At the "Reopen America" Protests, Vilifying Health Care Professionals to Protect the New Robber Barons

After the Trump administration's delayed and ineffectual efforts at containment failed (see relevant coverage here, here, here, here), the curve of exponentially increasing coronavirus cases and deaths may finally have started flattening due to social distancing.  The first responders, health care professionals and hospitals in the reddest zone, New York City, may be slightly less besieged.  But the pandemic is hardly over.

Vilifying Health Care Who Objected to Prematurely "Reopening" the Country

Nonetheless, supposedly popular protests, albeit very small, broke out calling for the end of onerous social distancing measures, ostensibly to let the economy recover.  President Trump then jumped in, suddenly called for the "liberation" of multiple states from these  measures. As the Washington Post reported on April 17, 2020

President Trump encouraged protesters in Minnesota, Michigan and Virginia who are defying social distancing orders to rally against the states’ safety measures intended to stop the coronavirus spread.

In back-to-back tweets Friday morning, Trump wrote: 'LIBERATE MINNESOTA' and then, 'LIBERATE MICHIGAN' and then, 'LIBERATE VIRGINIA, and save your great 2nd Amendment. It is under siege!'

It’s unclear why Trump seems to be siding with the protesters given that the states in question have imposed restrictions that follow the recommendations laid out by Trump’s White House coronavirus task force last month that go by the name 'The President’s Coronavirus Guidelines For America.'

When the guidelines were released, Trump urged all Americans to follow them for the sake of the country.

Never mind that prematurely ending pandemic suppression efforts would mainly liberate the virus to infect people at exponentially increasing rates.

The protests to "reopen" the states were met by small, peaceful counter-protests by health care professionals.  For their pains, they were vilified.

Four examples follow, in chronological order by the dates of the relevant reports:

Colorado

Per the Guardian, April 20, 2020

As protesters gathered outside the capitol steps and others assembled in their automobiles to ask the city to reopen for business, healthcare workers stood in the middle of the road in their scrubs. After having spent the last weeks treating Covid-19 patients, they staged their own demonstration: they wanted to remind the protesters of why the shutdown measures are important.

One protester in particular did not like it. She leaned out of her car window, wearing an American flag T-shirt, holding a placard that read 'land of the free'. Then, she yelled to the protester wearing scrubs: 'This is a free country. This is the land of the free. Go to China!'

She appeared to be expressing the view that closing down non-essential services in the US is equivalent to the actions of a communist state, as she continued: 'If you want communism, go to China. Now open up and go to work.'

Pennsylvania

Per the Pennsylvania Post, April 20, 2020

Armed with nothing but signs and science, half a dozen medical workers from across the state showed up near the capitol in Harrisburg on Monday to counter the message of hundreds of 'ReOpen PA' protesters calling for an end to coronavirus restrictions.

The small group of health care workers told people participating in the larger rally to go home to keep their loved ones safe. But they made their point from a distance.

However,

Anti-shut down protesters yelled at the nurses and physician assistants as they drove by. Some held up American or Gadsden flags to block the medical workers’ signs. Some angrily reminded the health care workers that they were lucky they were working.

'You have a job!' one protester screamed at Katrina Rectenwald, a 36-year-old registered nurse who works at a Pittsburgh hospital.

North Carolina

Per the Charlotte News-Observer, April 22, 2020

Tuesday morning, about 1,000 people converged on downtown Raleigh to protest in an effort to get Gov. Roy Cooper to reopen the state. North Carolina has been closed since March when he issued a stay-at-home order and closed schools and non-essential businesses due to the spread of the coronavirus.

[Amber] Brown, an oncology nurse practitioner, was there as the opposition.

Then

Brown arrived in Raleigh wearing a mask, goggles and a blue protective gown with the phrase 'Rally Together and Die Alone' written on it. As she maneuvered through the crowd of protesters, the hostility and heckling started when another counter-protester grabbed her arm and said, 'You’re with us.'

In front of the Legislative Building, other medical professionals dressed in scrubs, masks and lab coats awaited the ReOpen NC protesters. So Brown found a spot and stood there in a silent protest.

Protesters converged on her, first attacking her weight. Some called her a strain on the healthcare system, saying obesity kills more people than the coronavirus. But she stood strong.

'I didn’t say anything,' Brown said. 'I had a message, and I think it was pretty clear. I didn’t think I needed to say any words. When people are in a mob like that and they are angry and screaming, there is no reasoning with them. I wasn’t going to change their mind. I wasn’t there for them, I was there for my patients.'

She said she felt threatened. There were Raleigh police officers there, but Brown said there were not many counter-protesters. A dispute could have escalated quickly.

Arizona

Per the Arizona Republic, April 22, 2020

On Monday, [ICU nurse Lauren] Leander showed up at the Capitol, to serve as a counterweight to the hundreds of protesters demanding that Gov. Doug Ducey immediately reopen the economy.

To serve as a reminder that though jobs are at stake and that’s certainly important, so, too, are lives.

As The Republic’s Richard Ruelas described it, 'She would spend the next few hours standing silent, her facial expressions partly hidden behind her medical mask. Her body standing rigid in surgical scrubs.'

For that, she was insulted, scorned and generally screamed at by flag-waving protesters, some of whom carried signs about an overblown crisis and a 'pretend-demic'.

Note that not only was Ms Leander vilified at the protest, she was vilified on the internet by the Arizona State Republican Party Chairwoman

And, of course, by state GOP Chairwoman Kelli Ward, whose go-to response to anything with which she disagrees is to cry 'fake'.

Cue her Tuesday morning tweet, responding to nurses showing up to counter protests across the country: 'EVEN IF these 'spontaneously' appearing ppl at protests against govt overreach (sporting the same outfits, postures, & facial expressions) ARE involved in healthcare - when they appeared at rallies, they were actors playing parts. #Propaganda #FakeOutrage'

I’m guessing Leander, after a few 12-hour shifts working to save patients struck down by COVID-19, would tell you that her outrage at the prospect of reopening the state too soon is anything but fake.

In four states over a few days health care professionals were vilified by protesters calling for the premature "reopening" of the country.  A nurse was personally vilified by a local political notable, the state Chair of the Republican Party.  Why would people supposedly advocating for relaxing social distancing specifically to improve the economy and help working people and small businesses be so hostile to the health care professionals who would help them were they to get sick?

The answer appears to be that these protests were driven by political extremism more than worries about the economic misfortunes of working people and small businesses.

Trump and His Allies Had Previously Suggested the Acceptability of Attacking Health Care and Public Health Professionals

In the days leading up to these events, Trump and his enablers had pointed the ways towards the vilification health care and public health professionals.

Public Health Experts Who Created Statistical Models of the Pandemic Accused of Being Part of a "Deep-State" Plot

On March 27, 2020, the Washington Post published an article stating

In recent days, a growing contingent of Trump supporters have pushed the narrative that health experts are part of a deep-state plot to hurt Trump’s reelection efforts by damaging the economy and keeping the United States shut down as long as possible. Trump himself pushed this idea in the early days of the outbreak, calling warnings on coronavirus a kind of 'hoax' meant to undermine him.

Note that the notion of a "deep state" is a commonly heard conspiracy theory that members of the government bureaucracy are pursuing a independent agenda that includes a political vendetta against Trump and his followers. Trump then went on to validate the notion that the epidemiologists' models were "hoaxes"

On Thursday night, Trump cast doubt on experts’ projections on those as well. 'I have a feeling that a lot of the numbers that are being said in some areas are just bigger than they’re going to be,' Trump told Fox News host Sean Hannity in a phone interview. 'I don’t believe you need 40,000 or 30,000 ventilators. You know, you go into major hospitals, sometimes they’ll have two ventilators, and now all of a sudden they’re saying, ‘Can we order 30,000 ventilators?’'

Trump Accused Physicians Protesting the Lack of Personal Protective Equipment in Hospitals as  Seeking Media Fame

On April 11, the (UK) Independent reported that at his daily coronavirus press conference, Trump confronted CNN reporter Jim Acosta who had asked about physicians' complaints that they lacked sufficient testing and equipment, including personal protective equipment (PPE):

Acosta referred to doctors and other medical officials who have vented their frustrations about the dearth of essential equipment on CNN.

The president hit back: 'A lot of it is fake news.'

Acosta said: 'Doctors and medical officers come on our air and say ‘we don’t have enough tests, we don’t have enough masks’.'

Mr Trump chipped in: 'Well yeah, depending on your air they are always going to say that because otherwise, you are not going to put them on.'

Trump directly accused  health care professionals of lying about the lack of equipment and supplies merely to get media attention.  However, there are many easily found examples for all over the US about the inadequacy of such supplies and equipment.

So given this atmosphere, maybe it should not be a surprise that the "reopen" protests were also attended by political extremists.

The Extremists at the "Reopen" Protests


Presumably, the vilification of health professionals at the "reopen" protests had nothing to do with medicine and public health.  It was likely to be about political extremism, as exemplified by the participation of political extremists at the protests.  Reports suggested the involvement of several groups. 

