.   In health care, these changes led to an increasingly costly system which produced increasingly bad results for patients and the public.  
 
We have called for years for what we sometimes term "true health care reform" to derig the system. Unfortunately, despite our hopes, perceptions of a rigged system may not always inspire honest reform. Instead, they can enable the rise of demagogues and would be dictators who promise only they can solve the problem.  Donald Trump cried out that only he could fix our problems and drain our swamps.  However, at least in terms of policing white-collar crime, particularly in health care, he seems to be letting the swamp waters rise.

While we thus have bigger problems to solve than the impunity of health care leaders, let us remember the need for wholesale, real health care reform that would make health care leaders accountable for what their organizations do, particularly when these organizations misbehave.


Appendix - For the Record, Previously Missed US Settlements from 2017 

(January) Shire paid $350 million to settle allegations that it gave kick-backs to physicians and clinics to promote Dermagraft, and promoted it for unapproved uses (per the Wall Street Journal) .  One unusual aspect of this case was that three executives of a Shire subsidiary which sold this product were also convicted.

(April) Sanofi agreed to pay $19.8 million to settle allegations it overcharged the US Department of Veterans Affairs (per Modern Healthcare).

(May) Merck and Upsher-Smith Laboratories agreed to pay $60.2 million to settle an anti-trust class action lawsuit alleging they conspired  to delay a generic version of a potassium product.  Note that the FTC had sued the companies over this matter, but lost their case. (per Reuters).

(June) Allergan agreed to pay $13 million to settle allegations that it paid kick-backs to promote sales of various opthalmic preparations (per the Philadelphia Inquirer).


Sunday, May 20, 2018

A Higher Impunity - How Can we Reduce Health Care Leadership's Impunity When the President Claims His Own Impunity?

Impunity: an Introduction

We believe that unaccountable leadership is a major cause of health care dysfunction.  Impunity is an extreme form of unaccountable leadership.

We have noted that despite numerous legal settlements made by health care organizations of alllegations like fraud, bribery, and kickbacks, almost never do top leaders who presided over these actions face any negative consequences.  Lack of deterrence caused by such impunity appears to be a major cause of  the epidemic of continuing unethical behavior, crime and corruption on the part of large health care organizations. How executives got to the point of having such impunity has never been clear.

Timidity and lenience by regulatory agencies and law enforcement seem to be factors. For example, in 2014, we noted  that Attorney  General Eric Holder had previously been reluctant to go after big organizations because of the economic consequences of their failure:

The attorney general angered many last year when he reiterated those concerns at a congressional hearing, admitting 'that the size of some of these institutions becomes so large that it does become difficult for us to prosecute' because of the potential nasty economic effects of a major company failure.
In general we have seen much tougher enforcement directed against relatively small health care players than against bigger ones.  For example, we noted in 2014 that settlements by  Merck, Eli Lilly, Takeda, and Teva, all large pharmaceutical companies, allowed the companies to pay fines to settle allegations that they pushed dangerous products, while none of the executives who authorized, enabled, or directed these actions faced negative consequences.  In contrast, at that time, the CEO of a relatively tiny Sheffield Pharmaceuticals was convicted of a felonious wastewater discharge (see this post).

However, this rationale does not address the failure to pursue enforcement actions against organizational leaders who who enabled, authorized, directed or implemented misbehavior.  It is not that there are no good legal tools available to do so.  We wrote in 2012,
As we noted here, a Supreme Court case from 1943 empowered the government to seek penalties against responsible corporate officers (the "responsible corporate officer doctrine") who were in a position to stop a fraud that resulted in a guilty plea or conviction, particularly for the selling of misbranded or adulterated drugs into interstate commerce under the US Food and Drug Act.    Despite a threat made in 2010 by the chief counsel of the Inspector General's office of the US Department of Health and Human Services to use such legal authority to "get high level executives out of companies," nothing of the sort has happened.

Later, in 2015, under the previous administration, there was a tiny sign of progress against impunity.  Then, Attorney General Holder authorized the creation of a Corporate Strike Force to take strong actions in response to health care corporate fraud.  However, last year the Trump administration gutted even that small effort  (look here).

Why are efforts to reduce the impunity of health care corporate leaders going backward?  It may be because the very top leadership of the current administration, that is, the President himself, has long personally enjoyed his own impunity.


