Even given that some of the measures used are debatable, these are dismal results. No wonder US physicians are demoralized and burnt-out, as we first noted in our 2003 article. [Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Intern Med 14 (2003) 123–130. Link here.]
Health care dysfunction is commonly discussed in the US, especially since health care reform became a legislative priority during the Obama administration. The resulting Affordable Care Act (ACA, "Obamacare") resulted in some improvement in access to health insurance, but problems with access, quality and cost remain.
It is hard to understand how such a dysfunctional system continues without considering who benefits from it. One group who greatly benefit is health care organizational managers. We have frequently discussed their luxurious and ever increasing pay. Furthermore, often their pay seems wildly disproportionate to their accomplishments. For example, in June, 2017 we profiled the CEO of safety-net hospital who made over $1 million a year from an institution charged with caring for the poor. His institution demonstrated no great achievements in clinical care or improving patient outcomes. Meanwhile it was alleged that he tried to increase revenue via unethical means, and was even cozy with organized crime.
Such executive compensation is rarely challenged, but when it is, the responses are formulaic. Justifications are made by public relations flacks who are accountable to these executives, or the executives' cronies on their boards of trustees. As I wrote in 2015, and in May, 2016, It seems nearly every attempt made to defend the outsize compensation given hospital and health system executives involves the same arguments, thus suggesting they were authored as public relations talking points. Additional examples appear here, here here, here, here, and here, here and here.
They talking points are:
- We have to pay competitive rates
- We have to pay enough to retain at least competent executives, given how hard it is to be an executive
- Our executives are not merely competitive, but brilliant (and have to be to do such a difficult job).
As we discussed recently, these talking points are easily debunked. Additionally, rarely do those who mouth them in support of a particular leader show evidence that they apply to that leader. Could so many highly paid executives be so brilliant?
Instead we now we present cases from the second part of 2017 in which non-profit hospital executives were given lavish compensation just after they were forced out of their jobs.In alphabetical order by the states in which the hospitals are located...
Florida: Broward Health Vice President Got $214,008 After Allegations of Improper Payments Lead to Resignation
As reported by the Broward County (FL) Sun-Sentinel first on August 7, 2017,
Doris Peek resigned July 20 as senior vice president of Broward Health, which runs five hospitals and various clinics, after a law firm hired by Broward Health accused her of improperly directing nearly $1.7 million to a company owned by a prominent Republican consultant. At the time of the report, Broward Health released a statement saying that it took the report 'very seriously' and that 'every individual at Broward Health is held accountable in order to uphold established legal and ethical standards.'
Peek’s severance agreement, released by Broward Health in response to a public records request from the Sun-Sentinel, states that she will receive $214,008, most of which represents six months’ severance and the rest accrued leave.
Under the agreement, signed by Broward Health interim chief executive officer Beverly Capasso, Peek may cooperate with any government investigators or regulators looking into Broward Health, a taxpayer-supported system legally known as the North Broward Hospital District. But she promised to not take Broward Health to court and 'not engage in any activity either oral or written which disparage or adversely affect Broward Health.'
Such non-disparagement clauses are common in severance agreements, although they have been criticized for allowing employers to cover up problems.
The hospital administration gave no clear reason for the generosity of the agreement.
Asked why Broward Health would agree to such a payment, considering the highly critical contents of the report, Broward Health’s public relations agency, EvClay Public Relations, released this statement: 'It is the policy of Broward Health to not discuss severance agreements.' Pressed on the reason for this, the agency provided this statement: 'We respect the privacy of our employees.'
Given the placement of the non-disparagement clause in the agreement it is worth considering that the interim CEO, Ms Beverly Capasso, who approved the contract, was also under a cloud at the time it was written. The Sun Sentinel had previously reported,
The new chief executive of Broward’s largest public hospital system holds a master’s degree in health administration from a defunct university that has been identified by federal investigators as a diploma mill.
Beverly Capasso, who was just awarded a $650,000 annual salary to run Broward Health, received the degree from Kennedy-Western University, a mail and online institution based in California and Wyoming that closed in 2009 after failing to gain accreditation. Her resume invokes the degree at the very top, giving her name as 'Bev Capasso RN, BSN MHA.'
Furthermore, soon after the severance agreement was announced, the Sun-Sentinel reported more resignations among Broward Health management,
Two more top Broward Health executives quit this week, deepening the leadership turmoil at the taxpayer-supported hospital system.
Dionne Wong, senior vice president for human resources, and Mark Sprada, interim chief executive of Broward Health Medical Center in Fort Lauderdale, both resigned.
And in the months since, other major management problems became apparent.
The resignations come after Broward Health’s credit rating was lowered last month by S&P Global Ratings, which cited weak financial results and the leadership turmoil at the troubled system, legally known as the North Broward Hospital District.
After that, the hospital system was also alleged to have given a no-bid contract to 21st Century Oncology, allegedly with the involvement of Florida governor Rick Scott (News-Press, September 25); and has been under grand jury investigation for violations of the open meeting law (Sun-Sentinel, September 26).