The Proud Boys

The Anti-Defamation League describes the Proud Boys thus:

Misogynistic, Islamophobic, transphobic and anti-immigration. Some members espouse white supremacist and anti-Semitic ideologies and/or engage with white supremacist groups.

The  Guardian reported on April 17, 2020

Placards identified the Michigan Proud Boys as participants in the vehicle convoy.

The Proud Boys also showed up at the Colorado protest, according to Vice News, April 20, 2020:

Members of Proud Boys, a far-right street-fighting gang, were spotted at a protest in Denver over the weekend, and at last week's protest in Michigan where they were seen flashing the “OK” sign in photos with a Republican candidate for state office.

Finally, the Proud Boys showed up in Ohio, per the Cleveland Plain Dealer, April 21, 2020:

On Monday, at least one protestor at the Ohio Statehouse wore a Proud Boys T-shirt. The group is described as misogynistic and Islamophobic.

Michigan Liberty Militia

Again according to the Guardian:

Near the state house, local radio interviewed a man who identified himself as 'Phil Odinson'.

In fact the man is Phil Robinson, the prime mover in a group called the Michigan Liberty Militia, whose Facebook page features pictures of firearms, warnings of civil war, celebrations of Norse paganism and memes ultimately sourced from white nationalist groups like Patriot Front.

Ammon Bundy and Associates

Again via the Guardian, April 17, 2020, Bundy was tied to the Idaho protest, which

was also being promoted on a website dedicated to attacking [Idaho Governor] Little for his response to Covid-19. That website was set up by the Idaho businessman, pastor and one-time Republican state senate candidate, Diego Rodriguez.

Rodriguez launched the website at an Easter service held in defiance of the governor’s orders on Easter Sunday, which was also addressed by Ammon Bundy, the leader of the militia occupation of the Malheur national wildlife refuge in 2016 that become a rallying point for the anti-government right in the US.

Bundy has been holding similar gatherings for weeks in Emmett, Idaho, where he now lives. On Sunday, he repeated his opposition to the Idaho orders, writing on Facebook: 'We all have a duty to defend what is right and to make sure, that what God has given, man does not take away. Especially that great gift of agency, YES freedom!'

The Dorr Brothers' Gun Rights Groups

An article in the Washington Post on April 19, 2020 stated:

A trio of far-right, pro-gun provocateurs is behind some of the largest Facebook groups calling for anti-quarantine protests around the country, offering the latest illustration that some seemingly organic demonstrations are being engineered by a network of conservative activists.

The Facebook groups target Wisconsin, Ohio, Pennsylvania and New York, and they appear to be the work of Ben Dorr, the political director of a group called 'Minnesota Gun Rights,' and his siblings, Christopher and Aaron. By Sunday, the groups had roughly 200,000 members combined, and they continued to expand quickly, days after President Trump endorsed such protests by suggesting citizens should 'liberate' their states.

The Dorr brothers manage a slew of pro-gun groups across a wide range of states, from Iowa to Minnesota to New York, and seek primarily to discredit organizations like the National Rifle Association as being too compromising on gun safety. Minnesota Gun Rights, for instance, describes itself as the state’s 'no-compromise gun rights organization.'

In addition,

'Wisconsinites Against Excessive Quarantine' was created on Wednesday by Ben Dorr. His brother Christopher is the creator of 'Pennsylvanians Against Excessive Quarantine,' as well as 'Ohioans Against Excessive Quarantine.' A third brother, Aaron, is the creator of 'New Yorkers Against Excessive Quarantine.'

Various Unknown Anti-Semites

Per Channel 4 in Detroit on April 16, 2020 at the Michigan protest:

Nazi, swastika imagery used just days before Holocaust Remembrance Day

And,

The Jewish Community Relations Council of Detroit (AJC) has publicly condemned the behavior and signage of protestors that participated in 'Operation Gridlock' on Wednesday.

The Cleveland Plain Dealer reported on April 21, 2020:

A photo from Saturday’s stay-at-home protest at the Statehouse is gaining traction on Twitter for its anti-Semitic message.

The photograph captured two men in a minivan. One held a sign with an illustration of rodent with the Star of David on its side and the words 'The Real Plague.'

Participation by white supremacist, neo-Nazi, and extreme gun rights supporter at the "reopen" protests strongly suggests that these protests were more about extremist politics than working people and small businesses concerned mainly with maintaining their livelihoods.

The Plutocrats and Trump Donors Behind the "Reopen" Protests

Furthermore, numerous reports also suggested that the protests were products of political organizations tied to the Trump administration and some of its very rich donors which provided major funding and organizational help.

Michigan Conservative Coalition/ Michigan Trump Republicans

The Guardian reported on April 17, 2020 that the protest in Michigan:

was organized by the Michigan Conservative Coalition, which Michigan state corporate filings show has also operated under the name of Michigan Trump Republicans.

The Washington Post added on April 19, 2020:

Its founders are a Republican state lawmaker and his wife, Meshawn Maddock, who sits on the Trump campaign’s advisory board and is a prominent figure in the 'Women for Trump' coalition.

Michigan Freedom Fund

According to the Guardian, the Michigan protest:

was also heavily promoted by the Michigan Freedom Fund, a group linked to the Trump cabinet member Betsy DeVos.

The Washington Post (April 19) added that:

the Michigan Freedom Fund, ... is headed by Greg McNeilly, a longtime adviser to the DeVos family. He served as campaign manager for Dick DeVos, the husband of Education Secretary Betsy DeVos, when he ran unsuccessfully for governor of Michigan in 2006.

Idaho Freedom Foundation

Again, according to the Guardian April 17, 2020 article, the protest in Idaho

has been heavily promoted by the Idaho Freedom Foundation (IFF), which counts among its donors 'dark money' funds linked to the Koch brothers such as Donors Capital Fund, and Castle Rock, a foundation seeded with part of the fortune of Adolph Coors, the rightwing beer magnate.

Convention of States

The Washington Post reported on April 22, 2020:

The ads on Facebook sounded populist and passionate: 'The people are rising up against these insane shutdowns' they said. 'We’re fighting back to demand that our elected officials reopen America.'

But the posts, funded by an initiative called Convention of States, were not the product of a grass-roots uprising alone. Instead, they represented one salvo in a wide-ranging and well-financed conservative campaign to undermine restrictions that medical experts say are necessary to contain the coronavirus — but that protesters call overkill and whose economic fallout could damage President Trump’s political prospects.

A network of right-leaning individuals and groups, aided by nimble online outfits, has helped incubate the fervor erupting in state capitals across the country. The activism is often organic and the frustration deeply felt, but it is also being amplified, and in some cases coordinated, by longtime conservative activists, whose robust operations were initially set up with help from Republican megadonors.

The Convention of States project launched in 2015 with a high-dollar donation from the family foundation of Robert Mercer, a billionaire hedge fund manager and Republican patron. It boasts past support from two members of the Trump administration — Ken Cuccinelli, acting director of U.S. Citizenship and Immigration Services, and Ben Carson, secretary of housing and urban development.

Citizens for Self-Governance

The Washington Post also documented

Citizens for Self-Governance, [is] the parent organization of the Convention of States project.

A longtime associate of the conservative activist Koch family, [Convention of States board president Eric] O’Keefe helped manage David Koch’s 1980 bid for the White House when he served as the No. 2 on the Libertarian ticket.

Also,

In 2014, the year before it launched the Convention of States initiative, Citizens for Self-Governance received $500,000 from the Mercer Family Foundation, a donation Meckler said helped jump-start the campaign. Mercer declined to comment.

DonorsTrust

Furthermore, per the Washington Post April 22, 2020 article:

The Convention of States project, meanwhile, has received backing from DonorsTrust, a tax-exempt financial conduit for right-wing causes that does not disclose its contributors. The same fund has helped bankroll the Idaho Freedom Foundation, which is encouraging protests of a stay-at-home order imposed by the state’s Republican governor, Brad Little.

'Disobey Idaho,' say its Facebook ads, which use an image of the 'Join or Die' snake woodcut emblematic of the Revolutionary War and later adopted by the tea party movement.

Texas Public Policy Foundation

The April 22, 2020 Washington Post article also documented:

One of the most vocal groups opposing the lockdown in Texas is an Austin-based conservative think tank called the Texas Public Policy Foundation, which also hails the demonstrations nationwide.

'Some Americans are angry,' its director wrote in an op-ed promoted on Facebook and placed in the local media, telling readers in Texas about the achievements of protesters in Michigan.

The board vice chairman of the Texas Public Policy Foundation, oil executive Tim Dunn, is also a founding board member of the group promoting the Convention of States initiative. And the foundation’s former president, Brooke Rollins, now works as an assistant to Trump in the Office of American Innovation.

The Uihleins

On April 23, 2020, the Guardian reported:

One of Donald Trump’s most fervent billionaire donors is lobbying against strict stay-at-home rules in the election battleground state of Wisconsin, raising troubling new questions about how the president’s rightwing financial supporters may influence the US response to the pandemic.

