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.

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.

 

Who Owns, and Who is Accountable for the New US For-Profit Medical Schools?

Mysteries still abound in the not so wonderful world of health care dysfunction, so once again, quick, the game's afoot...

The current mysteries involve beneficial ownership.  Beneficial ownership questions are important to anti-corruption campaigners.  Beneficial ownership simply refers to "anyone who enjoys the benefits of ownership of a security or property, without being on the record as being the owner." (per Wikipedia). Concealing who really owns a company enables concealing sources of funds (as in money laundering), market power (when the owner also owns competitors), and sources of political influence, and enables those benefiting from the actions of the company to escape responsibility for their consequences.

We recently discussed the mystery of the beneficial ownership of a local pharmaceutical company, an issue that became more interesting when it was revealed it was owned by the Sackler family, the owners of the now somewhat infamous Purdue Pharma.  A while back we discussed the mysteries surrounding the ownership of several offshore medical schools (look here and here).

I was recently involved in a conversation about the rise of onshore, that is US based for-profit medical schools, four of which are now known to exist.  It turns out that their ownership is also rather unclear.

That for-profit medical schools now exist in the US is not widely known.  The best, and nearly only public discussion of the topic appeared in a 2017 article in JAMA [Adashi EY, Krishna GR, Grappuso PA. For-profit medical schools - a Flexnerian legacy upended.  JAMA 2017; 317: 1209-10.  Link here.]  It listed four such schools that were operating or in development.

Rocky Vista University College of Osteopathic Medicine

Rocky Vista was the first for-profit to open.  Its President is Clinton E Adams DO.  The university website is silent on its ownership.  Some searching reveals, however, that it, along with St Georges University in Grenada, is owned by Medforth Global Healthcare Education, whose CEO is Dr Andrew Sussman, who was "most recently Executive Vice President of Clinical Services at CVS Health."

However, who owns Medforth, and hence to whom Dr Sussman reports, is unclear.  We do know that in 2014, "Canadian private equity firm Altas Partners LP and pan Asia firm Baring Private Equity Asia have acquired a substantial stake in St George’s University," per Reuters.  A reference on the financial website Mergr suggested that Atlas and Baring targeted Medforth per se.  Who, in turn, actually owns Atlas and Baring, and to whom at those firms the leadership of Medforth, and thus ultimately the leadership of Rocky Vista report, is unclear.


Ponce Health Sciences University

The President of Ponce Health Sciences University is Dr David Lenihan.  According to his welcome statement,

Ponce was acquired by University Ventures Corporation in September 2014, to operate Ponce Health Sciences University and appoints Dr. David Lenihan. Dr. David Lenihan is used to taking risks. It is evidenced by his academic training in neuroscience, chiropractic and law. Also, his foray into the administrative side of science education. Recently, the greatest risk it has taken is the acquisition and transformation, through Arist Medical Sciences University, of the Ponce Health Sciences University. As the main academic officer of Arist, Lenihan guided the process of purchase and evolution of the School, a widely recognized institution with around 40 years of training professionals of excellence in the field of health in the south of Puerto Rico.

According to Bloomberg,

Arist Medical Sciences University, Public Benefit Corporation was founded in 2014. The company's line of business includes the operation of colleges and universities.

Arist Medical Sciences University is apparently part of Arist Education System.  Its website states

Arist Education System is an investment of Bertelsmann — a global media, services and education company.

Furthermore, it claims

Bertelsmann stands for entrepreneurship and creativity. This combination promotes first-class media content and innovative service solutions that inspire customers around the world. Bertelsmann’s supply of capital will support innovative graduate and professional health and human sciences programs that are making a positive impact.

So it appears that Ponce is now owned by Bertelsmann.  What a diversified global media company is doing running a medical school is not clear.

Nor is the identity to the person at Bertelsmann to whom the leadership of Arist, including Dr Lenihan, reports.  Although the Bertelsmann website lists the company's top executives, and the top managers of the Bertlesmann Education Group, the chain of command for the US for-profit medical school is not apparent.


California Northstate University College of Medicine

According to the university website, the president is Alvin Cheung, Pharm D.  The university has a board of trustees, but does not provide their biographies or explain their role.

The website provides no information about the ownership of the university, although a 2016 Sacramento Bee article stated "Backers raised more than $50 million to fund the school." I can find business listings for a California Northstate University LLC, eg here, stating it is a privately held business, but containing no information about ownership or if the business leadership is the same as the listed medical school leadership. Thus the ownership of California Northstate University LLC, and thus presumably of the medical school, is entirely opaque.


Burrell College of Osteopathic Medicine

The President is John Hummer MHA.  There is a board of trustees, chaired by Robert V Wingo, with biographies provided but whose role is not explained.

