healthy4u: economism

Health Care Corruption, "No Dirty Little Secret," but "An Open Sore" - Lessons from India for the US

<a href="http://hcrenewal.blogspot.com/search/label/health%20care%20corruption">Health care corruption</a> is widely prevalent around the globe, but remains the great unmentionable. Introduction: Global Health Care Corruption We have discussed health care corruption whenever we have an opportunity, but rarely does the topic appear in the English language media or in English language medical and health care journals, particularly in the US.  Some might think that this is because health care corruption is not so prevalent in the US and other "developed" countries.  However, our <a href="http://hcrenewal.blogspot.com/2013/07/43-believe-that-us-health-care-corrupt.html">most read post of all time</a> was about a Transparency International global survey that found that fully 43% of Americans believe our health care is corrupt.  A recent editorial in the BMJ(1) opened thus, <blockquote class="tr_bq">Healthcare is a high risk sector for corruption. Best estimates are that between 10% and 25% of global spend on public procurement of health is lost through corruption. This is big bucks. Total global spend on healthcare is more than $7 trillion each year. Corruption takes many forms, depending on the country’s level of development and health financing system. The United States, for example, lost between $82bn and $272bn in 2011 to medical embezzlement, mostly related to its health insurance system. No country is exempt from corruption. Patients everywhere are harmed when money is diverted to doctors’ pockets and away from priority services. Yet this complex challenge is one that medical professionals have failed to deal with, either by choosing to enrich themselves, turning a blind eye, or considering it too difficult. Transparency International, a watchdog on these matters, defines corruption as the abuse of entrusted power for private gain, which in healthcare encompasses bribery of regulators and medical professionals, manipulation of information on drug trials, diversion of medicines and supplies, corruption in procurement, and overbilling of insurance companies. This is no dirty little secret. It is one of the biggest open sores in medicine.</blockquote> When health care corruption is actually discussed in polite circles, including the scholarly literature about medicine and health care, the discussion usually refers to corruption elsewhere.  In particular, in developed countries, discussion of health care corruption usually focuses on less developed countries. Thus, maybe it should not be a surprise that the editorial by Jain et al accompanied another BMJ article about health care corruption in India. Yet by reading between their lines, both articles have global application, and are just as relevant to those nations in which the powers that be seem to have smugly concluded that health care corruption is only a problem in benighted third world countries. A Personal View on Health Care Corruption in India David Berger a UK trained general practitioner (GP), discussed the corruption he found while volunteering in India.(2)  His introduction was, <blockquote class="tr_bq">'The corruption strangles everything, Sir. It’s like a cancer.' Accompanied by apologetic shrugs and half smiles, statements like this are commonly heard in India. I knew this was the case before I went to work as a volunteer physician in a small charitable hospital in the Himalayas, but what I didn’t realise was how far the corruption permeates the world of medicine and the corrosive effect it has on the doctor-patient relationship.</blockquote> Berger raised several issues: Neoliberalism and Privitization <blockquote class="tr_bq">The healthcare system itself is a model of inequity; it is one of the most privatised in the world, with out of pocket expenditure on healthcare at more than 70%, far higher even than in the United States. This phenomenon is at least partly the result of the neoliberal World Bank policies of the 1990s, which mandated a reduction in public financing of healthcare, fuelling growth of the private sector. The latest in technological medicine is available to people who can pay, albeit at a high price,...</blockquote> Kickbacks to Physicians for Referrals This is a common form of corruption in India. <blockquote class="tr_bq">all investigations attract a 10-15% kickback to the referring doctor. One day, the marketing executive for this clinic had turned up at the hospital with an envelope full of cash—the commission for investigations ordered in the past few months. The senior doctor refused it and stipulated that in future the commission was to be paid back to patients, which is why the resident had to sign the form. The country’s doctors and medical institutions live in an 'unvirtuous circle' of referral and kickback that poisons their integrity and destroys any chance of a trusting relationship with their patients.