Liz Uihlein, the billionaire behind Wisconsin’s Uline shipping and packaging company – who with her husband, Richard, has been dubbed the most 'powerful conservative couple you’ve never heard of' – is using her clout to try to force Wisconsin’s Democratic governor to relax stay-at-home rules, claiming that the crisis has been 'overhyped' by the media.

Her actions – from lobbying Republican legislators in the state to circulating a petition to employees to have the governor, Tony Evers, removed from office – come as two protests have been organized against the Democratic governor on Friday.

Note that:

Uihlein, who said she and her husband 'loved Trump' and is believed to have a net worth of about $4bn, laughed off suggestions that she might influence the president.

'You honestly think that money influences Donald Trump, are you kidding me?' she said.

But Uline, she and her husband’s privately held company, has already donated $1.5m to Trump’s Super Pac, America First Action, and $20m to other Republican groups so far in the 2020 election cycle. In the past, their donations topped $90m, according to the Center for Responsive Politics.

In summary, the "reopen" protests, ostensibly about protecting working people and small businesses from the economic effects of social distancing, were organized to an extent by a network of Trump cronies, including multiple people currently serving in the executive branch of the government, and were funded by plutocrats including the Koch brothers, beer magnate Adolph Coors, the Mercer family, oil executive Tim Dunn, and the Uihlein family.

Why Are the Plutocrats Promoting Protests Against Social Distancing?


Why are plutocrats  suddenly interested in public health, or worried about the plight of the little people who have lost their jobs or otherwise suffered from the economic dislocations due to the shutdown of much of the economy?  Why are such people willing to comport with extremists like the Proud Boys to do so?

The answer is not known, but there are some disturbing theories.

One formulation from columnist Will Bunch in the Philadelphia Inquirer

These right-wing groups certainly want to reelect Trump (and keep the wretched DeVos in her Education Department post) but what they’re really afraid of is that both the public-health catastrophe and the growing economic meltdown will lead to a political, economic or even social revolution in the United States that will threaten the status quo — i.e., them. The coronavirus has exposed the everyday disaster that is America’s employer-based health-care system and the broader fragility where millions were just one lost paycheck away from a miles-long line at a food bank. The conservative movement in America, therefore, will die a deserved and overdue death unless the oligarchs can change the political conversation around to your God-given right to buy plant seeds and Baskin-Robbins — and fast.

It’s also worth noting (and probably worthy of a separate column) that these billionaires and millionaires have zero moral qualms about working with some of the worst white-supremacists or neo-fascists in order to make sure a crowd turns out....

Another from Theda Skocpol, Professor of Government and Sociology at Harvard, interviewed by Sean Illing in Vox.  She first asserted that the "reopen" protests arose from:

combination of top-down influence from high-dollar organizations and some genuine energy at the grassroots level. But I also suspect this is mostly being pushed and promoted from above.

Prof Skocpol cited this example:

There’s FreedomWorks, a right-wing advocacy group that also helped turn the famous CNBC television rant into dozens of rallies across the country in February of 2009 — that was the origins of the Tea Party. The people at FreedomWorks are egging this anti-lockdown protest on and providing encouragement and models for these events and helping to select cities.

Now, that doesn’t mean FreedomWorks or any one person is in control of all this. But groups like this provide email lists, help organize activists around the country, and facilitate these things as much as they can. And of course Trump himself is using his social media feeds in the same way, which is just an amazing resource if you want to coordinate and target protests. So that’s what I mean when I say a lot of this is driven from the top down.

"The money quote" re the plutocrats' motivation:

For the elite conservative groups sponsoring this stuff behind the scenes, I think it’s driven by a firm belief that if Americans become used to trusting government and relying on social benefits from government, then that’s dangerous to the victory they think they have almost won in destroying the New Deal and the Great Society reforms in this country.

That is,

I think they see this pandemic and the government response to it as a potentially dangerous moment for their vision of the American economy and people’s place in it. They don’t want people to see how helpful government can be, they don’t want them to change their minds about the role of government in society. So this is a dangerous moment for their ideological worldview.

Summary

Health care professionals confronted with a pandemic of a potentially deadly disease want to be able to help patients as best they can, avoid if possible sacrificing their own health and lives, and promote the greater public health.  Many health care professionals are not very interested in health policy, much less politics.  But most are interested in education. Seeing people protest the very public health measures that may enable their survivial inspired health care professionals to try to educate the protesters about the risky tradeoffs that reopening the economy would entail.

However, their relatively innocent and public health spirited counter-protests landed them within a hornets' nest.  They found themselves not leading an educational dialog, but insulted, if not intimidated. 

The protests were not just about the economy, particularly protecting the livelihoods of working people and small businesspeople.  They were about an extremist political agenda, the power of the Trump administration, and likely about a long term project that had been "destroying the New Deal and Great Society reforms," that sought to restore the power of the Robber Barons and maintain a new gilded age.

Therefore, for us to get through this pandemic, we now have to confront the plutocrats who would rule us - even at the cost of sacrificing many of us.  This may be about educating the public.  However, it will also be about going up against some very rich and powerful people who saw the world within their grasp, and now may be seeing it fade away.  They will lash out to try to protect their money and power.  As some health care professionals discovered in the last few weeks, this will be a difficult, if not brutal and dangerous task.

But lives are hanging in the balance.  Courage!

The ACP Leadership Stands Up to Health Care Dysfunction: A Good Beginning, but the Problems May be Even Bigger than They Realize

Introduction: Health Care Dysfunction Has Been With Us for a Long Time

The American College of Physicians (ACP) is the largest physician specialty society in the US.  So it was news when outgoing ACP  President Dr Robert M McLean's article, "Battling the Hydra of the Medical-Industrial Complex" in the ACP Internist, decried "the dysfunction that has become our [health care] system's status quo" and noted "how our health care delivery system is so dysfunctional and fragmented."

[Gustave Moreau, Hercules and the Lernaean Hydra, Art Institute of Chicago]

Better late than never. We have been decrying health care dysfunction since 2003, and on this blog since 2004.

To better understand health care dysfunction, I interviewed doctors and health professionals, and published the results in Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).  In that article, I postulated that US physicians were demoralized because their core values were under threat, and identified five concerns:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research studies

After that my colleagues and I have tried to raise awareness of these and related issues, now mainly through the Health Care Renewal blog.  We also set up FIRM - the Foundation for Integrity and Responsibility in Medicine,  a US non-profit organization, to try to provide some financial support for the blog.

Now the ACP seems to have embraced some of our concerns.

Putting Financial Concerns and Management Dogma Ahead of Patients

Dr McClean started by asserting that:

Smart minds have taken business models to the extreme in health care-related corporations. Decisions on resource allocation or new initiatives are driven by the critical concept of return on investment (ROI).

Also

budget items that we know are clinically necessary for better patient care don't get resourced and as other initiatives of dubious clinical value move forward, all due to the omnipotent ROI calculation.

Furthermore,

Corporations of many types (insurance, pharmaceuticals, pharmacy benefit managers, and medical devices, to name just a few) are making millions and billions in profits that are pulled out of the health care system instead of being used to provide better care to our patients.

These are clearly major issues.  Let me take this opportunity to enlarge upon Dr McClean's essay, based on our experience writing for Health Care Renewal.

Dr McLean briefly noted the problem of "business models" driving health care leaders' decision making. This has been called managerialism. As discussed in an article from the June, 2015 issue of the Medical Journal of Australia (which we noted here)
- 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, and in a health care context, not necessarily having any experience or background in biomedical science, medicine, health care, or public health
- 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 in health care undermines the health care mission and the values of health care professionals


Managerialism is not limited to the list of organizations mentioned by Dr McLean.  

Managerialists are often greatly influenced by currently fashionable management dogma.  A dominant dogma in management is that pursuit of shareholder value comes before all else, and thus that the pursuit of short-term revenue comes before all else. Managerialists running nominally non-profit organizations, like non-profit hospitals, still often put short-term revenue ahead of all other concerns.  As we posted here in 2012, quoting Lazonick:

in 1983, two financial economists, Eugene Fama of the University of Chicago and Michael Jensen of the University of Rochester, co-authored two articles in the Journal of Law and Economics which extolled corporate honchos who focused on 'maximizing shareholder value' — by which they meant using corporate resources to boost stock prices, however short the time-frame. In 1985 Jensen landed a higher profile pulpit at Harvard Business School. Soon, shareholder-value ideology became the mantra of thousands of MBA students who were unleashed in the corporate world.

Lazonick added:

When the shareholder-value mantra becomes the main focus, executives concentrate on avoiding taxes for the sake of higher profits, and they don’t think twice about permanently axing workers. They increase distributions of corporate cash to shareholders in the forms of dividends and, even more prominently, stock buybacks. When a corporation becomes financialized, the top executives no longer concern themselves with investing in the productive capabilities of employees, the foundation for rising living standards for all. They become focused instead on generating financial profits

Thus the influence of business thinking on health care (and public health) leadership is even greater than what Dr McLean discussed.

