Spin it Again - Four More Go Through the Revolving Door From the World of Corporate Health Care to Top US Government Leadership Positions

While we were distracted by the daily onslaught of news, it appears that the revolving door continues to spin.

This month there has been a flurry of transitions from big health care and health care related corporations to the federal government.  So it appeared to be time for another revolving door update.


We start with a transition from a few months ago that we had not previously discussed, and then list in chronologic order those occurring this month.

Dr Kurt Rasmussen from Senior Research Advisor, Eli Lilly & Co to Director of the Division of Therapuetics and Medical Consequences, National Institute for Drug Abuse (NIDA)

This was noted in Stat News Plus, behind a pay wall, and in an official announcement from NIDA on April 30, 2018,

The National Institute on Drug Abuse (NIDA), a component of the National Institutes of Health, welcomed Dr. Kurt Rasmussen today as the Director of the Division of Therapeutics and Medical Consequences (DTMC). Dr. Rasmussen’s career spans more than 30 years of research and leadership experiences in pharmacology and neuroscience therapeutics.

Dr. Rasmussen comes to NIDA from Eli Lilly & Co., where he served as a senior research advisor, leading drug discovery research programs.

At least he is an actual biomedical researcher.

I could not find any information on whether he has ongoing financial ties to Eli Lilly, e.g., stock holdings.

Dr Richard Stone from Vice President, Booz Allen Hamilton, [a Management Consultancy] to Temporary Executive in Charge of the Veterans Health Administration

Per the Wall Street Journal, July 17, 2018,

The Department of Veterans Affairs will replace the acting head of its health care system with a temporary appointee on Wednesday, the VA’s acting secretary said Tuesday, though the department still hasn’t settled on a permanent replacement to lead the sprawling division.

Dr. Richard Stone will take over the Veterans Health Administration, the VA’s acting secretary, Peter O’Rourke, told reporters. The health administration is one of the three main branches of the VA and comprises more than 1,500 health-care facilities, thousands of physicians and nurses and a budget of about $70 billion to treat some nine million veterans.

Also

Dr. Stone, a retired Army doctor, previously served at the VA as deputy undersecretary for health before becoming a vice president at Booz Allen Hamilton focused on military health.

Booz Allen Hamilton is a management consulting firm.  The Booz Allen Hamilton press release of January 29, 2016, issued when Dr Stone joined the firm, described his responsibilities 

General Stone will serve as medical advisor for Booz Allen’s healthcare clients who are transforming healthcare delivery in the defense, civil, and commercial markets. He will assume a leadership role in the firm’s work for the Military Health System (MHS) across the Services and ultimately across the new Defense Health Agency (DHA) and Enhanced Multi-Service Markets (eMSMs).

Booz Allen Hamilton apparently does not widely advertise the identities of its clients, but on the Markets section of its website, claims

We serve commercial clients across all industries, including some of the largest organizations in critical infrastructure sectors like financial services, energy, healthcare, and manufacturing, and we have a thriving cadre of international clients in the Middle East and Southeast Asia.

So presumably Dr Stone had responsibilities helping big commercial health care firms improve their bottom lines. In his new position, Dr Stone may be in a position to influence how some such big firms interact with the VA in an administration that is increasingly advocating privatization of many VA functions.

Paul Mango from Director, McKinsey & Company, [a Management Consultancy] to Chief of Staff and Principal Deputy Administrator, Center for Medicaid and Medicare Services (CMS), Department of Health and Human Services (DHHS)

Per the Philadelphis Inquirer on July 24, 2018,

Paul Mango, a former health-care consultant who lost a bid this year to be the Republican nominee for governor of Pennsylvania, is joining the Trump administration.

The Center for Medicare and Medicaid Services, which is housed in the Department of Health and Human Services, on Tuesday named Mango chief of staff and chief principal deputy administrator.
In addition,

Mango, who lives outside Pittsburgh, was a longtime executive at the consulting firm McKinsey & Co.

It appeared he needed something new to do.  He had left his very long-term position with McKinsey & Company to run for Governor of Pennsylvania in 2017, per Politics PA,

PoliticsPA has learned that Gubernatorial Candidate Paul Mango of Allegheny County is no longer with McKinsey & Company. This move could signal he is closer to an official announcement of a run for Governor.

Mango left the firm earlier this year. He joined McKinsey in 1988,

But then, per the Inquirer,

He finished second in a three-candidate primary in May for the GOP gubernatorial nomination, losing to former State Sen. Scott Wagner.

leaving Mr Mango temporarily unemployed.  His new employment apparently was not due to any actual background or expertise in medicine, health care, or public health,

An Army veteran, Mango graduated from the U.S. Military Academy and Harvard Business School.

The Inquirer article suggests Mr Tango was attractive to the Trump regime more for his political views than any expertise or lack thereof in health care,

Mango ran as a social conservative who attacked Wagner for supporting anti-discrimination legislation that would protect LGBT individuals. He said during the campaign that he supported work requirements for able-bodied adults on Medicaid. The Trump administration has adopted that approach.

Mr Mango does claim expertise as a business manager in the health care sphere.  He has an affiliation with the University of Pennsylvania's  Center for Health Incentives and Behavioral Economics in the Leonard Davis Institute.  His profile there explains his former work at McKinsey thus,

Mr. Paul Mango is a Director for McKinsey & Company and leads the North American Payor/Provider practice. Mr. Mango has been addressing new approaches to medical management, development of distinctive service strategies, physician channel management effectiveness, and applying lean manufacturing principles to patient care delivery processes. He has led health care engagements spanning a broad spectrum of strategy, operations and organization topics related to these new approaches. Paul works extensively with some of the country’s largest payers and providers....