Examples of Donald Trump and Family's Apparent Impunity Before He Became President

As a wealthy businessman, Donald Trump and his family were often linked to apparently illegal activities, but seemed to avoid any intensive investigation, much less negative consequences.


A 2016 Politico article cataloged Trump's ties to organized crime, and found "Some of Trump’s unsavory connections have been followed by investigators and substantiated in court; some haven’t." Also,
Trump’s career has benefited from a decades-long and largely successful effort to limit and deflect law enforcement investigations into his dealings with top mobsters, organized crime associates, labor fixers, corrupt union leaders, con artists and even a one-time drug trafficker whom Trump retained as the head of his personal helicopter service.
We have found numerous examples, whic are below listed chronologically according to the time of occurrence of relevant events.

Trump Accused of Lying to Federal Investigators about his Mafia Connections in the 1980s

A WNYC piece from October, 2016, was based on an interview with a federal prosecutor who had investigated organized crime in the 1980s,

Attorney Kenneth McCallion was one of the federal prosecutors involved in that investigation. He says there appeared to be a sweetheart deal between the Teamsters Local 282 and Trump, where Trump would get a promise of cooperation from organized labor—including breaking up any strikes by minority workers—in exchange for no-show jobs, a lucrative concrete contract and a luxury apartment for the union president's girlfriend.

'After we indicted them, the Teamster leaders called a citywide strike, but there were two job sites they exempted from that. One was Trump Tower and the other was Trump Plaza,' McCallion said.

Yet despite this, Trump was never prosecuted.

'Even though Donald Trump lied to law enforcement about his relationship and lying to federal agents is a federal crime, he basically got a pass at that point,' he said.

Trump Accused in Legal Papers of Accepting Kickbacks, but the Charges were not Investigated

The 2016 Politico article also noted:

[An associate of a convicted racketeer] in court papers accused Trump of taking kickbacks from contractors, asserting this could 'be the basis of a criminal proceeding requiring an attorney general’s investigation' into Trump. Trump then quickly settled, paying the woman a half-million dollars.

No further investigation ensued.

After a Judge Found that he Conspired to Violate Fiduciary Duty and Committed Fraud, Trump was able to Settle with Details Sealed

Again in Politico,

In 1991, a federal judge, Charles E. Stewart Jr., ruled that Trump had engaged in a conspiracy to violate a fiduciary duty, or duty of loyalty, to the workers and their union and that the 'breach involved fraud and the Trump defendants knowingly participated in his breach.' The judge did not find Trump’s testimony to be sufficiently credible and set damages at $325,000. The case was later settled by negotiation, and the agreement was sealed.

It is not clear that Trump was personally responsible for paying whatever the settlement entailed.  No criminal charges apparently followed.  

Applying for a Casino License, Trump Failed to Disclose he was Under Grand Jury Investigation, but Later Kept his License

As also reported by Politico, when Trump was trying to obtain a license for a New Jersey gambling casino,

Trump was required to disclose any investigations in which he might have been involved in the past, even if they never resulted in charges. Trump didn’t disclose a federal grand jury inquiry into how he obtained an option to buy the Penn Central railroad yards on the West Side of Manhattan. The failure to disclose either that inquiry or the Cody inquiry probably should have disqualified Trump from receiving a license under the standards set by the gaming authorities.

But it didn,'t. And despite the fact that

Once Trump was licensed in 1982, critical facts that should have resulted in license denial began emerging in Trump’s own books and in reports by Barrett—an embarrassment for the licensing commission and state investigators, who were supposed to have turned these stones over. Forced after the fact to look into Trump’s connections, the two federal investigations he failed to reveal and other matters, the New Jersey Division of Gaming Enforcement investigators circled the wagons to defend their work. First they dismissed as unreliable what mobsters, corrupt union bosses and Trump’s biggest customer, among others, had said to Barrett, to me and other journalists and filmmakers about their dealings with Trump. The investigators’ reports showed that they then put Trump under oath. Trump denied any misconduct or testified that he could not remember. They took him at his word. That meant his casino license was secure even though others in the gambling industry, including low-level licensees like card dealers, had been thrown out for far less.