Furthermore, Dr McLean issued the following apologia:

We cannot blame health care system executives solely for this ROI focus; they are merely playing by the existing rules of the game, dysfunctional as those rules are

In  my humble opinion, they do not deserve the only blame.  However, hospital system executives are part of the larger community of executives who run pharmaceutical/ biotechnology/ device companies, health insurance companies, organizations that provide direct patient care, consulting firms, medical societies, health care charities, etc, etc, etc  Most of them have been trained in these "rules of the game." 

These executives often reap considerable personal benefits from these rules.  For example, hospital system executives, even those of non-profit hospital systems, have become rich in the currently dysfunctional health care system. Our latest example of hospital executive compensation that seems wildly disproportionate to the value of their work appeared here in 2019.

We have long contended that a major reason for health care dysfunction is perverse incentives, including those that allow top health care leaders to become rich by putting money ahead of patient care.  We have presented case after case supporting this point.

The plutocratic compensation given leaders of non-profit hospitals is usually justified by the need to competitively pay exceptionally brilliant leaders who must do extremely difficult jobs.  Yet even leaders whose records seem to be the opposite of brilliance, or whose work does not seem very hard, often end up handsomely rewarded.

Other aspects of top health care managers' pay provide perverse incentives.  While ostensibly tied to hospitals' economic performance, their compensation  is rarely tied to clinical performance, health care outcomes, health care quality, or patients' safety.  Furthermore, how managers are paid seems wildly out of step with how other organizational employees, especially health care professionals, are paid.

I can understand the leadership of the ACP may feel very uncomfortable challenging the executives of hospitals in which most of the ACP membership's patients receive care.  Nonetheless, we need to reconsider the downsides of a health care system in which paying generic managers enough to make them rich now seems to be the leading goal of hospitals.

Private Equity as an Egregious Example

Dr McClean noted the

entry of private equity and venture capital firms into the health care space and the expansion of pharmacy chains into retail health clinics.... whose leadership] see ripe potential to disrupt the dysfunctional status quo quasi-marketplace, increasingly treat patients like consumers, develop systems of improved efficiency, at least on the surface, and in the process destroy or undermine the patient-physician relationship.

We have been writing about the nefarious role private equity has been playing in health care since 2010.  Private equity firms have been buying up for-profit hospital systems and other firms that employ physicians to provide direct patient care, like physician staffing firms.  They also may own medical education institutions, including offshore medical schools that  train physicians for the US (and Canada), and even for-profit medical schools in the US (look here).

We first discussed the perils of private equity takeovers of hospitals here in 2010, and of physicians providing direct patient care as employees of corporations owned by private equity here in 2011.   The private equity business model seems particularly unsuitable for organizations which provide patient care, as we discussed in some detail in 2012.

For a quick modern summary of why it is bad to have private equity involved in direct patient care, see Merrill Goozner writing in Modern Healthcare, September 5, 2019,

The private equity business model in healthcare parallels other industries: Use highly leveraged private capital to roll up a number of small firms into one entity, with the private equity firm providing collective management. In addition to hefty fees for arranging the transaction (generally 1% to 2% of the purchase price), the private equity firm typically demands a 20% return on its investment after paying interest on the debt.

After three to seven years, assuming all goes well in achieving the promised efficiencies, the private equity firm and its junior partners (who are the specialty physicians in this latest wave of takeovers) earn a windfall by taking the company public or flipping it to another set of private equity investors. If things don’t work out as planned, the firm cuts its losses and declares bankruptcy (most of its capital will have been recouped through the 20% annual returns).

The management company has two paths to achieve its financial targets. It can either reduce costs sharply or look for ways to increase revenue.

A private equity firm running a hospital is likely to be even more focused on putting short-term revenue ahead of all else, including patient's and the public's health, and ahead of health care professionals' safety and welfare.

The Role of Corporate Propaganda and Disinformation

Dr McClean noted:

The disinformation media blitz has already begun. Organizations with altruistic-sounding names such as Partnership for America's Health Care Future, a coalition representing insurers, pharmaceutical companies, and hospitals, assert that we should 'build on what's working in our health care system.' Do you remember the success of the Health Insurance Association of America at turning public opinion against the Clinton health plan back in 1994, using its year-long advertising campaign of 'Harry and Louise' commercials in which a couple expresses dismay at their dwindling insurance options and rising costs? We should expect a new generation of that type of commercial in the near future. 

Again, this is a severe, long-standing issue that involves are more than just health care insurance companies and related issues.

We had previously noted that promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or to the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.

As of 2019 we noted the participation of foreign powers, some potentially hostile, in the dissemination of health care related disinformation.  Even more disturbing, we began to see the dissemination of health care related disinformation by the executive branch of the US government under the Trump administration (look here).   In particular, disinformation is distorting the conversation about and maybe the response to coronavirus (look here). 

Thus countering the negative, and now often dangerous effects of propaganda and disinformation in health care and public health will require taking on far more bad actors than just health care insurance companies.

Conclusion: Issues Not Discussed

We have been cataloging aspects of US (and sometimes global) health care dysfunction for a long time.  There are many more issues than those about which Dr Cleary wrote.  In late 2019 I provided an updated summary of them. Reprinting it here would double the length of this post, so let me simply summarize the list of topics

Threats to the Integrity of the Clinical Evidence Base

Deceptive Marketing

Distortion of Health Care Regulation and Policy Making


Bad Leadership and Governance

Abandonment of Health Care as a Calling
 
Perverse Incentives Put Money Ahead of Patients, Education and Research

Cult of Leadership

Managerialism

Impunity Enabling Corrupt Leadership

Taboos

We strongly welcome the active participation of the ACP in the fight against health care dysfunction. Unfortunately, it may turn out to be a much more difficult and complex task than many would expect.

Now that health care dysfunction is in the headlines, we hope health care and public health professionals, patients, and all citizens will have a much more vigorous response to it.  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?  

A Pandemic of Silence: Hospital Managers Intimidate and Punish Coronavirus Whistle-Blowers

Under cover of a pandemic, managers and executives of hospitals, hospital systems, and other organizations that provide direct patient care are trying to silence health care professionals who point out leadership's failings.  We have seen a distressing parade of whistle-blowers intimidated and punished.

On March 25, an article in Medscape stated the basic problem.Per an anonymous orthopedic surgeon:

'It’s very clear; no one is allowed to speak for the institution or of the institution,' he said in an interview. 'We get a daily warning about being very prudent about posts on personal accounts. They’ve talked about this with respect to various issues: case numbers, case severity, testing availability, [and] PPEs.'

This clearly is not rare.

The silencing of physicians by hospitals about PPE shortages and other COVID-19 issues has become widespread, said Nisha Mehta, MD, a physician advocate and community leader who writes about PPE on social media. Physicians are being warned not to speak or post publicly about their COVID-19 experiences, including PPE shortages, case specifics, and the percentage of full hospital beds, Dr. Mehta said in an interview. In some cases, physicians who have posted have been forced to take down the posts or have faced retribution for speaking out, she said.

'There’s definitely a big fear among physicians, particularly employed physicians, in terms of what the consequences may be for telling their stories,' Dr. Mehta said. 'I find that counterproductive. I understand not inducing panic, but these are real stories that are important for people to understand so they do stay home and increase the systemic pressure to get sufficient PPE, so that we can preserve our health care workforce for a problem that is going to get worse before it gets better.'

Here is our round-up of specific cases, in the order that they came to light

Three Cases, Two Anonymous of the Silencing of Health Care Professionals who Blew the Whistle about Coronavirus Safety Issues

The Medscape article included:

an Indiana hospitalist who took to social media to ask for masks for hospitals in his area says he was immediately reprimanded by his management after the posts came to light.

Another frontline physician who works at a large New York hospital, said staff have been cautioned not to talk with the media and to be careful what they post on social media regarding COVID-19. The general rule is that only information approved by administrators can be shared

The Medscape article also detailed this case:

 [a] nurse, Lauri Mazurkiewicz, sent an email to staffers at Northwestern Memorial Hospital stating the surgical masks provided by the hospital were less effective against airborne particles than were N95 masks, according to a lawsuit filed March 23 in Cook County Circuit Court. Ms. Mazurkiewicz was terminated the next day in retaliation for her email, the lawsuit alleges.

In the short time since that article was published, more specific, and egregious examples have appeared

Emergency Physician Employed by TeamHealth, Owned by Private Equity Firm Blackstone, Fired at the Behest of PeaceHealth for "Inciting Public Fear"

Perhaps the best documented case is that of Dr Ming Lin.  As reported by the Seattle Times on March 29, 2020,

Dr. Ming Lin worked at PeaceHealth St. Joseph Medical Center for 17 years until he was removed on Friday by TeamHealth, a national staffing firm under contract to provide the hospital’s emergency department personnel. Lin became a national avatar for frustrated health care professionals during the COVID-19 outbreak by speaking up in the press and on social media with pleas for more medical supplies and stronger standards to protect health care workers combating the virus.

On March 16, Lin posted a letter on Facebook he’d sent to PeaceHealth St. Joseph’s chief medical officer, outlining how the hospital was mismanaging patient COVID-19 testing and exposing health care personnel and patients to unnecessary risks. He decried the hospital’s internal bureaucracy that prevented some doctors from ordering coronavirus tests, including a 'ludicrous' requirement that a flu test be completed before providing patients coronavirus screenings. Lin also criticized the hospital’s lack of a triage tent outside the emergency room to screen and test patients, to limit exposure of other patients and staff to potential infection.