</blockquote> Kickbacks from Pharmaceutical Firms <blockquote class="tr_bq">There is also widespread corruption in the pharmaceutical industry, with doctors bribed to prescribe particular drugs. Tales are common of hospital directors being given top of the range cars and other inducements when their hospitals sign contracts to prescribe particular antibiotics preferentially. I met a former pharmaceutical sales executive who left the industry, sickened by the corrupt practices he was supposed to employ. Working for one of the largest drug companies in the country, he was expected to bribe doctors with money and luxury goods. The crunch came when a doctor demanded that the company fly him to Thailand for a holiday and then provide him with prostitutes at his home. When the company representative queried this, his manager told him to comply, and he felt he had no choice but to resign, protesting that he was 'not a pimp.'</blockquote> Huge Fees Charged to Medical Students <blockquote class="tr_bq">Endemic corruption extends to medical studies themselves. In another 'unvirtuous circle,' students can have to pay very large “donations” (perhaps $200 000 or more, some 20 times the average doctor’s annual salary) to get into the rapidly increasing number of private medical colleges and to get on to sought after postgraduate training schemes. This means that doctors can have high levels of debt or family obligation when qualifying, which is a strong incentive against working as generalists in rural areas and favours them practising technological medicine for maximum profit in urban areas to try to recoup their investment.</blockquote> The US Parallels All the issues above have clear parallels in the US.  But in the US, hardly anyone talks about health care corruption as a local or national problem.    Neoliberalism and Privitization The US is known for its increasingly private health care system, pushed by the ideology of "neoliberalism" or "<a href="http://hcrenewal.blogspot.com/search/label/economism">economism</a>."  US health insurance is mostly provided by private, for-profit corporations, not non-profits, or government agencies.  US hospitals and hospital systems are increasingly private, as are other organizations that provide direct health care, e.g., <a href="http://hcrenewal.blogspot.com/search/label/hospices">hospices</a>.  US physicians are increasingly <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">corporate employees</a>.  India may be more privatized, but the US is close behind.  Kickbacks to Physicians for Referrals We have frequently posted about cases in which there was good evidence that physicians in the US got <a href="http://hcrenewal.blogspot.com/search/label/kickbacks">kickbacks</a>, or bribes.  Most involved legal settlements of cases in which there were allegations of widespread kickbacks.  Some of them involved kickbacks for referrals (e.g., the settlement involving Omnicare in 2013, look <a href="http://hcrenewal.blogspot.com/2013/10/there-they-go-again-omnicare-to-settle.html">here</a>).  On the other hand, resolution of cases involving kickbacks to small groups of physicians for referrals are so common in the US that we rarely discuss individual examples. For example, I found the following headlines from the last few weeks: <blockquote class="tr_bq"><a href="http://6abc.com/news/nj-arrests-more-than-12-in-alleged-kickback-scheme/134025/">NJ Arrests More than 12 in Alleged Kickback Scheme</a> <a href="http://www.nj.com/morris/index.ssf/2014/06/randolph_doctor_jailed_for_20_months_for_role_in_massive_kickbacks_scheme.html">Randolph Doctor Jailed for 20 Months for Role in Massive Kickback Scheme</a> <a href="http://www.ocregister.com/articles/ahmed-626942-indictment-million.html">O.C. Grand Jury Indicts 15 Doctors  </a>  </blockquote> We have also written extensively about how <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">corporate physicians</a> are pushed to avoid "leakage," that is referral of patients to health care facilities not owned by their corporate employees (e.g., look <a href="http://hcrenewal.blogspot.com/2011/02/new-steward-health-care-will-superbowl.html">here</a>).  Kickbacks from Pharmaceutical Firms We have posted about numerous examples of widespread <a href="http://hcrenewal.blogspot.com/search/label/kickbacks">kickbacks</a> given by health care corporations, particularly pharmaceutical, biotechnology, and medical device companies, to physicians to enhance their prescriptions for or use of their products.  