These days, with all the furor over whether Obamacare should be repealed and replaced, let alone, or improved, it is still the season for health care reform. Last week an article by David Ignatius in the Washington Post entitled "A Radical Idea for Health Care Reform: Listen to the Doctors," appeared. Since on Health Care Renewal we are all about trying to uphold physicians' professional values, I thought this deserved a closer look, with the hope that it would provide some down-to-earth wisdom from physicians in the real clinical world.
Background - Doctors Views on the Causes of Health Care Dysfunction
As we recently discussed, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes. Our first crude qualitative research(1) suggested that physicians' angst was due to perceived threats to their core values, and in turn that these threats arose from the issues this blog discusses: concentration and abuse of power, health care leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and health care governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting these proposed causes of health care dysfunction.
Other research provided some corroboration. Written comments from a 2001 survey of Massachusetts physicians made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line. Taken over by large corporations. Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(2) Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(3) (Also, see our comments on this paper.)(4) Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(5) We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(6)
The Latest Attempt to Listen to the Doctors about Health Care Reform
Ignatius' WaPo article was based on the pre-publication version of a new report by the National Academy of Medicine, (formerly the Institute of Medicine) made available on its website, entitled, Vital Directions for Health and Health Care. According to Ignatius' interpretation, the basic problem health care reformers need to address is that America "squanders money on the wrong things - expensive procedures and tests rather than preventive care and social programs." His summary of the supposed doctor recommended cures for this problem were:
First, providers should be paid for value — for patient outcomes, not for the volume of procedures. Second, incentives should empower people to take better care of themselves through wellness programs or lifestyle changes. Third, better connectivity is needed among doctors, patients and others to encourage data-driven advances. Finally, the Academy argues for community strategies that target the highest-need patients, who are also most costly to treat.
It sounded good at first, but I quickly thought of questions: Does it make sense to pay for patients' outcomes, when those outcomes may occur regardless of what doctors do? What sort of incentives would be needed to make patients who are not taking good care of themselves change their ways? Why would connectivity help when health care dyfunction has gotten worse as the world has become more connected? How to you find patients with highest need, and how would you target such patients? And above all, how would these cures, assuming one could figure out what they mean, prevent squandering money on the wrong things?
I left the Ignatius piece confused. Perhaps the NAM publication on which Ignatrius' WaPo article was based would provide enlightenment.
What the National Academy of Medicine Wrought
So my next step was to quickly read the underlying report. But that did not lessen the confusion.
The report did begin with sort of a definition of health care dysfunction
Health care today is marked by structural inefficiencies, unprecedented costs, and fragmented care delivery.
However it did not go on to providing an organized list of possible causes of these problems, with justifications for these diagnoses. At best, it sort of alluded to the following as possible causes:
- the "rapidly aging population;"
- "persisting care fragmentation and discontinuity;"
- "costs associated with unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed prevention opportunities, and fraud;" and
- "constrained innovation" due to "outdated regulatory, education and training models," particularly "uncertaintly and unpredictability around approval" of drugs and devices; and payment models that might place "excessive burden on manufacturers to demonstrate the value of their products."
"Rapidly again population" often appears as a postulated caused of health care dysfunction. On Health Care Renewal we frequently discuss the problem of outright criminality and corruption in health care, including fraud; and the take over of health care by managers, which can result in "excess administrative costs." However many of the other items were either too vaguely described to assess, or did not appear with clear justification.
Furthermore, this list also raised some obvious questions. For example, why are US costs so much higher than those of European countries whose populations are also aging? Who sets criteria for how "high" prices should be? What causes prices to be excessively high? Whose uncertainty and what unpredictability affect drug and device approvals? How is the burden on manufacturers excessive?
Here was more confusion. More was to follow.
