Circular Logic - A Revolving Door Update

We have actually managed to go for three months without posting on the revolving door.

Since then, however, we have accumulated a sufficient number of relevant cases to post another round up.


The Old School Outgoing Revolving Door

Let us begin with cases of the old fashioned outgoing revolving door, that is, of people leaving leadership positions in governmental bodies which regulate health care or make health care policy, then soon obtaining jobs in the health care industry, particularly organizations which they previously regulated or were affected by the policies they made.

However, it is striking that many of the people recently reported as transiting the outgoing revolving door have also had in the past transited the incoming revolving door (see below).

Cynthia Ridgeway, From Department of Justice Prosecuting White Collar Crimes to Anthem

As reported on July 15, 2019 by Modern Healthcare:

Health insurer Anthem has hired Cynthia Ridgeway, a longtime attorney for the U.S. Justice Department, to be its corporate strategy director.

Ridgeway is first assistant U.S. attorney in the Southern District of Indiana. During her 15-year tenure at the U.S. attorney's office, she litigated high-profile white collar crimes

The brief report had no information about Ms Ridgeway's expected duties for Anthem.  It is possible, but not certain, that they could be relevant to her work in white collar crime investigations and prosecutions for the government.

Marilyn Tavenner, From Administrator of Center for Medicare and Medicaid Services (CMS) of the Department of Health and Human Services (DHHS) to America's Health Insurance Plans (AHIP) and Now to Blue Cross Blue Shield of Arizona

As in a July 23, 2019, PR release:

Marilyn Tavenner, R.N., the former Administrator for the Centers for Medicare and Medicaid Services (CMS) and past president and CEO of America's Health Insurance Plans (AHIP), officially joined the BCBSAZ board, which provides strategic oversight to the company.

Note that Blue Cross Blue Shield of Arizona is a non-profit corporation.

Further note that Ms Tavenner had quite an interesting past history of revolving door transits.  According to her Wikipedia page, she worked for for-profit hospital system Columbia/ HCA, now HCA, from 1981 to 2005, starting as a nurse, and rising to President of the Central Atlantic Division.  While there, she worked for CEO Rick Scott, on whose watch the company made a huge settlement for Medicare fraud (look here).  Scott was not charged, left the company, and then was elected to be Governor of and the Senator for Florida as a Republican.  Ms Tavenner then went on to be Secretary of Health and Human Resources for Virginia, and then CMS administrator from 2013-15.

So Ms Tavenner moved from a for-profit hospital company to running the government agency that operates  government health insurance programs, and thus greatly influences hospital revenues.  The agency also obviously greatly influences the insurance industry, whose major trade association she then went on to lead.  Now she will be part of the governance of a large, albeit non-profit insurance company.

Erik Paulsen, From the House of Representatives to the Board of Cardiovascular Systems

As reported by the St Paul Business Journal, July 25, 2019:

Former U.S. Rep. Erik Paulsen has joined the board of directors for St. Paul medical device company Cardiovascular Systems Inc.

Cardiovascular Systems (Nasdaq: CSII) touted Paulsen’s support for the medical device industry and involvement with federal health care and economic policy in its announcement Thursday.

As a member of Congress from 2009 to 2019 representing Minnesota’s Third District, which covers suburbs of Hennepin County, Paulsen was co-chair of the bipartisan House Medical Technology Caucus. He also served on the House Ways and Means Committee, which covers taxes and policies governing health care, economics and trade.

Thus Mr Paulsen went from having a leadership role in government relationships with medical technology, and "taxes and policies governing health care," to a role in governance of a health technology company.

Dr Scott Gottlieb, From Commissioner of the Food and Drug Administration (FDA) to Venture Capital and the Pfizer Board of Directors, and now the Board of Aetion

Dr Scott Gottlieb has frequently appeard in posts on Health Care Renewal.  Our last summary of his relevant transits to the revolving door, from July, 2019 noted:

Dr Scott Gottlieb, FDA Commisioner from 2017 to May, 2019,  had been no stranger to the revolving door.  Prior to assuming leadership of the FDA, he had relationships with multiple for-profit health care corporations, which drew wide notice when he was appointed to head the FDA in 2017, as we noted at that time here.  Also, Dr Gottlieb was clearly very comfortable with the pharmaceutical and biotechnology industries.  For example, in 2007-2008, we discussed many examples of Dr Gottlieb's strident promotion of the interests of these industries (look here, here, here and here).