An article in the Las Cruces Sun-News from 2016 called it "a first-of-its-kind, privately funded U.S. medical school."  An Albuquerque Journal article from 2015 stated.

Burrell is entirely financed by private investors, led by Santa Fe businessman Dan Burrell in partnership with the Rice Management Co., which oversees Rice University’s $5.6 billion endowment fund. Although most public attention has centered on Burrell, a well-known real estate mogul, Rice Management is actually the majority investor in the project, estimated to cost a total of $105 million,

Other investors were not named.  Thus only some of the investors in, presumably therefore the owners of Burrell are known.  The rest are anonymous.

Discussion

The ownership of three of the four new US for-profit medical schools is unclear.  One is a private LLC whose ownership is entirely opaque.  One is partially owned by two private equity firms, whose investors are anonymous.  It may also have other, again anonymous owners.  One is owned by a group of investors, some local, some named, and some anonymous.

Anti-corruption campaigners have pushed to reveal the beneficial ownership of all corporate entities.  Transparency International's report on the problem of anonymous beneficial ownership (look here) states:

In the vast majority of countries, it remains legal for companies to hide the identity of their beneficial owners. Embezzlers use anonymously owned companies to move, launder and spend tainted money in the global financial system without being detected. Documents in the Panama Papers, for example, show how kleptocrats and their families used anonymous companies to secretly control state assets and purchase global real estate. Criminals including terrorists, human traffickers, sanctions-busters, drug dealers and tax evaders also use anonymous companies for the same reasons.

Thus anonymous ownership of any US medical school is highly troubling.  Physicians swear oaths to practice with honesty and integrity.  The institutions they train in should be above suspicion of wrong doing and corruption.  Hence medical schools should avoid practices associated with money laundering, fraud, and corruption.

Medical students, faculty, patients and accrediting boards should not trust medical schools who keep their ownership secret.

The people accountable for all four new for-profit medical schools' conduct and operations are likewise unclear. While the schools' hired managers cannot escape responsibility, it is the owners who are ultimately accountable.  But since some of the owners of three of the four new for-profit US medical schools are anonymous, some of the people actually accountable for those schools are also anonymous.


Maybe Sherlock Holmes could help...

but in his absence, medical students, faculty, patients and accrediting boards should not trust medical schools who keep the identity of those accountable for them secret.

Finally, a note about the one school which is apparently now a subsidiary of a publicly held German-based corporation.  Ultimately, the board of directors and top management of that corporation should be held accountable for that school.  However, even in this case, it would inspire more confidence of the exact lines of reporting from medical school to corporate leadership were more clear.

As Adashi et al noted, "the very notion of a for-profit medical school, anathema to generations of medical educators, is still the subject of mixed reviews."  The authors were optimistic that the higher standards for medical schools put in since the Flexner report led to the abolition of proprietary medical schools, and perhaps the supposed greater transparency of the modern era would make it possible for the new proprietary medical schools to educate students well.

However, the current for-profit schools' opacity should lead to great skepticism.  Flexner wrote:

[I]t is universally conceded that medical education cannot be conducted on proper lines at a profit, - or even at cost

His words may very well still be right.

Finally, what we now know about the new for-profit US medical schools suggests we must reexamine our fascination for "market based" approaches to health care, when almost nothing about any part of health care resembles, or could resemble a free market (see this post).  We need to make health care more transparent, and shine more sunshine on the nooks and crannies, like for-profit, anonymously owned US medical schools. 

ADDENDUM (14 January, 2020) - This post was re-posted on the Naked Capitalism blog here.

The Risks of Attending an Offshore Medical School: Students at Offshore Medical Schools Killed or Injured by Gas Explosions

US and Canadian medical education has a peculiar gray zone.  A substantial proportion of US and at least some Canadian doctors have received their medical degrees from offshore medical schools.  These are medical schools located in other countries, mainly the Caribbean, that exist only to train students for North American practice.  They are often owned by for-profit US or Canadian based companies, have little accountability to their host countries' governments, or to the US or Canada, and have generally flown under the radar despite being an important component of North American medical eduction..

Many questions have been raised by the quality of training received by students at such offshore schools.  We have recently discovered new risks to offshore medical students, in particular, that of dangerous living conditions.  We were alerted to two cases since 2018.


Gas Explosion Injured Two Medical University of the Americas (MUA) Students, Both Fatally, on Nevis in 2018

As reported by WINN FM on November 15, 2018

At around 8:00 pm on October 3, an explosion rocked the medical university and sent two American students to the hospital with severe burns across their bodies. The two students were subsequently flown to the United States for treatment.

On Wednesday (Nov 14) Acting Commissioner of Police, Hilroy Brandy disclosed that a faulty knob on the stove caused the explosion. He said one of the injured females was the actual occupant of the apartment and a female friend had come over to study. One of them lit a cigarette which ignited the gas.