Trump's Casino Company Paid Multiple Fines for Violating Regulations, but Trump was not Personally Sanctioned 

An Atlantic article from January, 2017, stated,

Trump has been repeatedly fined for breaking rules related to his operation of casinos. In 1990, with Trump Taj Mahal in trouble, Trump’s father Fred strolled in and bought 700 chips worth a total of $3.5 million. The purchase helped the casino pay debt that was due, but because Fred Trump had no plans to gamble, the New Jersey gaming commission ruled that it was a loan that violated operating rules. Trump paid a $30,000 fine; in the end, the loan didn’t prevent a bankruptcy the following year. As noted above, New Jersey also fined Trump $200,000 for arranging to keep black employees away from mafioso Robert LiButti’s gambling table. In 1991, the Casino Control Commission fined Trump’s company another $450,000 for buying LiButti nine luxury cars. And in 2000, Trump was fined $250,000 for breaking New York state law in lobbying to prevent an Indian casino from opening in the Catskills, for fear it would compete against his Atlantic City casinos.

Also, while Trump was attempting a hostile take-over of a rival casino,

the Federal Trade Commission fined him $750,000 for failing to disclose his purchases of stock in the two companies, which exceeded minimum disclosure levels.

Trump and Family were Accused of Self-Dealing and Accepting Illegal Donations while Operating the Trump Foundation, but were not Individually Penalized

Also reported by the Atlantic,

The [Trump] foundation appears to have broken IRS rules on 'self-dealing” by paying to resolve the legal disputes as well as buying a portrait of Trump and a Tim Tebow helmet that went back to the Trump family. In November, in tax filings posted online, the Trump Foundation said it had violated self-dealing rules in 2015 and in previous, indeterminate, years. On the donation, Trump and Bondi both say there was no quid-pro-quo, but the donation was an illegal one for a charitable nonprofit, and the foundation had to pay a $2,500 fine. Liberal watchdog group Citizens for Responsibility and Ethics in Washington charges other laws may have been broken as well. New York Attorney General Eric Schneiderman has reportedly launched an investigation into the foundation. Schneiderman has also informed the foundation that it is in violation of rules on fundraising and ordered it to quit. Trump has announced plans to shutter his foundation, but reportedly cannot do so while it is under investigation.

Yet so far no person has been charged with any related violations. Note that it appears that Trump may have had leverage on Mr Schneiderman, who has now resigned (see below).  Although there were reports in 2017 that the Foundation was going to shut down, as of March, 2018, according to an article in The Hill, the ranking Democratic member of the House Oversight and Government Reform Committee was still trying to get records related to the self-dealing described above from the leadership of the apparently still existing foundation (look here). 

Trump's Taj Mahal Casino Was Fined for Breaking Rules about Money Laundering, but Trump Paid no Penalties

A May, 2017, CNN story stated,

The Trump Taj Mahal casino broke anti-money laundering rules 106 times in its first year and a half of operation in the early 1990s, according to the IRS in a 1998 settlement agreement.

It's a bit of forgotten history that's buried in federal records held by an investigative unit of the Treasury Department, records that congressional committees investigating Trump's ties to Russia have obtained access to, CNN has learned.

The casino repeatedly failed to properly report gamblers who cashed out $10,000 or more in a single day, the government said.

Trump's casino ended up paying the Treasury Department a $477,000 fine in 1998 without admitting any liability under the Bank Secrecy Act.

There is no record suggesting anyone looked into Trump's involvement with these violations. Note that

The 1998 settlement was publicly reported at the time, and the Associated Press noted it was the largest fine the federal government ever slapped on a casino for violating the Bank Secrecy Act.

However,

But key details of the casino's cash reporting violations are missing from the publicly released documents, including the identities of the gamblers and casino employees involved in the transactions.

Then, in 2015, FINCEN publicly announced:

The Financial Crimes Enforcement Network (FinCEN) today imposed a $10 million civil money penalty against Trump Taj Mahal Casino Resort (Trump Taj Mahal), for willful and repeated violations of the Bank Secrecy Act (BSA). In addition to the civil money penalty, the casino is required to conduct periodic external audits to examine its anti-money laundering (AML) BSA compliance program and provide those audit reports to FinCEN and the casino’s Board of Directors.