Very quickly after leaving the FDA in 2019, Dr Gottlieb rejoined his old venture capital firm, New Enterprise Associates, as a full-time partner investing partner specializing in life sciences companies.

Then in June, 2019, he joined the board of Pfizer.

His latest move was reported on September 17, 2019 by Fierce Healthcare:

Former Food and Drug Administration (FDA) Commissioner Scott Gottlieb, M.D., has added another position to his roster of board and advisory roles since leaving the agency back in March.

He'll be joining healthcare technology company Aetion’s board of directors, the company announced Tuesday. The New York-based company offers real-world evidence and analytics to drug companies, payers, life sciences companies and regulatory agencies.

The company has an interesting array of financial backers:

Sanofi, Amgen, UCB, McKesson Ventures and Horizon Healthcare Services have all backed Aetion as strategic investors, according to the company.

It appears that Gottlieb's former role as leader of the FDA is highly relevant to the business of Pfizer, Aetion, and Aetion's "strategic investors." In particular, regarding Aetion:

Gottlieb will advise the company as it expands the reach and utility of the Aetion Evidence Platform, a scientifically validated tool to assess the safety, effectiveness and value of treatments using real-world evidence, the company said in a press release.

During his tenure, Gottlieb also pushed for the FDA’s use of real-world evidence, recognizing its potential to advance medical products and their development, Aetion said.

'The widespread adoption of real-world evidence to the development and application of new treatments will improve the precision of prescribing decisions and help make drug discovery far more efficient,' Gottlieb said in a statement.'“As a member of Aetion’s Board, I’m inspired by the opportunity to join the company’s efforts to bring RWE to the forefront of drug research and development.'

'Dr. Gottlieb has played a pivotal role in advancing the use of real-world evidence for regulatory decision-making. As a real-world evidence advocate and standard-setter, he’s an ideal partner in our work to help define RWE's role in the development, delivery, and payment of treatments,' Carolyn Magill, CEO of Aetion, said in a statement.

And regarding Pfizer and other pharmaceutical companies:

Aetion works with 12 of the top 20 biopharma firms in the world, along with leading payers.

We had discussed the conflicts of interest presented by Gottlieb's Pfizer board decision, which Senator Elizabeth Warren (D-MA) asserted "smacks of corrupion," here.

Matthew Whitaker, From Acting US Attorney General to Legal Advisor to a Marijuana and CBD Company

As reported on August 28, 2019 by Forbes:

Toronto-based CBD company Alternate Health Corp has hired Matthew Whitaker, former acting U.S. Attorney General, and his law firm Graves Garrett to serve as outside counsel.

Previously, he

served as Chief of Staff to then Attorney General Sessions from September 2017 to November 2018

Why was he selected?

'The legal environment surrounding CBD is rapidly evolving and it is essential that Alternate Health stays at the forefront of new government and FDA regulations,' he said. 'We believe his experience in government and the Department of Justice is a significant asset as we move forward.'

So Mr Whitaker, after taking a leading role in US government law enforcement, including enforcement of laws related to drugs like marijuana, would not be advising a foreign company trying to get favorable legal treatment from the government.

Rebecca Wood, from Chief Counsel at FDA to Leader of Food and Drug Practice at Sidley Austin

Ms Wood had been Chief Counsel at the FDA.

Recently reported by ProPublica (in a October 15, 2019 article to be discussed further below):

Wood now leads the food and drug practice at Sidley Austin, a powerful law and lobbying firm in Washington, where her colleagues lobby the FDA for various clients.

She is an example of

former Trump administration staffers who go back to K Street but don’t register as lobbyists — the Lobbying Disclosure Act only requires those who spend 20% or more of their time lobbying to register.

This still generates important conflicts of interest.

Wood said she 'advises clients on FDA-related issues and, in doing so, complies with all applicable ethics requirements.'