McKinsey & Company does not advertise its clients, but it is likely that the Payor/ Provider group worked with major, non-profit and for-profit hospital systems and health insurers.  Its website discusses its "payor strategy" thus,

The challenges facing the leaders of payor organizations—improving financial performance, increasing cost effectiveness, improving population health status, and boosting quality of care—are not new. What is different today is the increasing need to address them all.

Our strategy work focuses on driving value. The starting point varies depending on the clients and geography, but whether we are supporting a public payor, a private payor, or a mix, we have a deep understanding of the complexities our clients face and can draw upon our international experience for best practices and key insights.

Its website also discusses "provider performance" thus,

We help hospitals implement strategies, operating models, and organizational enhancements that sustain improvements in quality of care and boost cost effectiveness.

So presumably Mr Tango's responsibilities including the cost effectiveness of commercial health insurance firms and quite possibly for-profit hospital systems.  In his new position with CMS, Mr Mango may be in able to influence how big payors and providers interact with the Medicare and Medicaid systems, potentially to their benefit.


Chris Traylor from the [Health Care Consultancy] Advanced Perspectives Group to Deputy Administrator for Strategic Iniatives for the Center for Medicare and Medicaid Services (CMS) of DHHS

On July 24, 2018, an announcement from CMS noted that Chris Taylor was joining the organization along with Mr Mango,

Chris Traylor joins the Office of the Administrator as the Deputy Administrator for Strategic Initiatives. Chris comes to CMS with over 26 years of public sector service in the area of healthcare and social services. His lengthy public service career in Texas concluded in 2016 when he retired as the Executive Commissioner of the Texas Health and Human Services Commission (HHSC) after previously serving as the commission’s Chief Deputy Executive Commissioner.

So it appears Mr Taylor has a long experience in health care management within state government.  I could find nothing to indicate he has any direct experience or expertise in medicine, the actual provision of health care, or public health.  But also,

Since 2016, Chris has been leading a healthcare consulting firm serving clients in hospital operations and finance, long term services and supports, dental and oral health services, managed care and bio-health.

It appeared that since 2016, he worked for the Advanced Perspectives Group, which is, per its web-site,

a newly formed consortium of uniquely qualified consultants who have worked extensively in the health and human services arena both at the state and federal levels. Collectively, we have over 200 years of experience working in a variety of leadership positions in state and federal government. This experience brings our clients an important resource and an unparalleled understanding of agency operations and policy formulation-which enables us to help our clients create solutions that fit within the framework of Texas Health and Human agencies, their federal partners, and the policies that fall within those jurisdictions.

Advanced Perspectives Group, like other commercial health care consultancies, does not advertise its clients, but the biographies of individual principals suggest that clients include for-profit health care corporations.  Again, in his new position Mr Traylor may be able to influence how such corporations interact with Medicare and Medicaid. 

Discussion

So this round of revolving door transitions featured a top pharmaceutical company researcher going to a leadership position at the NIH, which was considered long ago as a producer or unbiased science; and one physician-manager and two pure managers going from big management consultancies to DHHS.  All these consultancies seem to have thriving businesses working with big commercial health care firms. So the Trump regime continues to stock top health care leadership positions with people from the commercial health care world.  These leadership positions will allow them to to control contracting with, policies that affect, and regulation of big health care corporations, including those they worked with or for, and their competitors, for that matter.

So, as I have said before, e.g., three and four months ago,

The revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door from industry to the Trump regime once again suggests how the revolving door may enable certain of those with private vested interests to have disproportionate influence on how the government works.  The country is increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

 The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.
 

Chipping Away at the Anechoic Effect: Now the New York Times Protests the Demise of the AHRQ National Guidelines Clearinghouse

Background: the Quiet Announcement of the Death of the Clearinghouse

On June 1, 2018, we wrote:

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.

We went on to summarize the importance of this clearinghouse as a reasonably comprehensive source of material about the myriad clinical practice guidelines that have been promulgated ostensibly to improve medical care.  Its importance was recently enhanced by the addition of ratings of the trustworthiness of particular guidelines derived from standards developed by the US Institute of Medicine (look here).  In turn, these standards were necessary because many published guidelines were afflicted with methodologic problems.  Some amounted to little more than informal recommendations of experts.  Many guidelines were suspected of being influenced by commercial sponsors or by the financial relationships of the people involved in developing them.  Pharmaceutical, biotechnology, device and other firms that market health care goods and services have long been interested in meddling in guideline development to assure that guidelines put their products and services in a favorable light.

We concluded

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.

Again, note that as of June 1, 2018, nothing about the shutdown of the clearinghouse had appeared in the media, or in medical or health care scholarly journals.  We hoped maybe the post in our humble blog would start some discussion.

Further Media Coverage

At the time, despite our hopes, experience suggested nothing much would happen.  This time, however, we were wrong.

Stat News

The topic was picked up on June 13, 2018 by Stat News.  Ivan Oransky and Adam Marcus opened with:

Diagnostic and treatment guidelines aren’t sexy, but they play a vital role in the practice of medicine.

Oransky and Marcus found that the NGC was actually fairly heavily used, drawing 200,000 visitors a month.  After further summarizing the issue, they noted the ambiguous official justification for the closure of the clearinghouse.