The bulk of the report is about "Vital Directions Issue Areas," again sort of a list of cures for health care dysfunction
Vital Directions Issue Areas
Better health and well-being
Systems strategies for better health throughout the life course
Addressing social determinants of health and health disparities
Preparing for better health and health care for an aging population
Chronic disease prevention: tobacco, physical activity, and nutrition for a healthy start
Improving access to effective care for people who have mental health and substance use disorders
Advancing the health of communities and populations
High-value health care
Benefit design to promote effective, efficient, and affordable care
Payment reform for better value and medical innovation
Competencies and tools to shift payments from volume to value
Tailoring complex care management, coordination, and integration for high-need, high-cost patients
Realizing the full potential of precision medicine in health and health care
Fostering transparency in outcomes, quality, safety, and costs
The democratization of health care
Workforce for 21st century health and health care
Strong science and technology
Information technology interoperability and use for better care and evidence
Data acquisition, curation, and use for a continuously learning health system
Innovation in development, regulatory review, and use of clinical advances
Targeted research: brain disorders as an example
Training the workforce for 21st century science
However these apparent action items were not clearly associated with the causes of health care dysfunction they were supposed to address. The discussions of these items raised yet more questions. For example, the report discussed how to "drive health care payment innovation providing incentives for outcomes and value," presumably related to "payment reform" in the above list. New payment and delivery models would have the "aim to reduce waste, increase value, and improve outcomes." What was the evidence that they would be able to do so? The next item was to "help clinicians develop the core competencies required for new payment models." Would physicians be willing to accept a new payment system that would not work without subjecting the same busy clinicians to extensive new training? Etc, etc, etc
So in summary, the ful report did not give a clear definiton of the health care dysfunction, did not discuss the causes of the problem, and did not provide solutions keyed to either. Furthermore, the report does did not provide clear justification for the action items it suggested.
Instead of a clear common-sense set of reforms, the new report just muddied the waters. Listening to the doctors was not helping at all.
Listening to Not So Much Doctors as Health Care Corporate Executives, Directors and Lobbyists
The reason may be that the National Academy of Medicine report was written more by health care corporate executives, members of health care corporations' boards of directors, and lobbyists for health care corporations than by doctos. The report's author list appeared thus on the NAM website:
Victor J. Dzau, National Academy of Medicine; Mark McClellan, Duke University; Sheila Burke, Harvard Kennedy School; Molly J. Coye, AVIA; The Honorable Thomas A. Daschle, The Daschle Group; Angela Diaz, Icahn School of Medicine at Mount Sinai; The Honorable William H. Frist, Vanderbilt University; Martha E. Gaines, University of Wisconsin Law School; Margaret A. Hamburg, National Academy of Medicine; Jane E. Henney, National Academy of Medicine; Shiriki Kumanyika, University of Pennsylvania Perelman School of Medicine; The Honorable Michael O. Leavitt, Leavitt Partners; J. Michael McGinnis, National Academy of Medicine; Ruth Parker, Emory University School of Medicine; Lewis G. Sandy, UnitedHealth Group; Leonard D. Schaeffer, University of Southern California; Glenn D. Steele, xG Health Solutions; Pamela Thompson, American Organization of Nurse Executives; Elias Zerhouni, Sanofi
Thus two physician authors were obviously employees of large health care corporations. Both in fact were high ranking executives. Dr Lewis G Sandy, is Senior Vice President, Advancement, for UnitedHealth Group; and Dr Elias Zerhouni, is President, Global Research and Development, for Sanofi. Also, The Honorable Michael O Leavitt was the founder of Leavitt Partners, a business consulting group, whose clients include companies in the "pharmaceuticals and biopharmaceuticals, medtech and medical devices, health IT, diagnostics" and "commercial [health care insurance] plans," according to its website.
The author information provided at the end of this version of the article also stated that "the Honorable Thomas A Daschle is Founder and CEO of The Daschle Group, a Public Policy Advisory of Baker Donelson.' Note that Baker Donelson is a Washington, DC lobbying firm. Furthermore the author information included the fact that The Honorable Willaim Frist is "chairman of the Executive Board of the health service private equity firm Cressey & Company." Finally, Leonard D Schaeffer was identified as "the founding Chairman & CEO of Wellpoint."
While most of the other authors were listed as affiliated with academic organizations, some searching reveals that most of them had major financial relationships with for-profit health care corporations, including some of the largest. Many, in fact, had come to the attention of Health Care Renewal in the past because of their important conflicts of interest.
When Dr Victor Dzau was proclaimed the new president of the then Institute of Medicine, there was little initial discussion of his major conflicts of interest. At the time of the announcement, he was on the boards of directors of Alnylam Pharmaceuticals, device maker Medtronic, and sugary drink maker Pepsico (see our 2014 blog post). At the time of the announcement, he owned millions of dollars of shares or share equivalents of the three companies. In 2010, Duke University students had protested his multi-million dollar salary as Chancellor for Health Affairs (see our blog post).