There is nothing illegal about returning to an old employer or being hired by a new one. Nor is there anything wrong with having colleagues who lobby the federal government. But the revolving door does present the possibility of conflicts of interests.

'The most important commodity in D.C. is information,' Hauser said. 'Former insiders have rare access to strategic intelligence, which is of significant value to corporate entities, and they can do so without registering as a lobbyist.'

Dr Karen DeSalvo, from Assistant Secretary of Health, DHHS and Office of the National Coordinator, to the University of Texas, now to Google as Chief Health Officer

As reported by Health Care Dive on October 18, 2019

Google has hired ex-Obama administration official Karen DeSalvo as its first chief health officer, further solidifying its investment in the $3.5 trillion industry by rounding out its healthcare team.

DeSalvo, a well-respected healthcare executive and public health expert, was the acting Assistant Secretary for Health at HHS and ran the Office of the National Coordinator, which manages the nation's health IT, under President Barack Obama. She has spent the past two years teaching at the University of Texas at Austin's Dell Medical School.

Note that there was a two year delay after Dr DeSalvo left the government until her hiring by Google.  This does apparently lessen the conflicts of interest generated.  However, many think 

The Au Courant Incoming Revolving Door

In the Trump era, many people have come through the incoming revolving door, that is, people with significant leadership positions in health care corporations or related groups have attained leadership positions in government agencies whose regulations or policies could affect their former employers.

On October 15, 2019, ProPublica published a striking article on people transiting the incoming revolving door from lobbying positions to leadership positions at government agencies whose regulations or policies could affect their lobbying clients.

Two of the people recently added to the ProPublica data base got major government health care leadership positions after working as lobbyists, and then returned to lobbying after ending their government "service."

By way of background:

At the halfway mark of President Donald Trump’s first term, his administration has hired a lobbyist for every 14 political appointments made, welcoming a total of 281 lobbyists on board, a ProPublica and Columbia Journalism Investigations analysis shows.

With a combination of weakened rules and loose enforcement easing the transition to government and back to K Street, Trump’s swamp is anything but drained. The number of lobbyists who have served in government jobs is four times more than the Obama administration had six years into office. And former lobbyists serving Trump are often involved in regulating the industries they worked for.

Even government watchdogs who’ve long monitored the revolving door say that its current scale is a major shift from previous administrations. It’s a 'staggering figure,' according to Virginia Canter, ethics chief counsel for the D.C.-based legal nonprofit Citizens for Responsibility and Ethics in Washington. 'It suggests that lobbyists see themselves as more effective in furthering their clients’ special interests from inside the government rather than from outside.'

Colin Roskey,  from Health Care Lobbying for Lincoln Policy Group to Deputy Secretary, DHHS, then back to Lobbying for Lincoln Policy Group

Per ProPublica:

Consider Colin Roskey. Days after leaving a two-decade career as what one former employer called the 'smartest' health care lobbyist, he joined the Department of Health and Human Services in January. As deputy secretary for legislation for mandatory health, he headed the portfolio that he tried to influence for most of his career.

HHS declined to reveal any recusals he signed while appointed. A spokesman said that “all employees are expected to abide by the ethics rules.”

Just days before joining HHS, Roskey listed among his clients major dialysis providers that receive federal payments through Medicare, including Fresenius Medical Care — an industry juggernaut, with more than 330,000 patients in thousands of dialysis clinics in the U.S. A third of the company’s billion-dollar revenue comes from Medicare. A recent revamp in the dialysis industry ordered by Trump, expected to shift millions of dollars from dialysis centers to cheaper home-based options, put Roskey’s office at the heart of regulating how much profit or loss some of his former clients will see in coming years. Roskey said in an interview that he recused himself from this matter.

Public records show that Roskey lobbied for at least 27 clients between January 2017 and December 2018 on an array of issues other than dialysis involving public health care programs, from prescription drugs to palliative care.

In early October, Roskey stepped out of government and went straight back to work for his old lobbying firm, Lincoln Policy Group, which specializes in health care policy. “Spending time at HHS will make [Roskey] even more valuable to our team — and we are so excited to have him back,” the lobbying firm announced in a statement.