Trump Taj Mahal, a casino in Atlantic City, New Jersey, admitted to several willful BSA violations, including violations of AML program requirements, reporting obligations, and recordkeeping requirements. Trump Taj Mahal has a long history of prior, repeated BSA violations cited by examiners dating back to 2003. Additionally, in 1998, FinCEN assessed a $477,700 civil money penalty against Trump Taj Mahal for currency transaction reporting violations.

'Trump Taj Mahal received many warnings about its deficiencies,' said FinCEN Director Jennifer Shasky Calvery. 'Like all casinos in this country, Trump Taj Mahal has a duty to help protect our financial system from being exploited by criminals, terrorists, and other bad actors. Far from meeting these expectations, poor compliance practices, over many years, left the casino and our financial system unacceptably exposed.'

Trump Taj Mahal admitted that it failed to implement and maintain an effective AML program; failed to report suspicious transactions; failed to properly file required currency transaction reports; and failed to keep appropriate records as required by the BSA. Notably, Trump Taj Mahal had ample notice of these deficiencies as many of the violations from 2012 and 2010 were discovered in previous examinations.

Again, there is no record of any negative consequences for Mr Trump

Trump Made False Statements Under Oath, but was not Charged with Perjury

A Mother Jones article published February, 2016, recounted that in connection with a libel suit Mr Trump filed against journalist Timothy O'Brien alleging O'Brien under-reported Mr Trump's wealth,

In 2007—two years before a New Jersey judge tossed out the case—Trump was questioned during a deposition. Over the course of the two-day-long interrogation, Trump was forced repeatedly to acknowledge having made false statements. And at one point, a lawyer for O’Brien and his publisher asked Trump a straightforward question: Have you ever before associated with individuals you knew were associated with organized crime?'

Trump, who was testifying under oath, answered, 'Not that I know of.'

That was a clear and unequivocal response. But it was not true. Two years earlier, O’Brien had interviewed Trump and specifically asked him about Sullivan and Shapiro. O’Brien, now an editor and writer at Bloomberg, has provided Mother Jones with a transcript of the interview, and it conclusively shows that Trump believed that these two men were associated with organized crime....

Trump: They were tough guys. In fact, they say that Dan Sullivan was the guy that killed Jimmy Hoffa. I don’t know if you ever heard that.

O’Brien: I have heard that. And that he was, you know…

Also,

Trump: I just was able to handle them. And I, really, I was able to handle them. I found Sullivan to be the tougher of the two. I started hearing reports about Sullivan, that he killed Jimmy Hoffa….

Also,

O’Brien: What was Shapiro like?

Trump: He was like a third-rate, local, real estate mob guy. Nothing spectacular. And I, you know, I got lucky. I heard a rumor that Sullivan, because Sullivan was a great con man, I heard a rumor that Sullivan killed Jimmy Hoffa. And because I heard that rumor I kept my guard up. You know, I said, 'Hey, I don’t want to be friends with this guy.'

So here was Trump connecting Sullivan to the Hoffa murder and calling Shapiro a 'mob guy.'

The same article also asserted that Trump lied in a deposition about knowing and working with Felix Sater, who who "had once been involved in a Mafia-linked stock swindle," and who "had worked with the Trump Organization."

Ivanka Trump and Donald Trump Jr Escaped Indictment for Fraud

As reported by the New Yorker in October, 2017, despite considerable evidence that the two children of Donald Trump had misled potential buyers of Trump SoHo condominiums, Cyrus Vance, the Manhattan District Attorney overruled his staff by halting an investigation of them in 2010.  Later, the Trumps' attorney, Marc Kasowitz, made a large donation to Mr Vance's campaign.   

Trump University Settled Fraud Allegations, Trump Not Charged

As reported by the New York Times in 2017, "the final settlement of allegations that 'Trump University students had been cheated out of thousands of dollars in tuition through high-pressure sales techniques and false claims about what they would learn" was approved by a judge. Litigation about these allegations had gone on for years, but after his election in November, Mr. Trump reversed course and agreed to pay $25 million to resolve the litigation. He did not admit fault, and he maintained in posts on Twitter after the settlement announcement that he "did not have the time to go through a long but winning trial on Trump U."

The settlement resolved lawsuits brought by the Attorney General of New York, Eric Schneiderman, among others.  However, Mr Trump was never charged with a crime by Mr Schneiderman among others.  There is some reason to think Mr Trump took actions to ensure his impunity.