We discussed in a 2013 blog post how Dr Mark McClellan transited the revolving door from his position as head of the Center for Medicare and Medicaid Services (CMS) in the Bush administration to positions as special advisor to private equity firm General Atlantic LLC, strategic advisory committee member for private equity firm Capital Royalty LP, on the advisory board for Castlight Health, and on the boards of directors of AvivReit and Johnson and Johnson. In 2016 we discussed how Dr McClellan pretended to be an independent scholar for the Brooking Institution while he was still on the board of Johnson and Johnson.
Sheila Burke is a strategic advisor to Baker Donelson, the Washington, DC lobbying firm for which Mr Daschle also works.
Dr Molly J Coye is currently on the boards of directors of health insurance company Aetna, and chairwoman of the board of Prosetta Biosciences Inc.
Former US Senator Thomas A Daschle's firm is actually a lobbying firm, and was officially registered as a lobbyist for Aetna in 2016 (per Politico). His firm is now part of Baker Donelson, a larger Washington, DC lobbying firm (as noted above).
Former US Senate Majority Leader Dr William H Frist was a founder of the Hospital Corporation of America (HCA) and likely holds millions of shares of related stock (per Wikipedia), and currently serves on the boards of directors of Teledoc, and "publicly held companies Select Medical and AECOM. In addition, he serves as a board member for several of Cressey & Company’s privately-held portfolio companies." He had been on the board of the controversial diagnostic testing company Theranos (per this news release).
After Dr Margaret Hamburg was confirmed commissioner of the US Food and Drug Administration (FDA) in 2009 in the Obama administration, we discussed how she had to divest herself of shares of medical supply company Henry Schein Inc, on whose board of directors she formerly sat, and how she and her husband, a top hedge fund manager, had to divest themselves of various other holdings that entailed conflicts of interest.
We first discussed Dr Jane E Henney's multiple conflicts of interest in 2006. Currently, she is on the board of directors of global pharmaceutical distributor AmeriSourceBergen and giant health insurance company Cigna. Recently, she had been on the boards of pharmaceutical companies AstraZeneca (through 2011), and Cubist (through 2014).
In 2011, we discussed how Michael D Leavitt, former US Secretary of Health and Human Services under the Bush administration, transited the revolving door to a position on the board of directors of Medtronic.
Leonard D Schaeffer serves on the boards of Walgreens Boots Alliance, Quintiles Transnational Holdings, Inc. and scPharmaceuticals Inc
Dr Glenn D. Steele is on the boards of directors for medical app developer Ingenious Med; Director, PTC Therapeutics; Director, Stratus Video; biotechnology company Synaptive Medical; and again large for-profit health insurance company Wellcare Health Plans Inc (look here).
By the way, in 2010, we discussed how Dr Elias Zerhouni, former Director of the National Institutes of Health (NIH) in the Bush administration, transited the revolving door to positions on the board of directors of biotechnology company Actelion and of Danaher, which makes, among other things, medical devices, and then to a full-time position with global pharmaceutical company Sanofi. In 2005 we discussed how Dr Zerhouni, as NIH director, lead a not very vigorous response to a series of scandals involving conflicts of interest at that august institution, after relevant government rules had been relaxed in the Clinton administration (see also this post and links backward).
Just to add to the confusion, while none of these relationships were noted in the version of the report on the NAM website, a few were listed in an online published version in JAMA.(7) The JAMA version omitted those of Dr Dzau; all of the relationships of Dr McClellan, save an admission that he "received personal fees from Johnson & Johnson"; Ms Burke's position with Baker Donelson; Dr Coye's position on the board of Aetna; Mr Daschle's position as lobbyist for Aetna; Dr Frist's positions on the boards of Select Medical and AECOM, and former position on the board of Theranos, although the JAMA version added a position on the board of Aspire Health; Mr Leavitt's board membership; Mr Schaeffer's membership on the boards of Quintiles and scPharmaceuticals; and all of Dr Steele's board memberships.
By my count, a majority, 13 of 19 authors had major financial ties to large for-profit health care corporations. The authors included three who worked for Washington, DC lobbying and consulting firms with major health care industry clients, including one who explicitly lobbied for for Aetna. The authors included top executives of UnitedHealth and Sanofi. The authors included current or recent members of the boards of directors of Alnylam Pharmaceuticals, Medtronic(2), Castlight Health, AvivReit, Johnson and Johnson, Aetna, Prosetta Biosciences, Teledoc, Select Medical, AECOM, Theranos, Aspire Health, AmeriSourceBergen, Cigna, AstraZeneca, Cubist, Walgreens Boots Alliance, Quintiles Transnational Holdings, scPharmaceuticals Inc, Ingenious Med, PTC Therapeutics, Synaptive Medical, and Wellcare.
