Introduction: the Sorry History of US Health Care Dysfunction
We have been talking about health care dysfunction for a very long time, starting with a publication in 2003.
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.
It has been a slog. For years health care dysfunction, at least we we defined and discussed it, was practically a taboo topic. From 2003 through 2016 we felt there were only a few incremental improvement in some aspects. However, the advent of Donald Trump and his "base," and the first years of the Trump presidency expanded the scope and increased the intensity of health care dysfunction. It got bad enough that the phrase "health care dysfunction" actually made it to a presidential debate, albeit a Democratic primary debate, in November, 2019. On that occasion we summarized what we thought were the ongoing issues.
Since then, things have only gotten worse. Then in 2020 the coronavirus pandemic spread around the globe. That only provided more opportunities for the Trump administration to amplify dysfunction.
Now, on the occasion of the Trump administration's apparent defeat in the presidential election (setting aside for the moment any legal or extra-legal challenges to the results), I will update what the state of play in health care dysfunction was prior the pandemic. At a later time we will discuss how the pandemic gave Trump et al an opportunity to supercharge health care dysfunction.
The Multiple Dimensions of Health Care Dysfunction Pre-Pandemic
Since 2003 we have broadened our thinking about what constitutes and
causes US (and more global) health care dysfunction. Early on we noticed
a number of factors that seemed to enable increasing
dysfunction, but were not much discussed. These factors notably
distorted how medical and health care decisions were made, leading to
overuse of excessively expensive tests and treatments that provided
minimal or no benefits to outweigh their harms. The more we looked, the
more complex this web of bad influences seemed. Furthermore, some
aspects of it seemed to grow in scope during the Trump administration.
A brisk summary of these often complex issues follows.
Threats to the Integrity of the Clinical Evidence Base
The clinical evidence has been increasingly affected by manipulation
of research studies. Such manipulation may benefit research sponsors, now
often corporations who seek to sell products like drugs and devices and
health care services. Manipulation may be more likely when research is
done by for-profit contract research organizations
(CROs). When research manipulation failed to produce
results to sponsors' liking, research studies could simply be suppressed or hidden.
The distorted research that was thus selectively produced was further
enhanced by biased research dissemination, including ghost-written
articles ghost-managed by for-profit medical education and
communications companies (MECCs). Furthermore, manipulation and
suppression of clinical research may be facilitated by health care
professionals and academics conflicted by financial ties to research sponsors.
These issues did not get much attention since November, 2019, during the Trump presidency, pushed aside by the administration's "flooding of the zone" with distractions.
Deceptive Marketing
The distorted evidence base was an ingredient that proved useful in deceptive marketing of health care products and services. Stealth marketing
campaigns became ultimate examples of decpetive marketing. Deceptive
marketing was further enabled by the use of health care professionals
paid as marketers by health care corporations, but disguised as unbiased
key opinion leaders, another example of the perils of deliberate generation of conflicts of interest affecting health care professionals and academics.
These issues also did not get much attention since November, 2019.
Distortion of Health Care Regulation and Policy Making
Similarly, 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.
More recently, as we noted here, we became aware of efforts by foreign powers to spread such disinformation for political, not just financial gain, e.g., in April, 2019,
we discussed evidence that Russia had orchestrated a systemic
disinformation campaign meant to discredit childhood vaccinations,
particularly for the measles, which was likely partly responsible for
the 2019 measles outbreak
Furthermore, companies selling health care products and services further enhanced their positions through regulatory capture,
that is, through their excessive influence on government regulators and
law enforcement. Their efforts to skew policy were additionally
enabled by the revolving door,
a species of conflict of interest in which people freely transitioned
between health care corporate and government leadership positions.
In the Trump era, we saw a remarkable increase in the incoming revolving
door, people with significant leadership positions in health care
corporations or related groups attaining leadership positions in
government agencies whose regulations or policies could affect their
former employers (look here). We found multiple managers from and lobbyists for big health care
corporations being put in charge of regulation of and policy affecting -
wait for it - big health care corporations, a staggering
intensification of the problem of the revolving door.
Since November, 2019, cases of US government officials traversing the revolving door continued (look here).
Bad Leadership and Governance
Health care leadership was often ill-informed.
More and more people leading non-profit, for-profit and government have
had no training or experience in actually caring for patients, or in
biomedical, clinical or public health research. Lately, during the
Trump administration, we began to find striking examples of top
government officials expressing ill-informed,
if not outright ignorant opinions about medical, health care and public
health topics look here). We had not previously expected leaders of government to
be personally knowledgeable about health related topics, but
traditionally they consulted with experts before making pronouncements.
Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile
to their organizations' health care mission, and/or health care
professionals' values. Often business trained leaders put short-term
revenue ahead of patients' or the public's health. In addition, we
began to see evidence that leaders of health care corporations were
using their power for partisan purposes, perhaps favoring their personal
political beliefs over their stated corporate missions, patients' and
the public's health, and even corporate revenues. Then, we started
seeing appointed government health care leaders who lacked medical,
health care or public health background
or expertise but also whose agenda also seemed to be overtly religious
or
ideological, without even a nod to patients' or the public' health (look
here).
Leaders of health care organizations increasingly have conflicts of interest. Moreover, we have found numerous examples of frank corruption of health care leadership. Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud. Some have resulted in criminal convictions,
albeit usually of corporate entities, not individuals.
In the Trump administration, corrupt leadership extends from the
corporate world to the highest levels of the US government. We
discussed the voluminous reports of conflicts of interest and corruption
affecting top leaders in the executive branch, up to and including the
president and his family (look here).
Since November, 2019, periodic updates about the President Trump and family's extensive conflicts of interest, and particularly how some of his conflicts appear to violate the US Constitution (eg, look here). Not unexpectedly, the latest version of Transparency International's Corruption Perception Index showed that the public perceived the US government under Trump has a worsening corruption problem (look here).
One cannot expect effective enforcement of ethics rules and anti-corruption laws in such an environment.
Abandonment of Health Care as a Calling
A US Supreme Court decision was interpreted to mean that
medical societies could no longer regulate the ethics of their members,
leading to the abandonment of traditional prohibitions on the commercial
practice of medicine.
Until 1980, the US American Medical Association had ruled that the
practice of medicine should not be "commercialized, nor treated as a
commodity in trade." After then, it ceased trying to maintain this
prohibition. Doctors were pushed to be businesspeople, and to give
making money the same priority as upholding their oaths. Meanwhile,
hospitals and other organizations that provide medical care are
increasingly run as for-profit organizations. The physicians and
other health care professionals they hire are thus providing care as
corporate employees, resulting in the rise of the corporate physician. These health care professionals may be further torn between their oaths, and the dictates of their corporate managers.
These issues also did not get much attention since November, 2019.
Perverse Incentives Put Money Ahead of Patients, Education and Research
We have extensively discussed the perverse incentives
that seem to rule the leaders of health care. Financial incentives may
be large enough to make leaders of health care organizations rich. Incentives often prioritize financial results over patient care. Some
seem to originate from the shareholder value dogma promoted in business
school, which de
facto translates into putting current revenue ahead of all other
considerations, including patient care, education and research (look here).
These issues also did not get much attention since November, 2019.
Cult of Leadership
Health care CEOs tend
now to be regarded as exalted beings, blessed with brilliance, if not
true "visionaries," deserving of ever increasing pay whatever their
organizations' performance. This phenomenon has been termed "CEO disease" (see this post).
Afflicted leaders tend to be protected from reality by their
sycophantic subordinates, and thus to believe their own propaganda.
These issues also did not get much attention since November, 2019.
Managerialism
Leadership of health care organizations by managers with no
background in actual health care, public health, or biomedical
science has been promoted by the doctrine of managerialism which
holds that general management training is sufficient for leaders of all
organizations, regardless of their knowledge of the organizations'
fundamental mission.
These issues also did not get much attention since November, 2019.
Impunity Enabling Corrupt Leadership
Most cases involving corruption in large health care organizations are resolved by legal settlements.
Such settlements may include fines paid by the corporations, but not by
any individuals. Such fines are usually small compared to the revenue
generated by the corrupt behavior, and may be regarded as costs of doing
business. Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements. The former were originally meant to give young, non-violent first offenders a second chance (look here). However, in most instances in which corruption became public, are no negative
consequences ensue for the leaders of the organizations on whose watch
corrupt behavior occurred, or who may have enabled, authorized, or
directed the behaviors.
These issues also did not get much attention since November, 2019.
Taboos
Some of the above topics rarely appeaedr in the media
or scholarly literature, and certainly seem to appear much less
frequently than their importance would warrant. We have termed the
failure of such issues to create any echoes of public discussion the anechoic effect.
Public discussion of the issues above might discomfit those who
personally profit from the status quo in health care. Those involved in the leadership
and governance of health care organizations and their cronies, also have
considerable power to damp down any public discussion that might cause
them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.
However,in the Trump administration, we began to also note examples of
government officials attempting to squelch discussion of scientific
topics that did not fit
in with its ideology, despite constitutional guarantees of speech and
press free from government control (look here).
These issues also did not get much attention since November, 2019.
Discussion
In 2017, we said that it was time to consider some of the real causes of health care dysfunction that
true health care reform needs to address, no matter how much that
distresses those who currently most personally profit from the status
quo.
Furthermore, in 2019 we asserted that all the trends we have seen since
2017 are towards tremendous government dysfunction, some of it overtly
malignant, and much of it likely enabling even worse health care
dysfunction.
Now that there is the prospect of a new US administration, 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. As the coronavirus pandemic rages, the need to make our health care and public health less dysfunctional is increasingly apparent. If not now, when?