Most recent examples include legal settlements by Pfizer about kickbacks to promote use of Neurontin (one of many by that company, look <a href="http://hcrenewal.blogspot.com/2014/06/justice-delayed-is-justice-denied.html">here</a>); by Medtronic to promote use of its pacemakers and defibrillators (look <a href="http://hcrenewal.blogspot.com/2014/06/fool-me-twice-boehringer-ingelheim.html">here</a>); and by Johnson and Johnson to promote use of Risperdal (look <a href="http://hcrenewal.blogspot.com/2013/11/another-and-huge-22-billion-settlement.html">here</a>).  Moreover, we have discussed many examples of physicians paid as "consultants" or given "honoraria" for talks by companies whose goal was to use these physicians as "<a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">key opinion leaders</a>," actually covert marketers for their drugs or devices.  Many of the <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest </a>we have discussed actually seemed to involve kickbacks or bribes, even though some physicians and policy-makers like to refer to them as "collaborations" with industry to increase "innovation."  Huge Fees Charged to Medical Students The huge tuition charged US medical students, their huge resulting debt, and their resulting tendency to pursue procedural specialties rather than cognitive specialties, particularly primary care, have become cliches. So it seems that the US has some of the same possible risk factors for corruption as does India, that there are many cases in the US of activities that are called corruption in India, and that a near majority of US citizens feel their health care is corrupt.  But health care corruption remains a largely taboo topic in the US.  Summary: Some General Approaches The editorial by Jain et al that to its authors' credit emphasized that health care corruption is a global problem suggested some general approaches to corruption(2) <blockquote class="tr_bq">Good governance, transparency, and zero tolerance must form the basis of any anti-corruption strategy. Changes must be implemented in society at large for reform to be sustained. Better governance requires rigorous legislation and functioning administrative mechanisms to provide fiscal oversight. Ethical standards of conduct must be explicitly established and staff held accountable for their performance. Punitive measures should be available to serve as a deterrent. Honest behaviour must be rewarded. These policies may be ineffective, however, unless healthcare professionals are assured of a decent salary and fair opportunities for professional growth</blockquote> Also <blockquote class="tr_bq">Simple and effective channels for complaints must be established, and appropriate legal support and protection provided to whistleblowers. Looking deeper, underlying issues such as education and social justice must not be forgotten if the battle against corruption is to be sustained and eventually won. Answers may also lie outside the world of medicine. </blockquote> Note that we have discussed all these approaches: <a href="http://hcrenewal.blogspot.com/search/label/accountability">accountability</a>, <a href="http://hcrenewal.blogspot.com/search/label/transparency">transparency</a>, <a href="http://hcrenewal.blogspot.com/search/label/governance">governance</a>, <a href="http://hcrenewal.blogspot.com/search/label/boards%20of%20trustees">boards of trustees</a>, <a href="http://hcrenewal.blogspot.com/search/label/boards%20of%20directors">boards of directors</a>, <a href="http://hcrenewal.blogspot.com/search/label/ethics%2F%20integrity%20policies">ethics and integrity policies</a> , <a href="http://hcrenewal.blogspot.com/search/label/impunity">impunity</a>, <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">legal settlements</a>, and education about corruption (look <a href="http://hcrenewal.blogspot.com/2010/12/lancet-emphasizes-threats-to-academic.html">here</a>).  Not that any of them have been widely adopted. So to repeat an ending to <a href="http://hcrenewal.blogspot.com/2013/07/43-believe-that-us-health-care-corrupt.html">one of my previous posts</a> on health care corruption....  if we really want to reform health care, in the little time we may have before our health care bubble bursts, we will need to take strong action against health care corruption.  Such action will really disturb the insiders within large health care organizations who have gotten rich from their organizations' misbehavior, and thus taking such action will require some courage. References 1.  Jain A, Nundy S, Abbasi K. Corruption: medicine's dirty open secret.  Brit Med J 2014.  Link <a href="http://www.bmj.com/content/348/bmj.g4184">here</a>.  2.  Berger D. Corruption ruins the doctor-patient relationship in India.  Brit Med J 2014.  Link <a href="http://www.bmj.com/content/348/bmj.g3169">here</a>.