'PeaceHealth is so far behind when it comes to protecting patients and the community, but even worse when it comes to protecting the staff,' Lin’s letter said.

The hospital's immediate response was to ask Dr Lin to "retract" or "recant" what he said.  When he refused, first

TeamHealth said Lin technically was not fired and remains employed by the company, but will no longer work at PeaceHealth St. Joseph Medical Center. A PeaceHealth St. Joseph spokesman on Friday confirmed Lin’s termination but declined to comment further because Lin was not directly employed by the hospital.

Note that:

TeamHealth was acquired by the Blackstone Group, a private equity firm, in 2016 for $6 billion. Since then, the company came under fire for a pattern of suing uninsured and low-income patients who were unable to pay their medical bills, but discontinued the practice after it gained public attention in the news.

An April 6, 2020 article in the Seattle Times disclosed the hospital's rationale for firing Dr Lin

Richard DeCarlo, chief operating officer of PeaceHealth, which operates Bellingham’s St. Joseph Medical Center, likened Lin’s public warnings about workplace coronavirus concerns to 'yelling fire in a crowded theater.'

that is,

allegedly inciting public fear by criticizing the hospital’s emergency precautions.

thus begging the question of what it was the public might fear.  Perhaps he was afraid they would fear going to his hospital, thus suppressing its revenues?

Note further that Mr DeCarlo, according to his official PeaceHealth biography, has no apparent experience of expertise in medicine, health care, or public health. The CEO apparently is a registered dietitian with no recent experience in medicine, health care, or public health.


NYU Langone Health Threatens to Fire Physicians who Talk to Press Without Authorization

The Wall Street Journal  reported on March 31, 2020 that after the head of the Department of Emergency Medicine at NYU Langone sent a message to physicians implying that they should consider withholding ventilators from some critically ill patients, the physicians

also got got a reminder not to speak to news reporters without permission from NYU Langone's Office of Communications and Marketing.

Kathy Lewis, executive vice president for communications and marketing, said in an email that NYU Langone's longstanding policy required faculty, residents and staff to forward all media inquiries to her.

'Anyone who does not adhere to this policy, or who speaks or disseminates information to the media without explicit permission of the Office of Communication and Marketing, will be subject to disciplinary action, including termination,' Ms Lewis wrote.

A blog post from the Foundation for Individual Rights in Education (FIRE) decried this threat to health care professionals' free speech about pandemic preparedness stated:

free speech and academic freedom do not become less important during a crisis, and that it’s critical that faculty members — many of them serving on the front lines of the pandemic — be able to share information with the broader public.

'It is precisely in times of crisis that it is most important that lines of communication to the public be open,' said Robert Shibley, FIRE’s executive director. 'These faculty members are there because they’re the experts. Inhibiting their ability to communicate important information about COVID-19 presents enormous risks.'

Consider also the source of the threat.  Note that according to her official bio,

Kathy Lewis, executive vice president for communications and marketing, is responsible for the advancement of NYU Langone Health’s unique brand identity as one of the nation’s premier centers for excellence in clinical care, biomedical research, and medical education.

Furthermore, Ms Lewis' qualifications to threaten physicians with termination appear to be limited to:

a BA from Montclair State University and an MA from Seton Hall University.

So the implication is that even in the midst of a deadly pandemic, the managers running NYU Langone think upholding the organization's brand identity comes before transparency and honest communication.

Note that this is not the first time Langone has put its brand identity ahead of transparency about disaster preparedness.  Back in 2012, after the medical center suffered a blackout and other problems due to super-storm Sandy, its board chairman, Mr Kenneth Langone, whose name the medical center carries, vociferously tried to avoid institutional accountability for poor disaster planning (look here.)  Mr Langone, a founder of Home Depot, who as described here had previously boasted

I am a fat cat, I'm not ashamed

is a big booster of President Trump (look here).

Other New York Hospitals Warn Health Care Professionals Not to Talk to Journalists

On April 1, 2020, Politico reported

As hospitals across New York City are filling up with patients gasping for air, health care executives are slapping gag orders on their workers to control the narrative amid the coronavirus pandemic.

Specific instances were:

Northwell Health recently sent medical professionals an email informing them all interviews with news media must first be cleared through the public relations department, a hospital employee told POLITICO.

Also,

Mount Sinai distributed its own set of guidelines discouraging speaking to the press and dictating social media policies as more health care professionals stepped forward to report problems in their hospitals. The guidance coincided with images shared on social media of employees wearing trash bags over their regular gear — an alarming picture from inside one of New York City’s premier and deep-pocketed health systems that has shaped public opinion of the shortage of personal protective equipment.

The email did not contain any reference to the ongoing pandemic or disciplinary action that could be taken, though some employees said the threat is present.

'I am very afraid I would be fired for [sharing the guidance with a reporter], which just makes me think they are more afraid of their image than actually having the patients cared for,' said one employee, who requested anonymity for fear of retaliation. 'I am a valuable asset, yet the fact that I am speaking up for my patients, colleagues and myself would have me terminated is not okay. It is an injustice that they overrule us with fear.'

A more recent New York Times article, from April 9, 2020, added:

'Do not respond or speak to any reporters, as well as current or former employees, regarding a pending news story,' wrote David A. Feinberg, the chief marketing and communications officer at the Mount Sinai Health System, in an email to all faculty and students on March 26.

In response,

health care workers on a coronavirus task force at Mount Sinai said they are demanding 'zero tolerance of employer retaliation or threats against those who are speaking up,' in a letter distributed among staffers and obtained by POLITICO.

Finally,

Eleven medical professionals across various health systems in New York City told POLITICO they signed nondisclosure agreements, had contracts that stipulated they not speak with the press without consent from their employer or feared losing their jobs if they spoke out publicly.

Mississippi Physicians Fired After Speaking Out

Health care professionals outside of states with the highest current coronavirus prevalence are not necessarily protected from punishment if they speak out.  On April 5, 2020, Mississippi Today reported:

An Oxford doctor is one of at least two Mississippi physicians claiming they were terminated for speaking out about their employers’ safety measures during the coronavirus pandemic.

Dr. Samantha Houston says she lost her job of four years at Baptist Memorial Hospital-North in late March for 'disruptive' behavior. In the weeks prior, Houston, a hospitalist, used Facebook to organize a local donation drive for masks and baby monitors so that hospital staff could cut down on face-to-face interactions with patients.

Houston, 34, also says she sent several emails to colleagues raising concerns about the availability of personal protective equipment, or PPE, for some workers.

'Every idea I had was just shut down and dismissed, and I just got very frustrated,' Houston told Mississippi Today. 'I just feel like they were not advocating for our safety, and that was what was so frustrating for me. And it really wasn’t even my safety. I felt safe enough because I had an N95 mask and I was able to get in there, but I felt like the nurses were not as safe.'

Also

Dr. Jennifer Bryan, who chairs the Mississippi State Medical Association board of trustees, told Mississippi Today that she knows of at least one other doctor in the state who was also fired for advocating for stronger safety measures.

A Los Angeles and Another New York Health Professional Punished

An article in the New York Times, April 9, 2020 included:

'They’re very protective of their reputation in the community,' said Jhonna Porter, a nurse who was suspended from West Hills Hospital in Los Angeles after raising safety concerns in a private Facebook group and publicly on her own page, including appeals for equipment. 'If anything seems like it might make them look bad, they’re going to stomp on it quick.'

And,

A doctor at Lincoln Medical and Mental Health Center in the Bronx, Deena Elkafrawi, was reprimanded after the British publication Metro quoted her as saying, 'I am scared that going to work could kill me,' according to the Committee of Interns and Residents, a national association that represented her.

Reactions to Silencing Health Care Professionals

Physicians Societies

Two physicians' societies have condemned hospital managers threatening or punishing health care professionals who spoke out about problems with hospitals' responses to the coronavirus pandemic. Per an April 4, 2020 Medscape article,

'Physicians have a professional and ethical responsibility and need to be able to speak out on these types of issues,' Robert McLean, MD, president of the American College of Physicians, told Medscape Medical News

The ACP is one of several professional organizations that have come out against attempts to silence physicians in recent days. Earlier this week, the ACP released a statement supporting physicians who shared concerns about their workplace conditions and lack of adequate PPE, while also rebuking attempts by hospital systems to silence clinician complaints or activism.

'We as a college felt the need to speak out about that and indicate that this is completely wrong,' said McLean. 'Physicians who are speaking out to make people aware of issues of public health and of public health concern should not be at risk of having their employment terminated or otherwise disciplined.'

According to the ACP's ethics policy, physicians who are able should speak out about public health issues for their safety and the safety of their patients, he said. 'The benefit to patients is that problems are identified and not swept under the rug.'