Roskey said he had no knowledge of how the new kidney care regulations will be implemented.

After his monthslong stint with the Health Department, Roskey said he plans to lobby the legislative branch, which is not prohibited by the current ethics rules. 'While working with the government I gained knowledge and background, intellectually and professionally, and I intend to unapologetically utilize those skills for my employer and clients,' he said.

The conflicts of interest generated by the moves from and to the lobbying firm are are obviously significant.

Laura Kemper from Health Care Lobbyist to Deputy Assistant Secretary of DHHS, then to Lobbying as Vice-President for Governmental Affairs for Fresenius

We had previously discussed Ms Kemper's transit from lobbyist to government health care leader here.   From the ProPublica article,

Laura Kemper, [is] a former HHS senior official who, within days of leaving her post in March, was hired by Fresenius. Now vice president for government affairs, Kemper heads the company’s policy group.

According to lobbying records, she is listed among the in-house lobbyists who have visited Congress, the White House and HHS since March, pushing everything from reimbursement for dialysis services to home dialysis. The records show Fresenius shelled out more than $2.2 million for lobbying activities during the first half of the year.

Furthermore, ProPublica noted:

Her pass through the revolving door tests the boundaries of ethics rules. Indeed, Trump’s pledge prohibits staffers-turned-registered lobbyists from advocating for the special interests of their corporate bosses before the agencies where they used to work for at least five years. It also restricts former employees from behind-the-scenes lobbying with any senior federal official for the remainder of Trump’s presidency. Kemper signed that pledge.

Kemper declined to comment. In a statement, Fresenius said Kemper “has strictly followed her legal and ethical obligations and has not been involved in lobbying the administration or anything related to the Executive Order.” Disclosure forms filed by Fresenius “cite the general activity of a team and do not ascribe any particular lobbying activity,” according to its statement.

Recently, during an earnings call to investors, Fresenius CEO Rice Powell said that the company has talked to the 'appropriate people in Washington,' without naming any particular Fresenius or government staffer. “We are in the midst of commenting and asking questions” with HHS officials, he added.

As ProPublica has reported, political appointees who return to lobbying have found ways to tiptoe around ethics rules. Some register as lobbyists but limit their interactions to Congress, leaving colleagues to lobby the executive branch. Ethics restrictions don’t apply to congressional lobbying.

Summary

We have repeatedly said,  most recently in March, 2019, ...

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 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.

Government Increasingly Promoting Sectarianism-Based Health Policy

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

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

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

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

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

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

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

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

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

ANDREW BREMBERG

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

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

MAGGIE WYNNE

Position: HHS, Counselor for Human Services Policy

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

STEVEN VALENTINE

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

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

VALERIE HUBER

Position: Senior policy advisor, HHS Office of Global Affairs

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

MARCH BELL

Position: Chief of Staff, Office for Civil Rights

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

MATTHEW BOWMAN

Position: Deputy general counsel, HHS

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

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

SCOTT LLOYD

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

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

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

More Administration Action Promoting Sectarianism-Based Health Policies

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

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

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

In May, another Reuters article noted

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

So,

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

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

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

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

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

Also,

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

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

Top Administration Leaders Advocating Government Establishment of Religion

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

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

Then,

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

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

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

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

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

Furthermore,

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

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

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

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

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

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

The Times of Israel quoted

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

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

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

Summary

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

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

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

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

If not now, when?

If not us, who? 

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

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

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

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

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

The Early Days of Managerialism

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

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

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

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

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

Recap: Managerialism

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

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


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

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

 Reference

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

Marketers Want Even More Control Over Hospitals

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

A Marketer Pushes More Marketing Influence on Hospital Management

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

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

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

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

It goes beyond Amazon, though:

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

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

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

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

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

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

The Rationale: a Misinterpretation of  the Social Determinants of Health

The rationalization for involving marketers in patients' experiences was:

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

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

Social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care.

What could hospital marketing do to affect such factors?  Instead, the writer explained:

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

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

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

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

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

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

Summary: Managerialism, Again

I applaud the writer's implication that

hospital systems want to keep patients healthy

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

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

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

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

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

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

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

 Reference

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