Health Care Corruption, "No Dirty Little Secret," but "An Open Sore" - Lessons from India for the US

Health care corruption is widely prevalent around the globe, but remains the great unmentionable. Introduction: Global Health Care Corrupti...

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Market Fundamentalism and the Denial of Conflicts of Interest, and of Worse Offenses

While we often point out the pervasiveness of <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a> in medicine and health care, and the likely ill effects of this state of affairs, it seems that the powers that be in health care tend to airily dismiss conflicts of interest as at most a minor problem that needs management (e.g., look <a href="http://hcrenewal.blogspot.com/2012/02/logical-fallacies-in-defense-of.html">here</a>.)  How Market Fundamentalist Ideology Nullifies the Concept of Conflicts of Interest On the Hooked: Ethics, Medicine and Pharma blog, Dr Howard Brody <a href="http://brodyhooked.blogspot.com/2013/09/why-theres-no-such-thing-as-conflict-of.html">discussed</a> how application of the reigning orthodoxy in economics, sometimes called neoliberalism, market fundamentalism, or <a href="http://hcrenewal.blogspot.com/search/label/economism">economism</a>, can be used to dismiss the concept of conflicts of interest. Basically, supporters of market fundamentalism et al seem to assume that all markets are idealized free markets, and that free markets are like a super computer combining all human thought to provide wisdom in the form of price information.  Furthermore, since the market is based on supposedly rational choices made by free individuals, one cannot go back to question such choices.  So when, for example, an academic physician makes the "free choice" to accept thousands of dollars from a drug company as a "market consultant," and then also gives talks about clinical topics that happen to favor that drug company's products, such choices cannot be questioned.  Therefore, the notion that these choices constitute a conflict of interest, and that the choice to accept the drug company money in particular might increase the likelihood of abuse of the physician's entrusted responsibility to make the best decisions for individual patients, and to teach other physicians honestly and without bias, essentially makes no sense within this framework. Dr Brody further enlarged on the internal contradictions within the ideology of neliberalism/ market fundamentalism/ economism, in <a href="http://theeconomismscam.blogspot.com/2013/09/more-on-inherent-contradictions-of.html">another post</a> on his Economism Scam blog. Of course, the ideology seems to ignore the possibilities that 1) people's choice may not be free, may not be rational, and may not be based on coldly rational cognition and the best possible knowledge; and 2) one person's economic choice may limit another person's choices, or directly harm another person.  By Extension, Fraud and Corruption Denialism Furthermore, not only does neoliberalism et al seem to deny the existence of meaningful conflicts of interest, it also could be used to deny the meaningful existence of deceptive marketing, of market domination through oligopoly or monopoly, and then of outright fraud, bribery, and extortion.  See for example how former US Federal Reserve chairman Alan Greenspan seemed to deny the existence of fraud, which he asserted would always be nullified by the ideal market.  As we posted <a href="http://hcrenewal.blogspot.com/2011/10/another-month-another-series-of-adverse.html">here</a>, according to an <a href="http://www.stanfordalumni.org/news/magazine/2009/marapr/features/born.html">article</a> in Stanford Magazine,  Greenspan told Ms Brooksley Born, the federal regulatory agency head who tried to develop some effective regulation of financial derivatives, <blockquote class="tr_bq">'Well, you probably will always believe there should be laws against fraud, and I don’t think there is any need for a law against fraud,' she recalls. Greenspan, Born says, believed the market would take care of itself.</blockquote> By further extension, market fundamentalism could be used to deny the evils of chattel slavery. The Conflicted as Defenders of Conflicts of Interest Finally, notice that neoliberalism/ market fundamentalism/ economism ideology seems to have conveniently been adopted by pundits, both in economics and in medicine and health policy who may be personally profiting from conflicts of interest on one hand, and whose conflicts seem to arise from payments from large corporations whose management seem to be personally profiting even more so.  For example, we have discussed examples of how defenders of existing financial relationships - which in my humble opinion are actually conflicts of interest - employ logical fallacies to make their points.  Some of these defenders seem to have obvious conflicts of their own (for example, <a href="http://hcrenewal.blogspot.com/2013/03/doctors-dubious-excuses-for-taking.html">this post</a> included examples of physicians rationalizing their financial ties to drug companies,  and <a href="http://hcrenewal.blogspot.com/2012/02/logical-fallacies-in-defense-of.html">this post</a> included fallacies employed by a current medical school leader, but former extremely well paid biotechnology company executive.).  On the other hand, I have yet to find a logical, reality-based defense of these conflicts of interest made by anyone who demonstrably does not have such conflicts of their own.   Summary Human beings have been wrestling with corruption since the dawn of history.  There are ancient arguments against bribery in the Bible  (e.g., in the Old Testament, in Exodus and Deuteronomy), and fraud (e.g., in Leviticus, the Proverbs, and the Gospel of Mark).  One can argue that a fundamental purpose of civilization is to reduce self-serving misbehavior such as bribery, fraud, and extortion, and other varieties of corruption.  The notion that free markets make the concepts of fraud, and of conflicts of interest (that are risk factors for corruption - look <a href="http://hcrenewal.blogspot.com/2012/03/another-cautionary-tale-about-conflicts.html">here</a>) meaningless is nothing more than school playground sophistry. To truly reform health care, we need to return it from its current Wild West mentality to a state more resembling civilization.  We need to reject silly notions that free markets erase the concepts of conflict of interest, or of fraud, or of other aspects of corruption.