According to Bloomberg on May 11, 2018,
Back in 2013, Donald Trump was exploring a presidential run. His Trump University was in the crosshairs of New York’s crusading attorney general. Around the same time, Trump and his personal lawyer got an interesting piece of information: Eric Schneiderman, the AG, was accused of sexually abusing two women.

The details of the accusations were not made public at that time, but later,
Trump took aim at Schneiderman in a tweet on Sept. 11, 2013, that also referred to New York politicians who’d resigned over allegations of sexual misconduct, Anthony Weiner and Eliot Spitzer.

'Weiner is gone, Spitzer is gone -- next will be lightweight A.G. Eric Schneiderman. Is he a crook? Wait and see, worse than Spitzer or Weiner,' Trump tweeted.

Mr Schneiderman never brought criminal charges against Mr Trump.  Could it be that he was made aware that Trump had information about Schneiderman's sexual behavior that he could use against him? This month, the allegations of his sexual misconduct were finally made public and he then resigned.  The settlement, again absent any charges against Mr Trump, was approved in March, 2017.

Summary of Trump's Pre-Presidency Impunity

While Trump's firms have had to pay multiple fines for breaking rules and laws, and Trump and the immediate family members who work with him in the Trump Organization were credibly accused of multiple types of wrong-doing, including various apparent crimes, neither Trump nor his family members were ever indicted, or apparently investigated for crimes. 

President Trump's Arguments That He Has De Jure Impunity

Since he was elected, President Trump and his proxies have asserted he now has de jure impunity that seems to go well beyond the sort of de facto impunity he enjoyed as a wealthy and powerful businessman and celebrity.  Note that none of these statements attempted to deny that he had or would violate laws.  They were all assertions that President Trump is not subject to the rule of law.

Examples appear again in order of apparent occurrence.


Trump Said He is Not Subject to Laws on Conflicts of Interest.

 As reported by CNN in November, 2016:

Donald Trump said on Tuesday that he faces no legal obligation to cut ties with his businesses, even as he described how winning the presidency has made his brand 'hotter' and acknowledged advancing his business interests during a conversation with a British politician.

'The law's totally on my side, the president can't have a conflict of interest,' Trump said in an interview with New York Times editors and writers.

Trump said he was surprised by how little was legally required of him. 'In theory I could run my business perfectly and then run the country perfectly. There's never been a case like this,' he said. 'I'd assumed that you'd have to set up some type of trust or whatever and you don’t.'

Yet,

It’s true that federal conflict-of-interest laws exempt the president, and he’ll have the power to change White House ethics rules. But there remains a constitutional ban on accepting payments from foreign governments, as well as anti-corruption laws against bribery and fraud.


Trump Stated His Personal or Family Finances Cannot be Subjects of Investigation

In an interview with the New York Times in July, 2017, he responded to a question:

SCHMIDT: Last thing, if Mueller was looking at your finances and your family finances, unrelated to Russia — is that a red line?

HABERMAN: Would that be a breach of what his actual charge is?

TRUMP: I would say yeah. I would say yes. By the way, I would say, I don’t — I don’t — I mean, it’s possible there’s a condo or something, so, you know, I sell a lot of condo units, and somebody from Russia buys a condo, who knows? I don’t make money from Russia. In fact, I put out a letter saying that I don’t make — from one of the most highly respected law firms, accounting firms. I don’t have buildings in Russia. They said I own buildings in Russia. I don’t. They said I made money from Russia. I don’t. It’s not my thing. I don’t, I don’t do that. Over the years, I’ve looked at maybe doing a deal in Russia, but I never did one. Other than I held the Miss Universe pageant there eight, nine years [crosstalk].

SCHMIDT: But if he was outside that lane, would that mean he’d have to go?

[crosstalk]

HABERMAN: Would you consider——

TRUMP: No, I think that’s a violation.

A typical interpretation of this rather incoherent response was in The Hill,

President Trump warned special counsel Robert Mueller from investigating his family’s finances beyond the scope of the probe into ties between his administration and Russia in an interview with The New York Times on Wednesday.

'I think that’s a violation. Look, this is about Russia,' Trump told the Times.

Trump during the interview said he wasn’t ruling out firing Mueller as special counsel on the probe into Russian meddling in the presidential election.