'The decision to end support for the NGC was an Agency decision based on assessing how best to use our current resources, including both appropriated dollars and dollars from the Patient-Centered Outcomes Research Trust Fund,' the AHRQ spokesperson told STAT. The AHRQ budget for the 2019 fiscal year, as proposed by the Trump administration, 'will re-focus support to only the highest priority research programs.'

They also excerpted our conclusions above, and lamented,

With the date of death for the NGG barely a month away, America’s doctors — and their patients — may, to paraphrase another clearinghouse, already be losers.

Daily Beast

One month later (July 12, 2018) the Daily Beast published a longer account of the then impending shut down of the clearinghouse, written by Jon Campbell, an investigator for the Sunlight Foundation.  Campbell noted how

medical research like that maintained by the NGC can be politicized, [so] AHRQ drew the ire of then-congressmember Tom Price in 2016 when it published a study critical of a drug manufactured by one of his campaign donors. According to ProPublica, one of Price’s aides emailed 'at least half a dozen times' asking the agency to pull the critical research down. Price was the first director of HHS, AHRQ’s parent agency, under the Trump Administration, before resigning under pressure last year over his spending on chartered flights.

Note that we had discussed then Representative Price's intervention here.

Campbell interviewed several people, including your humble scribe, about the meaning of the AHRQ's actions, and concluded with

'Losing [the NGC] is really losing a valuable resource,' said Ana Maria Lopez, President of the American College of Physicians. She said the NGC is a primary source for her organization’s research, and noted that digital repositories like the NGC are only more critical today.

Other Coverage

Since then, Vox and CNN have covered the issue on July 16, the day of the planned shutdown. The surge of concern about the topic did not apparently prevent it from happening, however.

The New York Times Weighs In

Today, however I was surprised by the lead editorial in the New York Times today about the demise of the NGC, entitled "Want Reliable Medical Information? The Trump Administration Doesn’t." It included this pithy comparison:

The official explanation is maddening enough: a budget shortfall that roughly equals the amount Tom Price spent on travel during his brief tenure as department secretary. The site costs just $1.2 million a year to operate, and is maintained by an agency with a budget of more than $300 million.

It concluded hopefully with:

A better solution would almost certainly be for Congress to appropriate the money needed to keep the database up and running. It could do that simply by renewing the Affordable Care Act fund that was covering the database’s operating costs, and that is scheduled to expire in 2019.

Of course, Congress will take that action only if constituents demand it. But in a country that has voted representatives in and out of office based on their health care policies, and that prides itself on drawing attention to intractable diseases (we dump ice buckets on our heads to raise funds to fight A.L.S., and walk countless miles for breast cancer), evidence-based medicine should be an easy sell. 

I am not holding my breath.  However, I never thought this issue, perhaps a small on given the huge political dysfunction that grips the country, would make it much farther than my blog post of June 1.  So we can hope. 

Furthermore, there has been movement towards preserving some of the clearinghouse's functions.  As discussed in Modern Healthcare on July 17, 2018, the ECRI Instsitute plans to resurrect the site.  It would no longer be free, but will be based on a subscription model which ECRI hopes will keep the costs reasonable.  So at least that is real progress since June 1.  

Discussion

Many people bemoan the current political situation, but some feel there is nothing they could possibly do the improve things.  We have been publishing this blog since 2004 with the hopes that chipping away at the anechoic effect which has hid the severity and nature of health care dysfunction might actually help to improve things.  However, at times we wondered if we were having any effect.  What good are individual actions like blog posts? 

It seems that most of us have little individual power.    Collectively, though we may have more than we realize.  Small individual actions can add up. I hope the at least partial resurrection of the National Clinical Guidelines Clearinghouse will provide an example that will inspire further individual actions to address health care dysfunction, and the much larger political and economic dysfunction that generate it, and that now threatens us all.  

A Physician Who Had Run Clinics Which Proselytized Patients is Now a Government Health Care Leader Positioned to Enforce Her Religious Beliefs on Patients and Citizens Who Do Not Hold Such Beliefs

Introduction: Physicians' Values and Organizational Missions

Physicians professional values require them to put the interests of their individual patients ahead of all else, including the physicians' self interest.  The AMA Principles of Medical Ethics, for example, includes

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

Similarly, in health policy and public health, the goal ought to be putting the health of patients as a group, and the public at large, ahead of other considerations.

However, we have often discussed how leaders of large health organizations seemed to put other considerations ahead of individual patients', patients' collectively, or the public's health.  Most of those examples of mission-hostile management involved putting organizational finances, or the leaders' own finances ahead of patients' and the public's health.  For example, in 2017 we discussed a New York hospital CEO who seemed to put revenue generation in support of his own very generous paycheck ahead of quality of care and patient safety (look here).  Also, the revered Mayo Clinic seemed to let patients with more remunerative commercial insurance coverage get attention before poor patients who have only government insurance, despite its stated mission "providing the best care to every patient" (look here).  Before November, 2016, our examples of mission-hostile management were mainly hospitals and health systems, insurance companies, and pharmaceutical, biotechnology and device companies.


That was then.  This is now.

A Physician Who Seemed to Put Her Religious Beliefs Ahead of Patients' Interests

Late this spring, we noticed the appointment of a US government health care leader which raised concerns about mission hostile management, but in a new dimension. The appointment was summarized by Rewire on May 30, 2018,

Diane Foley, who ran a Christian organization operating two Colorado anti-choice 'crisis pregnancy centers,' or fake clinics, was quietly installed on Tuesday as deputy assistant secretary for population affairs, where she will lead the office responsible for the Title X federal family planning program.