Market Fundamentalism and the Denial of Conflicts of Interest, and of Worse Offenses

While we often point out the pervasiveness of conflicts of interest in medicine and health care, and the likely ill effects of this state o...

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Guest Post: Incompetent Management Breeds Demoralized Physicians

Health Care Renewal presents a guest post by <a href="http://imh.utmb.edu/about-us/faculty/howard-brody">Dr Howard Brody,</a> John P McGovern Centennial Chair of Family Medicine, Director of the Institute for Medical Humanities at University of Texas - Medical Branch at Galveston, and blogger at <a href="http://brodyhooked.blogspot.com/">Hooked: Ethics, Medicine and Pharma</a>.  Danielle Ofri, a prominent internist/author at Bellevue in New York, started a recent <a href="http://danielleofri.com/an-epidemic-of-disillusioned-doctors/">op-ed</a> piece, “Last week I was ready to quit medicine."  <div class="MsoNormal">She described an encounter most physicians can relate to—a 15-minute appointment slot, a new patient who spoke only Bengali, a long and complicated problem list, a bag containing 18 different medicines, two forms that had to be filled out by the doctor on this day’s visit, and a computer that froze while she was trying to keep up with the electronic charting. She described how, 45 minutes into the supposedly 15-minute visit, she had a phone in one ear with the Bengali translator and tech support on hold in the other ear.</div><div class="MsoNormal"> </div><div class="MsoNormal">Ofri’s plaint caught my attention because I had recently put up a <a href="http://hcrenewal.blogspot.com/2013/05/guest-post-physician-rebels-against.html">guest post on Health Care Renewal</a> about another highly skilled, caring physician who was seriously considering quitting practice. This led me to write a <a href="http://www.utmb.edu/newsroom/article8763.aspx">column</a> for some of our local newspapers about demoralized doctors</div><div class="MsoNormal"></div> <div class="MsoNormal"> </div><div class="MsoNormal">In the space allowed in an op-ed column, you can’t go into great depth in analyzing a complicated situation. So here’s what I would have wanted to say.</div><div class="MsoNormal"> </div><div class="MsoNormal">We can list all the management failures that this encounter represents. I won’t even start with the electronic record as that’s such a frequent theme in this blog. Who scheduled such a patient for a 15-minute visit? Where is the pharmacist who could have done a better job of going through all the lady’s medicines? Where is the staffer who could have filled out the forms for Dr. Ofri to sign? This is just to scratch the surface.</div><div class="MsoNormal"> </div><div class="MsoNormal">There are two things worrisome about this long list of management failures. If the goal of the health care system is actually to take good care of patients, then it seems obvious that Dr. Ofri, who wanted to try to provide high-quality care, had roadblock after roadblock thrown in her way.</div><div class="MsoNormal"> </div><div class="MsoNormal">Cynics will protest that this system obviously has no interest in quality patient care and seeks only to maximize revenue. If that’s so, is it really true that a board-certified MD is the most efficient labor source for keyboarding data into a computer, filling out paper forms, and doing all the other busy-work tasks that Dr. Ofri had to juggle? Can anyone really believe that this management structure supports either quality care orefficient resource use?</div><div class="MsoNormal"> </div> If the management of U.S. hospitals was severely understaffed or underpaid, then we could perhaps forgive such lapses. But we know that while the growth of physicians in the U.S. has been slow, the number of administrators has grown by leaps and bounds [The number of health care managers increased by 726% from 1983-2000 while physician numbers increased by 39%, look <a href="http://hcrenewal.blogspot.com/2005/04/growing-proliferation-of-managers.html">here</a> - Ed]  . And we know that at least at the high end, these managers are paid <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">munificent sums</a>, and are lauded for their supposed genius (look <a href="http://hcrenewal.blogspot.com/2013/06/no-blues-but-lots-of-green-for-st-louis.html">here</a> for example).    <div class="MsoNormal">So we appear to have a system that is slowly (in some cases rapidly) driving the best doctors out of practice, and yet somehow imagines that everything is going all right and there’s no problem—or if there’s a problem, it’s those whining doctors.