Ms Peek was allegedly involved in improper contracting. While Ms Peek may not have been responsible for all the additional trouble and turmoil at the hospital system, she surely participated in it. On the other hand, there is no obvious offsetting evidence of the brilliance of her management. Why reward her with such a generous severance package?
Georgia: South Georgia Medical Center CEO Will Get More than $2M After Allegations of Violations of Open Meeting Law Lead to Termination
As reported by the Valdosta (GA) Daily Times, July 6, 2017,
The former South Georgia Medical Center CEO will be paid more than $2 million over the next three years, for doing nothing.
Raymond Snead was ousted as CEO in March, but he’ll stay on the payrolls for a while, according to his termination letter.
The April 19, 2017 letter, effectively firing Snead, called the ouster a 'termination without cause.'
The hospital will continue to pay Snead $650,000 per year — his base annual salary — for the next three years, the letter says. He’ll also get a $2,000 car allowance each month during that period.
The local Hospital Authority, which governs the hospital, also gave Snead and his wife the option to receive health benefits for the three years. He took the offer, said Sam Allen, Hospital Authority chairman.
However, it appears that this executive also had not previously covered himself in glory, certainly not sufficient to justify this level of post-employment compensation.
Snead became CEO in September 2015, and the hospital had been under fire for poor management practices under his watch.
There also was a major issue with an apparent subordinate of Snead's on his watch.
Snead’s ouster came on the heels of the resignation of hospital attorney Walter New.
New, along with the entire Hospital Authority, got into trouble in 2016 when the group held a closed meeting without the public’s knowledge, which is a violation of Georgia law.
Furthermore, City Councilman Robert Yost
has called repeatedly for the resignations of Hospital Authority members, saying their mismanagement has caused the hospital great harm. 'They have run the ER into the ground. They have run off doctors, nurses and regular employees, some who have worked there for 25 to 30 years,” he said at the June 22 City Council meeting.
'They have intimidated employees and treated them like dirt. When it is time to reappoint the City of Valdosta’s representatives on this authority, I say let’s make sure they are all reappointed.'
'… (They) have again made very bad business decisions on our behalf and they should all be fired.'
Again, it seems that Snead's management was the opposite of brilliant, yet he was allowed to walk away with a multi-million dollar severance package.
North Carolina: Nash UNC Health Center CEO Will Get More than $1M After Concerns about Revenue Losses and Patient Safety Lead to Retirement
As reported by the Rocky Mount (NC) Telegram, July 16, 2017, Larry Chewning the CEO of Nash UNC Health Care retired
with around $1 million since he has an ironclad two-year rolling contract, according to multiple sources familiar with the situation but not authorized to speak publicly on the matter.
Chewning didn't deny the amount he is receiving....
However, it turns out that he did not actually retire, but,
was asked to step down late last month by the local hospital board but was allowed to announce he was retiring.
The hospital was hardly transparent about the facts of the case, which were futher confused by (perhaps deliberately) complicated corporate relationships:
Inquiries into Chewning's salary and severance package led the Telegram on a goose chase involving lawyers, public relations spokesmen and uninformed officials.How public hospitals can have CEOs who are employees of a separate, private hospital system was not explained.
Beginning with Chewning, there has been a series of refusals to disclose the salary of the top executive at a publicly-owned hospital in a state-owned network of hospitals. Drilling down, it was discovered that all the CEOs in the UNC system except for the UNC Medical Center in Chapel Hill are employed by Rex Hospital, a privately-owned hospital in Raleigh.
'I am legally precluded from disclosing any information from my employment agreement with Rex Hospital,' Chewning said, including the contact information for Don Esposito, Rex Hospital's general counsel.
Esposito referred the Telegram to Alan Wolf, the media relations manager for UNC Health Care and UNC REX Healthcare.
'We comply with all legal requirements, but it's not our practice to disclose salary information, for competitive and privacy reasons,' Wolf said. 'Mr. Chewning is employed by Rex Hospital Inc., which is not a North Carolina governmental entity and therefore is not subject to Chapter 132, the Public Records Act.'
Even local government officials were kept in the dark.
Nash County officials said they understood that's they way it had to be, but none of them knew the CEO was being paid through Rex, which makes their salaries private.
Furthermore,
At least one member of the local hospital board said they don't understand how the process works and isn't sure how the hospital will get a new CEO. 'As part of the management agreement, UNC Health Care provides Nash with a CEO,' Wolf said. 'Having a centralized management team gives UNC Health Care more control over decisions and operations at its affiliated hospitals.'
But the hospital CEOs "provided" by state institution UNC all are employed by Rex?
Perhaps all this secrecy just added to the cognitive dissonance created when considering how Chewning's lucrative retirement package might have been related to events that lead up to Chewning's retirement:
Chewning's exit comes after the hospital has been losing money and in the wake of a negative patient safety report. Chewning will remain with the hospital while his replacement is sought, according to his retirement announcement.