The U.S. Department of Health & Human Services (HHS) said little about Foley in its announcement of her appointment to the Office of the Assistant Secretary for Health, saying she 'has a long and distinguished career working in the healthcare and the public health arenas.'

Foley will oversee the Office of Population Affairs (OPA), which administers Title X, a program providing family planning and related services to more than 4 million primarily low-income people in the United States, many of whom face systemic barriers to health care.

While Dr Foley's purview would be providing family planning services, she seems to opposed to the provision of most conventional family planning services,not only abortion, which is admittedly controversial, but also including contraception, and adoption.  For example, as reported by Tonic (a part of Vice News) on June 5, 2018, she said in a speech on 2016 that a pregnant woman has three choices

parent the child, give it up for adoption, or have an abortion .... She said that having the baby is thought of as 'death to [the parents] and the life they thought they were going to have,' adding, 'The next choice is, let’s do an adoption plan. Well, that’s a double death, because not only does it interrupt [the parents] plans for the next several months, right? But then their child is going to be adopted, and they’re going to grow up thinking they’ve been abandoned by their parents. So they’re going to have all kinds of issues with their life. So that’s a double death. That’s worse.'

Given her opposition to adoption, it is not much of a surprise that she seems opposed to even talking about the simplest forms of contraception. The Rewire article stated,

Foley suggested that it may be considered 'sexually harassing' to demonstrate in a classroom how to use a condom on a banana, the Colorado Springs Independent reported in 2010.

Foley is a physician.  Another Tonic (from Vice) article on June 5, 2018, noted that an official DHHS statement about Dr Foley's hiring stressed,

that Foley is a board-certified pediatrician with 30 years of experience, most recently in private practice in Colorado.

 
The DHHS official leadership bio for Dr Foley went into more detail,

Dr. Foley is a graduate of Marion College (now Indiana Wesleyan University) and of Indiana University School of Medicine. She is a Diplomat of the American Board of Pediatrics, a member of the Society of Adolescent Health, and served on numerous other national boards and committees.

Also,

Dr. Foley has spent her professional career in the clinical practice of pediatrics with a focus on adolescent health. Originally from Indiana, Dr. Foley founded and served as medical director of Northpoint Pediatrics shortly after completing a residency in pediatrics. She spent the next seventeen years establishing what is still one of the largest pediatric practices in central Indiana. During this same period, she also served as a pediatric clinical instructor for pediatric and family practice residency programs at the Indiana University School of Medicine. Dr. Foley’s areas of special interest are adolescent gynecology, prevention and treatment of sexually transmitted diseases, healthy family formation, and global health, all of which she continued to focus on after her move to Colorado in 2004.

Most recently, she was in part-time clinical practice at a certified Centers for Medicare & Medicaid Services Critical Access Hospital in Lamar, Colorado.

As a physician, Dr Foley's prime directive was to put the interests of individual patients ahead of her self-interest.  If Dr Foley had religious convictions that would not allow her offering women patients mainstream management approaches to family planning, for example, adoption or contraception planning, Dr Foley could have chosen to practice in a setting where she need not have ever offered those options, for an example relevant to pediatrics, neonatology.  However, it seemed that Dr Foley chose to explicitly put herself in situations where she could combine proselytizing with practice.  As described in a Slate article of June 1, 2018, stated,

Until last year, she was the president and CEO of the Life Network, an organization that operates two anti-abortion crisis pregnancy centers in Colorado Springs that run abstinence-only education programs for teens. The purpose of crisis pregnancy centers is to convince women not to have abortions, sometimes after luring them in with deceptive advertising that makes them seem like abortion clinics or general health facilities. 'Through our pregnancy centers we have the opportunity to see God use the miracle of ultrasound to change and save lives,' Life Network’s website says. The first element of its mission is 'presenting the gospel of Jesus Christ.'

The fundamentally deceptive nature of these clinics seem to suggest that Dr Foley violated another provision of the AMA Principles of Medical Ethics

II. A physician shall uphold the standards of professionalism, be honest in all professional interactions,...

Thus, rather than avoid clinical situations in which abortion would be considered to be a management option, she chose to work in such settings in order to try to prevent patients from having abortions, based on religious grounds.  She worked in what looked like clinics, but which were dedicated to preaching the gospel.

Furthermore, the organization Dr Foley ran also specifically sought to deter young women from using conventional contraception. Tonic (part of Vice News) reported that the organization Dr Foley led

Life Network, the organization that Foley led until 2017, offers 'sexual risk avoidance programming,' aka abstinence-only sex ed, for middle and high school students, under the moniker Education for a Lifetime. As part of her work with that program, Foley told a reporter in 2010 that it’s too difficult to teach teenagers how to use condoms and that demonstrating how to use a condom on a banana could be considered 'sexually harassing.'

As an aside, in an interview reported by Tonic, Dr Foley seemed to espouse views on adverse effects of abortion that are unsupported by clinical research evidence,

'The way abortions are done, there is not enough supervision or regulation for them and it puts women at risk. There are not the same standards as other surgical centers, there are not the same requirements in terms of having the same hospital privileges in case something goes wrong,' she said. 'What I'm concerned about is that there is a sense that it's healthcare for women and there are a lot of things about it that are not good healthcare," Foley added. Abortion care has significantly lower complication rates than other common procedures (like wisdom tooth extraction and tonsillectomy), and patient satisfaction rates are much higher than they are for general medical care.