On Wednesday, the American Medical Association (AMA) also put out a short statement in support of physicians' right to advocate for their patients in the current climate:

'In recent weeks, as physicians have battled the COVID-19 pandemic, the question of when and how to express concern about conditions and safety has become a flashpoint for physicians and their hospital employers.'

The hospital managers trade association responded by minimizing the problem.

When contacted by Medscape Medical News to comment on these reports, the American Hospital Association (AHA) referred to a letter sent by AHA President and CEO Richard Pollack on March 27 to the consumer advocacy group Public Citizen, in response to a complaint filed by the group on behalf of themselves and 54 other organizations.

'Outside of the anecdotal reports you shared, the AHA has not heard any reports of hospitals or health systems restricting the free speech of physicians, nurses, or others regarding the conditions related to COVID-19,' the letter reads.

I wonder if the AHA is now aware of all the cases listed above?

Frontline Health Care Professionals

An April 9, 2020, article in StatNews discussed widespread anger among health care professionals over responses to coronavirus from health care leaders, including local and national government leaders, but also hospital leadership.  In particular,

Among the physicians, there’s a growing fear that they’ll face repercussions if they speak out.

Specifically,

'The thought of being fired right now, when my patients need me the most, is even more terrifying than the idea of potentially getting ill from Covid-19,' the Los Angeles primary care physician said.

Whistleblower International Network

The Whistleblower International Network (WIN) wrote a protest letter saying the coronavirus pandemic has led to "the largest attack on whistleblower in the world."

Coronavirus whistleblowers have been exposing inadequate health system capacity and delivery, public procurement problems, violations of health and safety and labor law, inequitable and ill-prepared global supply chains, unfair competition practices and market abuses, and large-scale violations of personal privacy rights. Employers and public authorities have responded to many of the doctors, scientists, and other frontline workers who told the truth by firing them. In countries like the US, UK, and Italy, such termination of employment is illegal whistleblower retaliation, but that hasn’t stopped employers. Other countries such as China, India, and Poland, employees don’t have any whistleblower rights on paper at all. In either scenario, employer retaliation chills others from engaging in public interest speech, which serves the overall mission of preventing the truth from getting to the community. The act of keeping the truth from the public during a pandemic is gross negligence, which is the deliberate and reckless disregard for the safety and reasonable treatment of others. Every time a whistleblower is retaliated against, the public’s rights are being trampled on too. Indeed, we are all victims in the wake of the largest attack on whistleblowers in the world.

The letter concluded:

Suppressing the truth is a clear and present danger to public health and safety that could turn the pandemic into a modern Black Plague. Employers and governments are silencing their early warning systems, but the effect is trans-national. The outrage must be as well.

Why Are Hospital Managers So Quick to Silence Health Care Professionals?

Thus threats against physicians and other health care professionals who blow the whistle about patient care and safety issues, and dangers to health care professionals in the era of the coronavirus pandemic are likely to continue. 

In medicine and health care, there is a long and sorry history of management trying to silence whistle-blowers who might put the leadership in a bad light.  As noted in the March 25 Medscape article,

John Mandrola, MD, a Louisville, Ky.–based cardiologist who has written about the recent muzzling of frontline physicians with respect to the coronavirus, said he is not surprised that some hospitals are preventing physicians from sharing their experience

'Before C19, in many hospital systems, there was a culture of fear amongst employed clinicians,' he said. 'Employed clinicians see other employed physicians being terminated for speaking frankly about problems. It takes scant few of these cases to create a culture of silence.'

We have been posting about problems with management and governance in health care for a long time.  Some of these problems seem to be grossly manifest in cases in which whistleblowers were threatened or punished to inspire silence, and may explain why the practice continues even in a time of pandemic.

Managerialism

In some cases above, the executives threatening to silence health care professionals were themselves not health care professionals, and seemed to have no direct medical, health care, or public health care experience. In two cases, executives in charge of  communications or marketing intimidated professionals to secure their silence. This implicates managerialism as a source of the problem.

Per an article from the June, 2015 issue of the Medical Journal of Australia (look here):
- 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

Such generic managers, who have sworn no oaths to put patient care ahead of all other concerns, may have few qualms about silencing whistle-blowers to protect their organizations' and their own reputations. 

Putting Revenue Ahead of Patients' and Health Care Professionals' Safety

In several cases, hospital management seemed more concerned about loss of patients and revenue resulting from degradation of their hospitals' brand identity or reputation than about patients' and professionals' safety.

As noted above, managers of hospitals are increasingly from business, not health care backgrounds.  Whatever their background, they seem more likely to be influenced by currently fashionable management dogma.  A dominant dogma in management is that pursuit of shareholder value comes before all else.  Even though many, but not all hospitals are still ostensibly non-profit, many hospital managers have likely been influenced by this dogma.  As we posted here, quoting Lazonick:

in 1983, two financial economists, Eugene Fama of the University of Chicago and Michael Jensen of the University of Rochester, co-authored two articles in the Journal of Law and Economics which extolled corporate honchos who focused on 'maximizing shareholder value' — by which they meant using corporate resources to boost stock prices, however short the time-frame. In 1985 Jensen landed a higher profile pulpit at Harvard Business School. Soon, shareholder-value ideology became the mantra of thousands of MBA students who were unleashed in the corporate world.

Lazonick added:

When the shareholder-value mantra becomes the main focus, executives concentrate on avoiding taxes for the sake of higher profits, and they don’t think twice about permanently axing workers. They increase distributions of corporate cash to shareholders in the forms of dividends and, even more prominently, stock buybacks. When a corporation becomes financialized, the top executives no longer concern themselves with investing in the productive capabilities of employees, the foundation for rising living standards for all. They become focused instead on generating financial profits

So many hospital managers may have no qualms about punishing whistle-blowers to protect their organizations' revenues.


What Needs to Be Done?

In the short run, we must do all we can to protect health care professional whistleblowers, as suggested by the Whistleblower International Network above.

In the long run, hopefully assuming there is one, we further need to address the systemic features of our dysfunctional health care system that enabled the rise of leaders who are happy to silence health care professionals to preserve their organizations' reputations and revenue, no matter what.  We need leaders who put patient's and the public's health ahead of all else, and who understand and uphold health care professionals' values.  We need hospitals, hospital systems, and other organizations that provide direct patient care that are not responsible for producing profits for their owners or shareholders.

COVID-19: It's Now Time for Health IT Vendors to Traffick in Patient Data

In numerous posts at this blog, I've brought up the issue of hospitals and health IT sellers extracting and exchanging/selling (ostensibly) anonymized clinical data from their EMR systems.  The buyers are varied, from pharma and PBM's to academic researchers to government, and likely many others.

This practice is not new.  For example, see my Oct. 7, 2009 post "Health IT Vendors Trafficking in Patient Data?" at https://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html.

An example of EMR vendor (Cerner) data sales of "anonymous, HIPAA-compliant, EHR-derived data" for analysis. 
Cerner and EPIC are among the largest enterprise EMR sellers in the world.

Also see my November 12, 2019 post "Google’s ‘Project Nightingale’ Secretly Gathers Personal Health Data on Millions of Americans - Time to Refuse Use Of EMR's In Your Healthcare?" at https://hcrenewal.blogspot.com/2019/11/googles-project-nightingale-secretly.html.  In that post I cited an article on Google's efforts in this domain:

Google’s ‘Project Nightingale’ Secretly Gathers Personal Health Data on Millions of Americans

By Katabella Roberts

November 12, 2019

https://www.theepochtimes.com/googles-project-nightingale-secretly-gathers-personal-health-data-on-millions-of-americans_3143843.html

Google has been working with one of the largest healthcare systems in the U.S. to collect and analyze the personal health information of millions of citizens across 21 states, The Wall Street Journal reports.  The Tech giant reportedly teamed up with St. Louis-based Ascension, the largest non-profit health system in the country, last year, and the data sharing has accelerated since summer.

Code-named Nightingale, the project saw both companies collect personal data from patients, which included lab results, doctor diagnoses, and hospitalization records, as well as patient names and dates of birth.

Google said it plans to use the data to create new software that will improve patient care and suggest changes to their care.

More recently, a court review of a noncompete clause-related lawsuit "FLATIRON HEALTH, INC. v. Carson" at https://scholar.google.com/scholar_case?case=7629237467560597212, received by me via a Google alert I have active on EHR-related litigation, describes the market for medical data in more detail.

For instance:

... Flatiron's largest line of business is its real-world evidence ("RWE") service, which converts raw clinical data from patient records into a structured format so that the data can be used for research purposes.[3] After structuring the data, Flatiron aggregates the data into data sets. Flatiron generates revenue by selling data sets to biopharmaceutical companies, as well as some regulatory agencies and researchers...

... Flatiron has developed methodologies and software systems for gathering, curating, and analyzing data from electronic health records. For example, to curate data, Flatiron has formulated rules governing how Flatiron converts information conveyed by physician notes, or other raw data in a patient record, into numeric values for variables in Flatiron's data set...