So Chewning's management was hardly brilliant. Yet those responsible for hospital governance were not only happy to let the CEO walk away with a munificent retirement package, they also did their best to obscure the facts of the matter
Ohio: Ohio State University Werner Medical Center CEO Receiving More than $1M Per Year as Senior Consultant After Complaints by Physicians Lead to Resignation
According to the Columbus (OH) Dispatch, August 16, 2017, after Dr Sheldon Retchin, the CEO of Ohio State University Wexner Medical Center resigned in May, but
from his resignation, which was announced on May 10, through June 30, Retchin was still paid the CEO and executive vice president salary and benefits for performing 'transitional duties,...
That base salary was $1.1 million.
[To make full disclosure, note that I was a colleague of Dr Retchin's when we were both young faculty members in the Department of Internal Medicine at the Medical College of Virginia from 1987 - 1994.]
Thereafter,
a contract obtained by the The Dispatch on Tuesday shows that, since July 1, Retchin has been serving as senior advisor to the president for health policy at a base salary of $500,000 annually. The university is also making a $600,000 annual contribution to a retirement plan for Retchin, who will hold the position for two years.
So his total compensation would be at least $1.1 million a year for two years post-retirement. Also,
the new contract says he will be paid a 35 percent performance bonus.
The rationale for this new position per university spokesman Chris Davey was that
Retchin will make important contributions to Ohio State.
'Sheldon Retchin is a nationally known leader in health-care policy,' Davey said. 'During his two-year administrative appointment, he will advise the university concerning the critical issues of health-care reform, Medicaid policy and data-driven improvements to health outcomes.'
Left unsaid is that $1.1 million a year seems like greatly inflated compensation for a health policy adviser.
Also left unsaid were the circumstances surrounding Dr Retchin's departure.
Complaints against Rechin surfaced after a May 1 letter signed by 25 leading physicians criticized his leadership. That was followed by a letter from five doctors representing the senior leadership of the medical center's Neurological Institute. Another group of 14 physicians, who head clinical departments at the medical center, had engaged in discussions with top university l eaders.
Upon Retchin's resignation, the university issued a statement in which it said that allegations raised in the letters were untrue. That prompted another critical letter from leaders in the College of Medicine's Department of Internal Medicine.
A report from a local television station's news department provided further details about why the physicians declared no confidence in Dr Retchin
Dozens of doctors and professors have written letters expressing 'no confidence' in the CEO of Ohio State's Wexner Medical Center.
10TV has obtained three letters from three different groups of doctors and staff members, including department chairs and senior leadership.
They all described problems with management and morale that they said are damaging care and endangering patients and issued a 'Vote of No Confidence' in CEO Sheldon Retchin and his leadership team.
They accused Retchin of a 'management style that is inconsistent with the University's values of excellence, integrity, transparency and trust' and of fostering a culture where physicians have been described as 'lazy' and the program called 'a complete mess.'
It has led to what they call a 'dramatic impact on morale' and 'an increasing number of faculty resignations.'
They said the consequences reach beyond the walls of the Wexner citing an ongoing shortage of doctors which in their words, 'endanger(s) patient safety and lowers the quality of care,' adding to the stress of remaining faculty.
Furthermore,
In the first letter, 25 staffers who signed it said they represent many more employees, but limited the number signing out of concern for retaliation.
They complained of threats against faculty leaders who don't 'get on board' with the plans of medical center leadership.
From the information publicly available, I cannot tell whether the complaints about patient safety and quality of care are valid. Certainly, however, Dr Retchin's management was questionable. Creating this degree of anger among the physician staff of an academic medical center hardly seems the mark of brilliant leadership. Yet Dr Retchin, like the other executives above, seems to have been generously rewarded after he was forced out.
Summary
The plutocratic compensation given leaders of non-profit hospitals is usually justified by the need to competitively pay exceptionally brilliant leaders. Yet even leaders whose records seem to be the opposite of brilliance often end up handsomely rewarded. Thes are examples of perverse incentives.
Other aspects of top health care managers' pay provide perverse incentives. While ostensibly tied to hospitals' economic performance, their pay is rarely tied to clinical performance, health care outcomes, health care quality, or patients' safety. Furthermore, how managers are paid seems wildly out of step with how other organizational employees, espeically health care medical professionals, are paid.
Exalted pay of hospital managers occurred after managers largely supplanted health care professionals as leaders of health care organizations. This is part of a societal wave of "managerialism." Most organizations are now run by generic managers, rather than people familiar with the particulars of the organizations' work. The best current example is the election of a business executive with an MBA to the Presidency of the United States.
Rather than putting patient care first, paying managers sufficiently to make them rich now seems to be the leading goal of hospitals. I postulate that managerialism is a major reason the US health care system costs much more than that of any other developed country, while providing mediocre access and health care quality.
Improving the situation might first require changing regulation of executive compensation practices in hospitals, improving its oversight, and making hospital boards of trustees more accountable. But that would be just a few small steps in the right direction
True health care reform might require something more revolutionary, the reversal of the managers' coup d'etat, returning leadership of health care to health care professionals who actually care about patients and put their and the public's health first, ahead of their personal gain. Of course, that might not be possible without a societal revolution to separate managers from the levers of power in government, industry, and non-profit organizations.
And it continues....
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