Another falsehood Foley has repeated, and that her former company Life Network also claims is true, is that abortion causes lasting mental-health problems. In a September 2016 presentation for Charis Bible College where Foley was introduced as the president of Life Network, she claims ... that this is a condition with an accepted diagnosis:

'There is actually a true, emotional diagnosis that is now starting to be recognized—even though if you look at national media and secular media, they still try to ignore the fact—but there is actually a diagnosis called post-abortion stress and also post-abortion traumatic syndrome, that is a result directly of someone having an abortion or being involved with an abortion that happens,' she said. 'Here is the thing that is incredible to me. I am a trained physician, went through training, got not one single lecture throughout the course of my training about this situation.'

The American Psychiatric Association does not recognize post-abortion syndrome or any related category as an identifiable mental health condition in the DSM-V , a manual that defines and classifies mental disorders.

 So Dr Foley seemed to have engineered an ostensibly clinical career that put her in a position to proselytize patients in the guise of medical practice, not only about abortion, but about contraception.  It is not at all obvious that Dr Foley limited her anti-abortion, anti-contraception, and presumably even anti-adoption preaching to women who agreed with her religious views and who had no interest in any of these options.

Discussion

Dr Foley is certainly entitled to her religious views.  She is also entitled as a physician to avoid situations in which normal standards of care would push her to provide services to patients that conflict with her religious conviction.  But she is not entitled as a physician to proselytize in the guise of medical practice.

Furthermore, as a leader in a government health agency, she is not entitled to use that agency's power to enforce her personal religious beliefs on patients who do not hold such beliefs.  Given her career, though, there is every reason to worry that she will do so.  Furthermore, it was not clear why she was selected for this powerful government leadership position other than to allow her to proselytize.

We recently discussed other examples of people appointed to top positions in the US Department of Health and Human Services who seemed very hostile to the organization's mission.  Again, it seemed unlikely that these people were appointed for any reason other than to attack the mission.

Furthermore, like Dr Foley, they seemed to have been appointed to impose their personal religious views on the American population.  As we stated then, they all seem to be in a postion to undermine fundamental principles of US government enshrined in the Constitution, including prohibiting the government from establishing a religion or preventing the free expression of any religion, and equal application of the laws and provision of due process to all people, again regardless of their religious beliefs, race, ethnicity or sex.

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.    

"Hope in a Bottle" - Components of Purdue Pharma Stealth Marketing Campaign for Oxycontin Revealed by Legal Documents from Tennessee

Introduction: Disinformation and Stealth Marketing Campaigns

Back in the distant past the US government made some attempt to hold big health care corporations to account for misleading marketing practices.  We learned a lot about these practices from documents revealed in the resulting litigation, and in particular, about stealthy, deceptive systematic marketing, lobbying, and policy advocacy campaigns on behalf of big health care organizations, often pharmaceutical, biotechnology and medical device companies.  For example, in 2012 we found out about the stealth marketing campaign used by GlaxoSmithKline to sell its antidepressant Paxil.  This included manipulating and suppressing clinical research, bribing physicians to prescribe the drug, use of key opinion leaders as disguised marketers, and manipulation of continuing medical education.  Other notable examples included Johnson and Johnson's campaign to sell Risperdal (look here),  and the infamous Pfizer campaign to sell Neurontin (look here and here).  We also found that stealth marketing seemed to be partially responsible for the growing popularity of narcotics (opioids) starting in the 1990s (look here).

The organization and complexity of stealth marketing, lobbying and policy advocacy campaigns have often been sufficient to characterize them as disinformation.  For example, we characterized the campaign by commercial health insurance companies to derail the Clinton administration's attempt at health reform in the 1990s, as described by Wendell Potter in his book, Deadly Spin, as just that (look here).  The tactics employed in that campaign included: use of front groups and third parties (useful idiots?); use of spies; distractions to make important issues anechoic; message discipline; and entrapment (double-think).

Nowadays, the current Trump administration does not seem interested in pursuing unethical or corrupt practices by big health care corporations.  A health care corporate fraud strike force was downsized by the Trump administration as we noted in July, 2017.  By May, 2018, legal actions by the US government against apparently corrupt acts by large US health care organizations seemed to be falling off.  Only one significant settlement had made that year.  Bloomberg published a report with the headline, "White-Collar Prosecutions Fall to 20-Year Low Under Trump," on May 25, 2018.  Meanwhile, the administration pulled one former stealth marketer through the revolving door to serve in the White House (look here), and has been  pushing its own disinformation campaigns (look here).
 
However, some state attorneys general and local prosecutors have picked up the baton.  In particular, as the opioid epidemic continues, they have filed many lawsuits against corporations that profited from narcotics sales.

Sleazy Marketing Tactics Used to Sell Oxycontin

And glory be, one such lawsuit has led to the disclosure of the shady marketing tactics used by the now notorious Purdue Pharma to sell Oxycontin.  Several news reports summarized the lawsuit filed by the Tennessee Attorney General against that company.  As described by the Knoxville News Sentinel,

The lawsuit, filed by Tennessee Attorney General Herbert H. Slatery III, uses Purdue’s own company records and its staffers’ own words to show the firm’s founders and executives pushed medical providers to prescribe increasingly high doses of OxyContin for longer periods — even after Purdue promised the state it would stop.

It lays bare a marketing campaign that was highly regimented and highly profitable, built upon a foundation of lies and trickery, and specifically targeted Tennessee’s most vulnerable medical providers and patients, including the elderly and veterans.