The Washington Post article would better have been sub-titled, "Listen to Health Care Corporate Eexecutives, Directors, and Lobbyists."
A recent report by the prestigious National Academy of Medicine, now published electronically in JAMA, and an accompanying newspaper article promised common sense ideas for health care reform suggested by physicians. On its website, the Academy did not disclose most of the multitudinous and serious conflicts of interest of its authors. A version electronically published by JAMA disclosed a few more, but was still very incomplete. Relationships that were not disclosed included positions on the boards of directors of for-profit health care corporations, from start-ups to some of the biggest such corporations in the US. In my humble opinion, such incomplete and inconsistent disclosures was dishonest and deceptive.
The prevalence of health care corporate board members as authors of this report is particularly concerning. In 2006, we first blogged about a "new species of conflict of interest" which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care. We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] So it should be no surprise that the NAM report did not really suggest any radical ideas for health care reform, despite Mr Ignatius' title. Most of its authors were in a position to benefit from the status quo in health care.
Furthermore, it is no wonder the NAM report was confusing and muddled. As Joe Collier observed, "people who have conflicts of interest often find giving clear advice (or opinions) particularly difficult."(8)
In my humble opinion, the NAM report represents the sort of obfuscation that has been befogging discussion of health care policy for a long time. Wendell Potter described how years of debate on health care policy that started during the Clinton administration was defined by concepts developed by for-profit insurance company public relations departments to steer debate away from ideas would threaten their profits. In his book Deadly Spin, (p 64) he described a the AHIP (America's Health Insurance Plans, an insurance industry lobbying group) Strategic Communications Committee discourse on
the approach the industry would be taking when the reform debate heated up. The goal would be to divert the public's and the media's attention from the uninsured and toward problems the insurers coudl insist were beyond their control. The industry's spin, in other words, was going to be something like this: Health care costs are out of control because new treatments and technologies are more expensive than ever, the population's getting older and sicker, too many people are seeking care they don't really need, and health care professionals and providers are all too willing to provide the care that people don't need.
These putative causes of health care dysfunction, derived from an insurance industry organized public relations effort, have become the accepted wisdom. Note that there were vestiges of them ("rapidly aging population") among the somewhat disorganized presentation of causes of health care dysfunction in the NAM report. That there were not more of them may reflect the fact that the NAM report was not written just by people tied to the insurance industry. It also included many people tied to biotechnology, drug, device, etc companies.
Now during an era in which "fake news," propaganda and disinformation are in the headlines, we still see the terms of debate seemingly engineered by powerful health care organizations.
Physicians, other health care professionals, journalists, policy makers and the public at large should be extremely skeptical of apparently authoritative pronouncements on health care reform, especially when it is not clear what financial interests the authors of the pronouncements have, or when it is clear that the authors have important financial ties to large health care organizations, particularly large for-profit health care corporations.
At a minimum, media and certainly scholarly articles on health care reform and related policy issues should have at least as rigorous disclosure of conflicts of interests as clinical research articles.
Real health care reform would start with honest debate in which the contestants at least make clear their underlying financial interests.
1. Poses MD. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130. Link here.
2. Massachusetts Medical Society. Physician satisfaction survey (2001). Link here.
3.Pololi L, Kern DE, Carr P, et al. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med 2009; 24: 1289-95. Link here.
4. Poses RM, Smith WR. Faculty values. J Gen Intern Med 2010; 25: 646. Link here.
5. Pololi L, Ash A, Krupat E. Faculty values in the culture of academic medicine: findings of a national faculty survey. Link here.
6. Poses RM, Baier-Manwell L, Mundt M, Linzer M. Perceived leadership integrity and physicians’ stress, burnout, and intention to leave practice. J Gen Intern Med 2005; 20: S182. Link here.
7. Dzau DJ et al. Vital directions for health and health care: priorities from a National Academy of Medicine initiative. JAMA 2017; doi:10.1001/jama.2017.1964. Link here.
8. Collier J. The price of independence. Br Med J 2006; 332: 1447-9. Link here