... Flatiron develops and implements these methods and systems using cross-functional teams consisting of software engineers, oncologists, clinical data specialists, data entry personnel, and others. For example, Flatiron's clinical data team writes policies and procedures to govern how Flatiron's data entry personnel curate data from unstructured records, and Flatiron's research oncology team must generally sign off on those policies and procedures. Research oncologists also describe clinically relevant concepts and rules, which software engineers incorporate into Flatiron's software codes.

This is one of numerous companies who perform services like this.  (Disclaimer:  I have no connections, financial or other interests, or involvement in this company, or others like it, whatsoever.)

Some observations:

1.  Expertise for analysis of EHR-derived datasets is relatively common.

2.  Enterprise EHR systems are widespread and are capturing highly-detailed, relatively standardized data that is easily extracted, as compared to paper records.

3.  Nearly all COVID-19 patients treated in hospitals in the United States, and in other countries with widespread EHR adoption, will have detailed data stored about their demographics (including residences and recent travel), medical and social history, medication history, pre-existing medical conditions, timelines of their signs and symptoms, chronological results of labwork and imaging studies showing response (or not) to therapy, and so forth.

4.  While systems may not be "interoperable", extraction of a uniform constrained dataset from the major EHR systems is both straightforward and, apparently, done regularly for commercial and/or research purposes.

5.  Therefore, in view of the current medical and mass economic upheaval, and what seems to be increasing public impatience and distrust of the experts:

I believe and recommend that anonymized, HIPAA-compliant datasets on COVID-19 patients should be made available ASAP, for example, on an HHS website.

This would allow leveraging of widespread expertise in analysis of the data for crucial purposes including, but not limited to (just off the top of my head): a better understanding of just who is susceptible to getting severe symptoms and ARDS from COVID-19; the role of co-morbidities in outcomes; comparative effectiveness research on new and experimental treatments (such as the currently controversy-provoking hydroxychloroquine/zithromycin/zinc triad); comparison of strategies in use of mechanical ventilators; and others.

One of the motivations of widespread EHR adoption (including government incentives, and, after a few years, penalties for non-adopters) was the potential of EHRs for enabling "virtual clinical trials" to be conducted.

Up to now, EHRs have largely been an albatross to practicing physicians and nurses, who are called upon - mandated, actually - to perform a massive amounts of clerical work in data entry, in addition to clinical work. 

It's time IMHO to leverage and democratize EHR potential, not just for the benefit of high-paying data customers.

(I don't think what I describe is happening on a significant scale; I believe the data is being kept on a short leash.  I would appreciate knowing if this is not correct.)

Finally, I note that politics and the data analytics I describe don't mix well.

-- SS

During the Pandemic, Follow the Money: Hospitals and Health Care Provider Organizations Put Money Ahead of Clinician and Patient Safety, Public's Health

As the coronavirus pandemic continues its relentless course, we see many examples of selflessness and courage. They come from huge numbers of people keeping their social distance, to those in essential work, including primary care and public health professionals, facing long hours and increased risk, to first responders and hospital based doctors, nurses and other health professionals facing even longer hours, more risk, and the sorrows of sick and dying patients.  We also see economic hardships to many, including layoffs, lost wages, and closed small businesses. 

However, in the commercialized and dysfunctional US health care system, whose theme, like that of The Apprentice, should be "For the Love of Money," we see some stark contrasts. 


[For the Love of Money, the O'Jays]

So to understand why things keep going so wrong, we need to follow the money.  Let us consider some recent cases, roughly in order of when they came to light.


Hospitals Fail to Order Ventilators for Predicted Surge in Coronavirus Patients

As reported by the Washington Post on March 18, 2020, the background is now all too familiar:

Mechanical ventilators, which help patients breathe or breathe for them, are considered critical to the nation’s effort to contain the worst effects of the pandemic and avoid a crisis like the one Italy is facing. Depending on how bad the coronavirus pandemic gets in the United States, individual cities could come up thousands of ventilators short as patients flood hospitals, researchers say.

However,

Orders have not flooded in, she said, because most hospitals can’t afford to increase inventory of expensive equipment for what could turn out to be a short-term event.

'The risk is that they’ll never be used, and hospitals can’t eat the cost,' she said. 'Most hospitals in this country are not profitable.'

And why do hospitals not have any extra ventilators in case of a surge in demand?

Keeping backup ventilators is impractical for most hospitals because of the need to service and maintain them and train additional staff during rare events when they are needed, said Lewis Kaplan, a trauma surgeon at the University of Pennsylvania and president of the Society of Critical Care Medicine.

'It’s like taking military planes out of your boneyard,' he said. 'There can be a variety of economic disincentives to be prepared for the worst thing that can happen.'

Left unsaid is how the dollars saved might be balanced against any lives that could be lost were backup ventilators unavailable. Left also unsaid is whether the hospital could have bought the ventilators by using money earmarked for other purposes, like public relations, marketing, or increasing the compensation of top executives.   

Note that these comments came from early March, before US hospitals were overwhelmed.  They suggest that hospital leadership was not willing to sacrifice the short-term bottom line to be better prepared for a catastrophic event, despite, the mission of the hospital that should place the care of patients first, way ahead of short-term financial issues.

The reason is likely that most hospitals, like other health care organizations, are in the grip of managerialism.  Per an article from the June, 2015 issue of the Medical Journal of Australia (look here):
- 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

The dangers of managerialism are becoming more apparent in this era of the pandemic.

Hospitals Still Allowing Elective Procedures, Despite Use of Resources that might be Needed for Pandemic Preparation, and Risks of Disease Transmission

An anonymous post on the KevinMD blog on March 24, 2020 suggested that hospital managers are pressuring doctors to do elective procedures, despite guidelines suggesting such procedures should be on hold during the pandemic:

Despite the guidelines issued from the American Society of Anesthesiologists, The Anesthesia Patient Safety Foundation, The American College of Surgeons, and the Center for Disease Control, many hospitals are continuing with elective cases during the COVID-19 crisis. Or worse, they are hiding behind the facade of canceling or postponing elective cases. At many hospitals, a tiered system of urgency allows leeway to surgeons or family to manipulate or distort the urgency by overplaying symptoms.

Furthermore,

For many of you, your hospital administration has forced your hand to continue operations or made examples of you if you disagree. There is pressure from your chiefs who are also likely being intimidated at the risk of losing their jobs.

The author noted that continuing elective surgery has risks, and gets in the way of pandemic preparedness

In addition to gambling on my very existence, every case you participate in that is not absolutely necessary right now is putting your community at risk. We do not have the luxury of practicing social distancing in our job. Every family that comes into the hospital is a potential vector for this virus, and we have no choice but to do the cases and then potentially spread this to our patients or our own family. We are sending mixed messages to our family by encouraging them to stay home in every aspect except this one. Every case you leave on the board requires us to use gloves, gowns, masks for all parties in the operating room. In addition, we must use anesthesia circuits, airway interventions, and medication that will be critically important in the coming days. As I alluded to earlier, even cases that do not typically require intubation might require it. In the same vein, intubation does not guarantee extubation. You must consider that your patient may need postoperative ventilation.

The implication is that the hospital managers are putting short-term revenue ahead of patient and health care professional safety, and using intimidation to do so.  Why? See the comments on managerialism above.

Within days, specific examples of the pressure by hospital management to continue performing elective procedures have appeared.

For baseball fans: on March 31, 2020, NJ.com reported:

On March 19, the Boston Red Sox learned ace Chris Sale needed Tommy John surgery. Five days later, New York Mets right-hander Noah Syndergaard found out he needed Tommy John surgery as well. Syndergaard went under the knife two days later. Sale had his operation on Monday, according to the Boston Globe.

There was no question both procedures were elective

When Red Sox chief baseball officer Chaim Bloom announced Sale’s impending surgery, he admitted the southpaw’s operation was elective. 'Obviously something we’re mindful of,'

Syndegaard's surgeon tried a little spin:

One of Syndergaard’s doctors said the right-hander’s operation was completely justified. According to the Mets, Dr. Neal ElAttrache gave Syndergaard a second opinion and defended Syndergaard going under the knife because the 27-year-old pitcher’s 'livelihood is at stake.'

The teams apparently set up the procedures to avoid hospitals and states where they were discouraged.

Each state has its own standards for medically-necessary procedures. Syndergaard went to Florida for his operation because at the time, the Sunshine State was allowing such operations whereas New York was becoming the epicenter of the coronavirus fight.

The Boston Globe reports Sale went to California for his operation because of the state’s lack of restrictions on procedures. His operation was performed by Dr. ElAttrache, who as we said, sees no problem with these surgeries.

In the modern sports world, team owners have shown they are in it for the money.  However, the physicians and doctors who collaborated to provide obviously elective surgery on wealthy, high-profile athletes also seemed to be putting money ahead of the public's health.

Some hospital systems seemed particularly cavalier about elective procedures. On April 1, USA Today reported,

This month, nearly 300 University of Pittsburgh Medical Center medical staff members – the majority of them residents and anesthesiologists – signed a seven-page letter outlining concerns about elective surgery and routine visits. It was sent to the health systems' management March 21, but some elective procedures have continued, according to two doctors who asked to remain anonymous.

Employees reported backlash from management because of the letter, one of the doctors said.