'Purdue summarized the marketing for its opioid products with the tagline, ‘We sell hope in a bottle’ in one of the company’s hiring guides for incoming marketing employees,' the lawsuit revealed.

Targeting the Beleaguered

Hope could best be sold through the prescriptions of the most beleaguered prescribers:

Purdue told its sales staffers to target medical providers who were overworked, serving poor communities in Tennessee and had less training, calling them 'high value prescribers' who could be easily persuaded to increase prescriptions and dosages of OxyContin.

To do this, most likely the pharma representatives used psychological manipulation, such as assuring the practitioners that the representatives were their true friends in a hostile health care environment.  Such tactics were well-documented in articles by Ahari and Fugh-Berman, e.g., look here and here. 

Perverse Incentives for Sales Reps

The company provided perverse incentives to its pharmaceutical representatives (perverse, at least, from the standpoint of the patients' welfare and health professionals' values):

Sales staffers’ bonuses were tied to how well they pushed 'super core' providers — the Tennessee prescribers handing out OxyContin prescriptions at a rate guaranteed to cause fatal overdoses — to keep pushing the drug on their patients.

The firm even had a 'toppers club' for sales staffers who pushed the most OxyContin, awarding them trips and cash, the lawsuit stated.

Deceptions and Third-Party Strategies

Although none of the Tennessee pharma reps were "medical professionals," they

were trained to position themselves as medical experts and then supply providers with carefully scripted lies about the addictive and deadly properties of OxyContin, the internal records show.

'Do (providers) believe (in) me on info?' one sales staffer wrote. 'Buy-in … (Provider) buys me first.'

Again, to do this they likely traded on the misguided trust of the physicians generated by the representatives' psychological manipulations.

Practitioners were supplied with biased, and in today's argot, fake literature to give to the physicians,

literature from fake advocacy groups touting the safety of opioids and labeling the growing opioid epidemic as 'pseudoaddiction' that would level off if providers simply prescribed more OxyContin.

Sales staffers were trained to teach providers that the best way to keep patients from addiction was 'to actually prescribe more and higher doses' until the 'symptoms' of addiction went away, the lawsuit stated.

The suit claimed that Purdue set up a "third party strategy," using "astroturf" organizations to pretend that influential health care professionals and sincere patient advocates supported ever increasing narcotics use:

The firm funded the creation of advocacy groups with names such as the American Pain Society and American Pain Foundation, and pamphlets, videos and social media campaigns to convince Tennesseans that OxyContin was a wonder drug — even as the number of fatal overdoses tied to it began to skyrocket.

The firm specifically targeted veterans with a web campaign titled 'Exit Wounds,' and called OxyContin the 'gold standard' for pain treatment.

'Long experience with opioids shows that people who are not predisposed to addiction are unlikely to become addicted to opioid medications,' veterans were told. 'When used correctly, opioid pain medications increase a person’s level of functioning.'

Third party strategies have been widely used in public relations/ propaganda/ disinformation campaigns. 

Profits Before Patients, and the Law

Purdue Pharma reps were instructed to keep pushing narcotic prescribing by physicians who were in danger of being sanctioned.

The lawsuit reveals Purdue’s sales staffers were instructed to ignore police warnings, indictments and overdose deaths involving Tennessee medical providers and to continue to call on them to hand out high-dose OxyContin — the firm’s most profitable brand — so long as they still had prescription pads.

The lawsuit and Purdue’s internal records link the firm’s sales staffers to some of Tennessee’s most notorious pill mill doctors, including one of the largest such operations in East Tennessee.

Purdue staffers called one medical provider, who is not identified in the lawsuit, 48 times — after law enforcement told the firm the provider had prescribed fatal doses of OxyContin and was running a cash-for-pills clinic.

A Nashville Public Radio report additionally noted that

According to the lawsuit, Purdue reps also continued to call on doctors after:

Law enforcement identified two particular doctors responsible for significant diversion
Credible reports of patient overdoses
A provider admitting to heroin addiction
Muggings over controlled substances outside a pharmacy linked to a provider
Admission by a provider he was running a pill mill
Observing a patient being coached in a waiting room
Choreographed pill counts and urine screenings
Standing-room-only waiting rooms

Clearly, generating more revenue by selling more drugs trumped respect for ethics or the law. 

Summary

Thus, Purdue Pharma appeared to use the same sort of multi-pronged deceptive marketing approach to ramp up prescriptions of its potent narcotics, even as more and more people became addicted.

While we have been (probably appropriately) distracted by larger scandals, managers of big health care corporations have continued their cynical tactics that put profits ahead of patients, and ahead of professional values. It is likely that deceptive marketing, and full blown stealth marketing is flourishing even more in the shadows created by a government that seems to put the profits of President and family's company ahead of taking "care that the laws be faithfully executed."

At least to some degree state law enforcement is beginning to step into the breach.  As a Tenessee attorney who is also involved in lawsuits against Purdue said (per NPR)  "I think it helps all of us engaged in this fight to better understand what has happened and ultimately to get more quickly and more efficiently to a resolution,..."

So to conclude,

 We have long advocated better awareness of insidious disinformation campaigns in health care, which we previously separated into stealth systematic marketing, lobbying, and policy advocacy campaigns.  Furthermore, we have long advocated more vigorous regulatory and law-enforcement action against them.  Remember that many of the stealth marketing campaigns we discussed came to light through regulatory and law enforcement action.

Yet what sense does that make when the federal regulators and law enforcers operate under a regime that was perfectly happy to use disinformation to secure its election?