He did not say that he would order the Justice Department to fire Mueller or under what circumstances he would fire him, but he indicated Mueller investigating his family's finances would cross a line.

Trump's Attorney Argued that a President Cannot be Charged with Obstructing Justice

An article in Axios from December, 2017, strated

John Dowd, President Trump's outside lawyer, outlined to me a new and highly controversial defense/theory in the Russia probe: A president cannot be guilty of obstruction of justice.

The 'President cannot obstruct justice because he is the chief law enforcement officer under [the Constitution's Article II] and has every right to express his view of any case,' Dowd claims.

However, a Washington Post article published on May 18, 2018, stated that Mr Trump's current attorney is not so sure about that,

But apparently [current Trump laywer Rudy] Giuliani disagrees. Trump's own lawyer said Friday that his client is not immune from charges of obstructing justice — which is clearly the most troubling part of special counsel Robert S. Mueller III's investigation for Trump personally. While Trump hasn't been directly linked to potential collusion with Russia, he has taken many actions as president that have caught Mueller's attention and could feasibly be seen as trying to influence the course of the investigation. So whether Trump can technically obstruct justice at all is a key point, and it's one Giuliani just conceded.

Trump's Attorneys Argued He Is Immune from Civil Court Proceedings while President

They had argued that he has immunity from lawsuits as President, but as Reuters reported this month,

A New York state judge on Tuesday said U.S. President Donald Trump must face a defamation lawsuit by a woman who accused him of sexually harassing her after she appeared on his former reality TV show.

The decision by Justice Jennifer Schecter of the New York state court in Manhattan in favor of California restaurateur Summer Zervos, a former contestant on NBC’s 'The Apprentice,' raises the prospect that Trump might have to answer embarrassing questions in court about his behavior toward women.

She rejected Trump’s claim that he was immune from being sued, finding 'absolutely no authority' to dismiss litigation related 'purely to unofficial conduct' solely because he occupied the White House.

'No one is above the law,' the judge wrote.


Trump's Attorney Asserted He Cannot be Forced to Testify in Court

As reported by Reuters two days ago, on May 17, 2018, President Trump's current lawyer Rudolf Giuliani:

told Fox News Thursday morning not just that the special counsel cannot indict President Trump but that Mueller’s team cannot even subpoena the president to appear before a grand jury. Giuliani’s theory is that if the president cannot be prosecuted, he cannot be called to testify in an investigation of his conduct.

'We’re pretty comfortable, in the circumstances of this case, they wouldn’t be able to subpoena him personally,' Giuliani said. 'They could probably require documents to be produced. That’s what was required of Nixon. We’ve provided 1.4 million documents. They probably could require you to testify in a civil case, possibly even as a witness in a criminal case, but they can’t require you to testify in what would be your own case.'

However,

I talked Thursday to eight lawyers who’ve been involved in previous probes of U.S. presidents. Every one of them said Giuliani’s theory is incorrect.

Some of them had quite strong words.

George Conway wrote the Supreme Court briefs for Bill Clinton accuser Paula Jones in the case that led to a unanimous ruling from the justices that the Constitution does not shield presidents from testifying in certain civil suits. He said Giuliani’s assertion that President Trump cannot be subpoenaed is 'drivel.'

Lawrence Robbins, who represented White House officials in the Whitewater investigation, said Giuliani’s theory is 'facially preposterous.'

Solomon Wisenberg, who worked on the Whitewater probe of Clinton, called the theory 'delusional.'


Summary

Unaccountable leadership, particularly leadership with impunity, has been a major feature of modern US health care, and probably explains the continuing bad behavior, including criminally bad behavior and outright corrupt behavior ongoing in US health care organizations. While the US government began to address impunity in the last few years, those efforts have apparently halted during the current Trump regime.  Given President Trump's long record of personal impunity during his career as a wealthy and prominent businessman, and his assertions that as President he is above the law, that should be no surprise.

Yet, true health care reform requires well-informed leaders who uphold health care professionals' values, put patient's and the public's health ahead of all other considerations, avoid self-interest and conflicts of interest, are honest and ethical, and surely are not corrupt.  They need to work in the context of a government that is of, by and for the people, not of, by and for a demagogic leader.

In these times, true health reform is not possible under the current president. We will watch health care dysfunction continue to grow, and patients' and the public's health continue to decline until someone new takes the oath of office.