That explosion eventually proved fatal to one medical student, as reported again by WINN FM on November 21, 2018:

One of the students who sustained major burns in an explosion and fire on Nevis in October has succumbed to her injuries.

28-year-old Nada Magdy Khalil of East Brunswick, New Jersey was one of two female students of the Medical University of the Americas (MUA) in Nevis inside the apartment when it exploded on Oct 3.

WINN FM confirmed that Khalil died on Sunday, November 18 in Florida where she had been receiving treatment.

The other student was very severely injured

The other victim is 31-year-old Gayane Borisovna Balasanyan from San Francisco; she is still hospitalized in Miami, Florida with burns across 90% of her body.

According to her GoFundMe page, Ms Balasanyan died in January, 2019.


There is no other publicly available  information on this explosion. Importantly, there has never been a public response from MUA, or its owners:

Since the explosion, the medical university has not issued a statement on the matter.

Gas Explosion Severely Injured Two Saba University School of Medicine (SUSOM) Students in 2019

There was an unnervingly similar case one year later, as reported by Saba News on October 15, 2019:

Saba’s emergency services were rushed to a dormitory building on Thais Hill Road in The Bottom around 7:30am Saturday, for a gas explosion that left one man severely burned.

A loud crack was heard throughout The Bottom that morning and a large plume of white smoke was seen coming out of the building and drifting into the sky. Several village residents also reported feeling the explosion’s aftershocks, which prompted them to call the Caribbean Netherlands Police Force KPCN and the Saba Fire Department.

Police, firefighters and the Ambulance Department were then dispatched to the building.

The dormitory is a privately-owned building that mainly houses students of Saba University School of Medicine (SUSOM).

Again, two students were injured:

One student was severely burned in the incident and was taken to A.M. Edwards Medical Center for treatment. He was later flown to Miami, Florida, for further medical attention.

A second victim was treated for smoke inhalation and was admitted at A.M. Edwards Medical Center for observation. She was released several hours later.

There is a GoFundMe page which is apparently for the student most seriously burned in this explosion.  It was created 3 days after the explosion, but I could find no other followup information on the explosion or the student.  Again, I could find no public response from SUSOM.

Who Should be Accountable?

These cases have been uncannily anechoic.  While the students injured were from the US, their fate has received no coverage in the US media.  Nor have the cases received recognition in the US health care literature, particularly the medical education literature.

The silence from the medical schools involved is quite unsettling.  That immediately leads to an obvious question.  Just who at these schools might be responsible for their students' physical safety?  Who currently runs and is accountable for both Caribbean schools is not glaringly obvious.

The website for the Medical University of the Americas lists an Executive Dean, but no President or CEO, or Board of Directors.  Its Wikipedia page states:

Medical University of the Americas (MUA) is a for-profit medical school in Saint James Windward Parish, Saint Kitts and Nevis.

Buried in the MUA 2018 catalog, however, is this statement:

Medical University of the Americas is a foreign profit corporation owned by R3 Education Inc. which is registered with the Florida Department of State, Division of Corporations to do business in Florida as Medical University of the Americas.

Saba University School of Medicine has a President, Dr Joseph Chu, according to its website. Its Wikipedia page does not state whether it is non-profit or for-profit.  However, like that  of MUA, the SUSOM 2018 catalog states

Saba University School of Medicine is a foreign profit corporation owned by R3 Education Inc.  which is registered with the Florida Department of State, Division of Corporations to do business in Florida as Saba University School of Medicine.

R3 Education Inc turns out to have a remarkable history, which we  discussed back in 2013.   To summarize what we found then...

The couple who founded two Caribbean medical schools which catered almost entirely to US and Canadian students ran into significant legal trouble.  Founder David Leon Fredrick and his wife, Dr Patricia Lynn Hough were indicted for tax evasion for failing to report income from the two medical schools they allegedly owned, and later sold.

The schools were Saba University School of Medicine, on Saba, and the Medical University of the Americas, on Nevis.  The initial legal proceedings revealed that while Saba University School of Medicine was apparently first set up by a non-profit foundation (or NGO) run by the couple, somehow it became for-profit owned by Mr Fredrick and Dr Hough, and Saba and the Medical University of the Americas were subsequently sold to a private equity group, Equinox Capital.  R3 Education Inc, owned by Equinox Capital, appears to have been given responsibility for running the schools, along with St Matthew University.

Before jury selection started, Mr Fredrick disappeared.  Dr Hough was eventually convicted of defrauding the US Internal Revenue Service, and income tax evasion, after trial testimony to the effect that the couple concealed money in a Swiss bank, got $36 million from the sale of the schools, and bought an airplane, two houses, and a condominium.