It apparently makes no more sense than advocating for better federal law enforcement measures to reduce conflicts of interest and corruption in health care under an extraordinarily conflicted and corrupt regime (look here.)

The fish is rotting from the head. 

So in parallel with what we said then, the only way we can now address health care deception, crime, and corruption is to excise the deception, crime and corruption at the heart of our government.

Growing Health Care and Grand Governmental Corruption - But Still Anechoic After All These Years

Here we go again.  We have long been concerned about health care corruption as a major cause of health care dysfunction. Our last post on the topic was in January, 2018.


Summary: the Corruption of Health Care Leadership as a Major Cause of Health Care Dysfunction

As we wrote in August, 2017, Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.

the scale of corruption is vast in both rich and poor countries.

Also,

Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.

The report got little attention.  Health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,

However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects somewhere else, mainly  presumably benighted less developed countries.  At best, the corruption in developed countries that gets discussed is at low levels.  In the US, frequent examples are the "pill mills"  and various cheating of government and private insurance programs by practitioners and patients.  Lately these have gotten even more attention as they are decried as a cause of the narcotics (opioids) crisis (e.g., look here).  In contrast, the US government has been less inclined to address the activities of the leaders of the pharmaceutical companies who have pushed legal narcotics (e.g., see this post). 

However, Health Care Renewal has stressed "grand corruption," or the corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements that result in fines that small relative to their  multi-billion revenues without admitting guilt.  Almost never are top corporate managers subject to any negative consequences.

While we at Health Care Renewal have written about this for years, we saw little improvement.  However, in the past few years we began to feel a little more encouraged.  For example, we had long complained that US law enforcement had not been devoting enough effort going after the corruption of the leadership of large health care organizations, thus effectively allowing these leaders' impunity. However, the US Department of Justice during the Obama administration made some modest attempts to decrease such impunity.  One such measure was the formation of a Health Care Corporate Strike Force.

As reported by Law.com,

the strike force was created in the fall of 2015, with five dedicated lawyers working on about a dozen of the most complex corporate fraud cases in the health care space.

Andrew Weissmann, the then-chief of the DOJ’s fraud section, told a health care conference in April 2016 that the section was placing 'a heightened emphasis' on corporate health care fraud investigations. He pointed to the recently established Corporate Fraud Strike Force that he said would focus resources in investigation and prosecution of larger corporate health care law violations, as opposed to smaller groups or individuals.

Unfortunately, that strike force was downsized by the Trump administration as we noted in July, 2017.  Perhaps that could have been viewed as just a minor setback.

However, we noted in May, 2018, that legal actions by the US government against apparently corrupt acts by large US health care organizations seemed to be falling off.  At that point, we found only one significant settlement made this year.  We also found a report by Bloomberg, with the headline, "White-Collar Prosecutions Fall to 20-Year Low Under Trump," on May 25, 2018.

 Increasing Evidence of Corruption in the Trump Administration


We had noted in January that corruption in the US was becoming even more systemic, and worse, it appeared that the administration itself was fundamentally corrupt. We noted sources that summarized Trump's personal, family, and the Trump administration's corruption, a website, entitled "Tracking Trump's Conflicts of Interest" published by the Sunlight Foundation, and two articles published in the Washington Monthly in January, 2018, "Commander-in-Thief," which categorized Mr Trump's conflicted and corrupt behavior.  The second, "A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

The evidence of corruption has only gotten more substantial since then.

April, 2018: The New York Magazine Timeline

In April, 2018, New York Magazine published "501 Days in Swampland," a time-line of  starting just after the 2016 presidential election.   Its introduction included,

The rewards of government would now be reaped by a single man — and the people would bear the cost.

More than at any time in history, the president of the United States is actively using the power and prestige of his office to line his own pockets: landing loans for his businesses, steering wealthy buyers to his condos, securing cheap foreign labor for his resorts, preserving federal subsidies for his housing projects, easing regulations on his golf courses, licensing his name to overseas projects, even peddling coffee mugs and shot glasses bearing the presidential seal. For Trump, whose business revolves around the marketability of his name, there has proved to be no public policy too big, and no private opportunity too crass, to exploit for personal profit.

The timeline was  organized by mode of malfeasance.  Pages were devoted to how foreign governments and private entities curried favor with Trump by lavish spending at his hotels, golf clubs, and other properties.  More pages were devoted to dubious dealings by Trump's family and friends, and officials in his administration.  Yet more recounted relationships with lobbyists and "petty graft."

Although it was not focused on health care corruption, some of the cases it listed involved health care and public health:

[Under Trump's Hotel in DC - 2017]

7/17 E-cigarette-makers hold their annual conference at the hotel. Ten days later, the FDA announces it will delay federal oversight of e-cigarettes until 2022.

Note that this suggests not just regulatory capture, but the possibility of a quid pro quo bribe.

[Under Officials & Their Pals - 2017]

1/24 During his confirmation as secretary of Health and Human Services, Tom Price fails to disclose an insider deal he got on $520,000 in stock in a biotech company. As secretary, he will be in a position to approve a drug the company has developed.

[2018]


1/31 CDC chief Brenda Fitzgerald is forced to resign over her purchase of stock in one of the world’s largest tobacco companies. She bought the shares a month after taking over the agency tasked with reducing tobacco use.

[Under Lobbyistss & Other Sleaze - 2018]

1/29 Alex Azar, a former lobbyist who worked his way up to the presidency of a drug company, is sworn in as secretary of Health and Human Services. Azar, whose company hiked the price of insulin and other drugs under his watch, is now in charge of making drugs more affordable.