A second example,

Facilities allowing nonemergency surgeries include Steward Health Care. The more than 30-hospital chain, which operates in states including Texas and Louisiana, said in a statement that it will 'continue to support all scheduled surgeries and procedures, and we will leave the decision on whether it is appropriate to proceed now to our physicians and their patients.'

Steward said it is 'committed to preserving access to scheduled procedure time for as long as possible.' Steward did not respond to a request for comment Tuesday.

Just to reiterate,

Doctors and hospital staff 'have been put in a situation of deliberate sacrifice and are told to put our personal safety aside for monetary reasons,' said [Dr Nivedita] Lakhera, who has written two books on mental health and healing. 'When hospitals do nonemergency procedures, we see them as being OK with our death over their greed about short-term revenue. We resent that, but we are powerless, and we are forced to be there anyway.'

Note that UPMC is something of a poster child for managerialism in health care.  We have frequently discussed the hospital system management's ethical misadventures, led by a business-trained generic manager who has received outlandish compensation.  Our most recent round-up of the troubles at UPMC was in 2015.  

Furthermore, note that Steward Health Care is actually a for-profit hospital system owned by a private equity group, Cerberus Capital Management.  Thus it exemplifies another feature of the US commercialized health care system, financialization.  Steward Health Care, as run by Cerberus, was one of the earlier leaders in hiring corporate physicians, whom it pressured to avoid "leakage" of patients to other hospitals and doctors, even if some might question whether the care provided elsewhere might be better for those patients (look here).  The multimillion dollar a year CEO of Steward suggested the health care had become a commodity, objectionable to those who thought that health care should be a mission-based calling (look here). A 2016 summary of Steward's operational misadventures is here. As an aside, Steward was caught up in a dodgy scheme called World Health Networks to sell travelers quick analyses of their health via kiosks.  The scheme involved shady foreign participants, and a number of associates of ... Donald Trump (look here). 

Despite their sometimes dark pasts, both UPMC and Steward have remained major hospital systems, so maybe it should be no surprised that they are now seen as involved in ethically dubious activities that are hampering coronavirus preparedness, and possibly putting patients and health care professionals  at risk.


Hospitals Cutting Pay of Frontline Health Care Professionals Who Are at Personal Risk from Coronavirus

On March 27, 2020, the Boston Globe reported:

Emergency room doctors at Beth Israel Deaconess Medical Center have been told some of their accrued pay is being held back. More than 1,100 Atrius Health physicians and staffers are facing reduced paychecks or unpaid furloughs, while pay raises for medical staff at South Shore Health, set for April, are being delayed.

In particular, at the Beth Israel Deaconess Medical Center,

the physicians group announced that effective April 1, it is suspending employer contributions to the retirement plan for doctors in the group, as well as at an affiliated group that staffs many other hospitals in the state, Associated Physicians of Harvard Medical Faculty Physicians at BIDMC. There are 1,600 doctors in both groups, and the majority of them are affected by the cutback, according to a company spokesperson.

The physicians group also told ER doctors this week that it is withholding and deferring half of their quarterly 'bonuses' scheduled for March 30, according to another e-mail shared with the Globe. Those payments, which can reach tens of thousands of dollars per quarter, are based on extra shifts or additional patients the ER doctors took on months earlier, according to the doctors.

'The bonus is just pay we’ve earned,' [ED Doctor Matt] Bivens explained. 'It’s analogous to re-branding ‘overtime pay’ as ‘your bonus.’' Meanwhile physicians in other specialties in the group will not be receiving bonuses at all on March 30, according to the e-mail.

However,

'This is at a time when many of us have moved out to live like lepers separate from family to prevent spreading infection, and have already been working huge extra hours trying to scrape together [personal protective equipment] and otherwise brace for COVID-19,' said Dr. Matt Bivens, an ER doctor at Beth Israel Deaconess Medical Center and St. Luke’s Hospital in New Bedford.

What was the rationale? The need to preserve short-term revenue, of course:

'Like many other health care and physician organizations, the economics of the care we provide has changed quickly and dramatically,' wrote Dr. Alexa B. Kimball, chief executive of the Harvard Medical Faculty Physicians group practice at Beth Israel Deaconess Medical Center

I could find nothing in the article suggesting that the hospitals were cutting the pay of management personnel, however.  It seems particularly egregious to cut the pay of the health care professionals working the hardest and exposed to the most risk from coronavirus, while leaving the pay of already extremely well-compensated managers intact (if that is, in fact, the case).  But that's how the managerialist cookie crumbles....

Private Equity Owned Physician Staffing Company Cutting Pay of Front-Line Health Care Professionals Who Are at Personal Risk from Coronavirus

On March 31, 2020, ProPublica reported:

Most ER providers in the U.S. work for staffing companies that have contracts with hospitals. Those staffing companies are losing revenue as hospitals postpone elective procedures and non-coronavirus patients avoid emergency rooms. Health insurers are processing claims more slowly as they adapt to a remote workforce.

'Despite the risks our providers are facing, and the great work being done by our teams, the economic challenges brought forth by COVID-19 have not spared our industry,' Steve Holtzclaw, the CEO of Alteon Health, one of the largest staffing companies, wrote in a memo to employees on Monday.

The memo announced that the company would be reducing hours for clinicians, cutting pay for administrative employees by 20%, and suspending 401(k) matches, bonuses and paid time off. Holtzclaw indicated that the measures were temporary but didn’t know how long they would last.

In a follow-up memo sent to salaried physicians on Tuesday night, Alteon said it would convert them to an hourly rate, implying that they would start earning less money since the company had already said it would reduce their hours. The memo asked employees to accept the change or else contact the human resources department within five days “to discuss alternatives,” without saying what those might be. The memo said Alteon was trying to avoid laying anyone off.

'It’s completely demoralizing,' said an Alteon clinician who spoke on the condition of anonymity. 'At this time, of all times, we’re putting ourselves at risk but also putting our families at risk.'

So many ED physicians are neither private practitioners or hospital employees, but work for medical staffing companies, to whom hospitals have outsourced ED functions.  Presumably, hospital managers did this based on management dogma favoring outsourcing as a way to increase financial efficiency, thus improving the hospitals' revenue.  Here we see managerialism in action once again.

But wait, there is more.... It is not merely that the ED physicians in this case are employees of an organization led by managers with business training, but no health care background.  In fact, they work for for-profit companies owned again by private equity firms:

Private equity investors have increasingly acquired doctors’ practices in recent years, according to a study published in February in JAMA. TeamHealth was bought by Blackstone Group in 2016; another top staffing firm, Envision Healthcare, is owned by KKR. (The staffing companies have also been implicated in the controversy over 'surprise billing.')

What about Alteon?

Alteon and its private-equity backers, Frazier Healthcare Partners and New Mountain Capital, didn’t immediately respond to requests for comment.

ED clinicians now faced with pay cuts while they work harder, face more hardships, and are subject to more risks, were not happy.

'It’s completely demoralizing,' said an Alteon clinician who spoke on the condition of anonymity. 'At this time, of all times, we’re putting ourselves at risk but also putting our families at risk.'

So,

'I’ve completely lost trust with this company.'

The big question is why that clinician ever thought a private equity company would put patient care, and patient and clinician safety ahead of its own revenue?

We first discussed the perils of private equity takeovers of hospitals here in 2010, and of physicians providing direct patient care as employees of corporations owned by private equity here in 2011.   The private equity business model seems particularly unsuitable for organizations which provide patient care, as we discussed in some detail in 2012.

For a quick modern summary of why it is bad to have private equity involved in direct patient care, see Merrill Goozner writing in Modern Healthcare, September 5, 2019,

The private equity business model in healthcare parallels other industries: Use highly leveraged private capital to roll up a number of small firms into one entity, with the private equity firm providing collective management. In addition to hefty fees for arranging the transaction (generally 1% to 2% of the purchase price), the private equity firm typically demands a 20% return on its investment after paying interest on the debt.

After three to seven years, assuming all goes well in achieving the promised efficiencies, the private equity firm and its junior partners (who are the specialty physicians in this latest wave of takeovers) earn a windfall by taking the company public or flipping it to another set of private equity investors. If things don’t work out as planned, the firm cuts its losses and declares bankruptcy (most of its capital will have been recouped through the 20% annual returns).

The management company has two paths to achieve its financial targets. It can either reduce costs sharply or look for ways to increase revenue.

A private equity firm running a hospital is likely to be even more focused on putting short-term revenue ahead of all else, including patient's and the public's health, and ahead of health care professionals' safety and welfare.

Summary

We have been ranting about the perils of the US commercialized, dysfunctional health care system for a long time, unfortunately often with little effect.  But expect these perils to loom very large when the health care system and the nation's public health are under a deadly threat, like that from a pandemic.  I hope most of us will survive this pandemic.  When it is over, we have to rethink our societal devotion to neoliberalism, (or market fundamentalism) (look here).

We could start by banning the commercial practice of medicine, as we did in the past, and banning for-profit corporations from owing hospitals, or providing direct care to patients.

Until we do, we will continue to live in a dystopic version of The Apprentice.