Left mysterious at that time were Mr Fredrick's whereabouts, where the money that the couple received from the sale of the medical schools went, and how a school that began as a non-profit organization run by the couple became a for-profit corporation owned by them.  The case should have lead to some concerns about the leadership and governance of the off-shore medical schools that now train increasing numbers of would be US and Canadian physicians.

In 2014 we provided something of an update. Mr Fredrick and Ms Hough made more than $35 million from the sale of the schools.  Ms Hough eventually went to prison.  Mr Fredrick's whereabouts remained unknown.  My internet searching in 2019 failed to produce any new information about him.


Now in 2019 we do not know much more about who is really accountable for MUA and SUSOM.  According to the Bloomberg corporate information website,

R3 Education Inc. operates as a holding company that acquires and manages for-profit educational institutions such as Saba University School of Medicine, the Medical University of the Americas, and St. Matthew's University. The company was incorporated in 2007 and is based in Devens, Massachusetts.

According to his LinkedIn Profile, the CEO and Chairman of R3 Education is Steven Rodger, of Greenwich, CT. For 23 years he has also been Managing Partner, Equinox Capital.

The Equinox Capital website make it clear that it still owns three Caribbean medical schools:

Saba University: Since its founding in 1993, more than 1,500 physicians have earned their M.D. at Saba University (www.saba.edu). Saba University School of Medicine has been accredited by the Accreditation Commission on Colleges of Medicine (ACCM) and its program has received approvals from licensing boards in New York, California and Florida. The campus is on Saba, which is located very near St. Maarten.

Medical University of the Americas: Since its founding 1998, Medical University of the Americas (www.mua.edu) has awarded approximately 500 M.D.’s. The MUA program is accredited by the Accreditation Commission on Colleges of Medicine (ACCM) and its program has received approvals from the licensing board in New York. MUA is located on Nevis, near St. Kitts.

St. Matthew’s University (www.stmatthews.edu) offers both a medical and a veterinary program. Since 1997, almost 1,500 students have obtained their M.D. and D.V.M. degrees from St. Matthews. The program is accredited by the Accreditation Commission on Colleges of Medicine (ACCM). St. Matthews is located in the Cayman Islands.

Who are the leaders of MUA and SUSOM who are accountable for what happens to their students, including their physical safety?  What allegiance do they owe their for-profit, private equity owners?  Who is responsible for the governance of the schools?  What responsibility does the private equity firm that owns the schools bear? All these questions remain unanswered.

The Perils of Offshore Medical Schools

US and Canadian medical students are promised a lot on the flashy websites (eg for MUA and SUSOM) for offshore medical schools. They may depend more on their medical schools for basics like housing than would students at American and Canadian schools. Yet they end up in physical environments with which they may be unfamiliar, and which may expose them to unexpected perils.

We should not forget that the US invasion of Grenada in 1983 was rationalized by the physical risks to US medical students at St George's University School of Medicine. The school was then a private for-profit owned by its founder Dr Charles R Modica and partners (but now partially owned by a private equity firm, Atlas Partners, per their news release.)   As the New York Times reported at the time, some students

told of bullets crashing through their dormitory rooms, of fears of being taken hostage, of a week of campus confinement under the Government's 'shoot to kill' curfew, of soldiers pointing guns at them

In particular,

Many of the students said that supplies of food and water began running low Tuesday after a weeklong curfew had been imposed by Grenada's military leaders following the slaying of Prime Minister Maurice Bishop on Oct. 19. Under the terms of the curfew, people on the street were to be shot on sight, the students said.

'I saw soldiers with guns during the curfew,' said Miss Nelson, 'and while none of them ever threatened me, several of my friends told me guns had been aimed at them, and they were terrified.'

[US Department of Defense image, Grenada invasion, 1983, via WikiMedia]


In the 21st century, the risks may be of gas explosions in accommodations more basic. and risky than students may have expected.    Yet who is ultimately accountable for disclosing and mitigating the risks?  In the case of MUA and SUSOM I cannot tell.

For would-be medical students trying to cope with the vagaries of medical school admissions in the US and Canada, the apparently easier accessibility of off-shore medical schools may be attractive.  Yet such accessibility may come with costs, and risks.  Until more is known about the risks, caveat emptor.


While Eckhert wrote in 2010(1) that the increasing presence of offshore medical graduates in the US "obligates U.S. medicine to take a closer look at these educational programs," no such scrutiny has occurred since then.  While offshore medical schools account for the training of an increasing proportion of US (and presumably Canadian) physicians, we know next to nothing about their leadership and governance.  This seems to be just another part of the decreasing accountability of the leadership of US health care, and the increasing opacity of the governance and stewardship of US health care organizations.  True US health care reform would make leadership transparent and accountable.

 Reference

1.  Eckhert NL.  Private schools of the Caribbean: outsourcing medical education.  Acad Med 2010; 85: 622-630.  Link here.