[Under Petty Graft - 2017]

6/2 David Shulkin’s chief of staff falsifies an email to suggest that the VA secretary needed to travel to Europe to receive an award. Shulkin’s 11-day trip with his wife, most of which was devoted to sightseeing, cost taxpayers $122,344.

8/4 HHS Secretary Tom Price takes a private jet at taxpayer expense to St. Simons Island, an exclusive resort where he owns land. The trip, like many of the 26 flights Price took on corporate jets, could have been accomplished with a routine commercial flight.

9/29 HHS Secretary Price is forced to resign over the nearly $1 million in taxpayer money he spent taking military planes and private jets, often to visit family and friends.

This list also included several other examples, not directly health care or public health related, suggesting quid pro quo bribery.  For example, in 2017 at the Trump International Hotel in Washington, DC:

10/4 At its annual board meeting, the National Mining Association is addressed by three Cabinet members: Commerce Secretary Wilbur Ross, Labor Secretary Alexander Acosta, and Energy Secretary Rick Perry. 'Coal is fighting back,' Perry exults over breakfast with the country’s top mining executives. 'Clearly the president wants to revive, not revile, this vital resource.' Five days later, the Trump administration announces the repeal of Obama’s Clean Power Plan, which would have encouraged states to replace coal with wind and solar energy. The plan would have cut climate-warming pollution from coal plants by a third and saved taxpayers and consumers as much as $93 billion a year. The venue for the mining board’s meeting: the Trump International Hotel in Washington, D.C.

So the evidence base of conflicts of interest and outright corruption is becoming more massive, includes cases relevant to health care and public health, and includes examples that seem like outright bribery.


June, 2018: the ProPublica Database of Spending at Trump Properties

In June, 2018, ProPublica reviewed questionable spending amounting to $16.1 million since the beginning of Trump's candidacy for president at Trump properties by the US government, and by Trump's campaign, and by state and local governments.  Its introduction included,

Since Donald Trump declared his candidacy for president in late 2015, at least $16.1 million has poured into Trump Organization-managed and branded hotels, golf courses and restaurants from his campaign, Republican organizations, and government agencies. Because Trump’s business empire is overseen by a trust of which he is the sole beneficiary, he profits from these hotel stays, banquet hall rentals and meals.

Note that

The use of taxpayer dollars at Trump hotels is under scrutiny in a closely watched lawsuit in Maryland federal court. The District of Columbia and the state of Maryland sued Trump, citing a venerable anti-corruption provision of the U.S. Constitution known as the Emoluments Clause. It prohibits any financial gift, or emolument, from benefiting a sitting public official, including the president.

June, 2018: Public Citizen's Corporate Presidency's Hotel Swamplandia

Meanwhile, Public Citizen released a report on money spent at Trump's hospitality properties.  

In its introduction

For those seeking to get on Trump’s good side, it certainly helps to fork over some cash at one of his properties. There simply is no other plausible explanation why so many companies, business groups and foreign governments are spending big money eating, drinking, socializing and sleeping at Trump’s properties around the country. And there’s always the chance that the president himself will show up, as he did in June....

Also,

Trump came to office with the most blatant corrupting conflicts of interest in the history of American politics, so what followed should not be a surprise. By spending money at his properties, corporations and foreign governments are being transparent about their desire to curry favor with the president and influence the Trump administration’s policies.

Information on how much is being spent at Trump properties for political events is available, but remains unknown for the vast majority of spenders at Trump properties. An exception was the Saudi embassy, whose $270,000 in spending at the D.C. hotel was disclosed through a PR firm’s filing with the Justice Department. That said, we were able to document $1.75 million in spending, with more than half coming from the Republican Party.

Examples of spending by health care and public health related organizations included

Allign Technology [medical device company]
American Association of Orthodontists
Curetivity Foundation [supports St Jude Hospital]
National Drug & Alcohol Screening Association
University of Wisconsin
Vapor Technology Association [trade assocation for manufacturers of e-cigarettes]

So it seems that various large health care and public health related organizations are happy to shovel money  into the Trump Organization, and hence into the pocket of the president himself, if doing so can advance their business agendas.


Meanwhile Corruption, Even of a President, Remains a Virtually Taboo Topic

And still, we don't talk about it. 

 As noted above, corruption in health care has always seemed a taboo topic.  In November, 2017, we noted that once again, a report by Transparency International that showed that in an international survey of corruption perceptions, substantial minorities of US respondents thought that US corruption was increasing, and was a particular affliction of the executive and legislative branches of the national government, other government officials, and top business executives.  There was virtually no coverage of these results in the US media, just as there was virtually no coverage of a 2013 survey that showed 43% of US respondents believed that US health care was corrupt.

Similarly, the reports listed above have generated little discussion.  Despite the extensive and ever-increasing list of apparently corrupt acts by the Trump and cronies, grand corruption at the top of US government, with its potential to corrupt not just health care, but the entire country and society, still seems like a taboo topic.  The US news media continues to tip-toe around the topic of corruption, in health care, of top health care leaders, and in government, including the top of the US executive branch.  As long as such discussion seems taboo, how can we ever address, much less reduce the scourge of corruption?  The first step against health care corruption is to be able to say or write the words, health care corruption.


But even if we can take that step, when the fish is rotting from the head, it makes little sense to try to clean up minor problems halfway towards the tail. Why would a corrupt regime led by a president who is actively benefiting from corruption act to reduce corruption? The only way we can now address health care corruption is to excise the corruption at the heart of our government.