</div><div class="MsoNormal"> </div><div class="MsoNormal">All us medical educators know that when we ask the first-year class how may of them have been told by practicing physicians that they’re making a big mistake coming to medical school, the majority will raise their hands. Yet the managers of America’s health systems apparently believe that they can go on demoralizing good practitioners and nothing bad will happen.</div><div class="MsoNormal"> </div><div class="MsoNormal">This may sound as if I am saying that health care managers are all evil people, but that’s an unfair characterization. These folks are simply trying to do what our society tells them. As I <a href="http://hcrenewal.blogspot.com/2012/03/golden-calf-explains-how-economism-lead.html">explained</a> some time ago, most of our popular and political discourse has been captured by a belief system that can be variously called neoliberalism, market fundamentalism, or <a href="http://hcrenewal.blogspot.com/search/label/economism">economism</a>. The ideology can be summarized as a quasi-religious faith in the so-called “free market,” steadfast opposition to government regulation of the market, and opposition to just about any form of taxes (for more on the nature of economism, look <a href="http://theeconomismscam.blogspot.com/2012/09/economism-primer.html">here</a>.)</div><div class="MsoNormal"> </div><div class="MsoNormal"></div><div class="MsoNormal"> </div><div class="MsoNormal"> Among other things, this ideology teaches us that everything important in our society can be accurately captured in objective measures of “productivity” and “efficiency.”  [This is akin to the "shareholder value" theory of management (look <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">here</a>), or "<a href="http://hcrenewal.blogspot.com/search/label/financialization">financialization</a>." - Ed]  Once one has mastered the basic concepts taught in MBA school, there’s no need to learn anything about health care and what makes it a unique activity; there’s no basic difference between providing health care and flipping burgers at McDonalds or making widgets. [We have called this <a href="http://hcrenewal.blogspot.com/search/label/generic%20management">generic management</a>. - Ed.]. And so we get the crazy style of management well documented on this blog, not because of personal nastiness or ill will, but due to the ideological Kool-Aid everyone has been drinking for several decades now. </div><div class="MsoNormal"> </div><div style="margin-bottom: .0001pt; margin: 0in;">Today’s physicians seem to be like the proverbial frog being boiled in the pot of water because the heat was turned up so gradually the frog never figured out it needed to jump. [That is, they are suffering from "<a href="http://hcrenewal.blogspot.com/search/label/learned%20helplessness">learned helplessness</a>." - Ed] Dr. Ofri herself seems to represent a typical frog. Why? Perhaps it’s the style of the blog or op-ed writer to start off with a downer and then try to end on an upbeat note. Or perhaps it’s the natural physician’s tendency to stay away from policy questions. I’m not sure.</div><div style="margin-bottom: .0001pt; margin: 0in;"> </div><div style="margin-bottom: .0001pt; margin: 0in;">After starting us off with this hard-hitting description of a dysfunctional system, Dr. Ofri ends by opining that things are going to be better in the future because more women are entering medicine and because today’s medical students are more tech savvy. She gives herself credit for managing to forge a bond with the patient because they sat together and faced this adversity. She cites an upbeat study, “when asked what was the most satisfying aspect of medical practice, the number one answer was relationships with patients. This is what keeps us going on even the most trying of days.”</div><div style="margin-bottom: .0001pt; margin: 0in;"> </div>Dr. Ofri gets full credit for remembering the importance of relationships, and feels that she bonded more firmly with her patient because they went through all this together. How about a word, though, about the people behind the curtain, who are responsible for all that she and her patient had to go through, and who don’t seem to have a clue how bad it is and what it all means?  <div class="MsoNormal"> </div><div class="MsoNormal">Dr Howard Brody </div>

Guest Post: Incompetent Management Breeds Demoralized Physicians

Health Care Renewal presents a guest post by Dr Howard Brody, John P McGovern Centennial Chair of Family Medicine, Director of the Institu...

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Why Health Care Leaders Remain Unaccountable: How the Family Invisibly Promoted the "Divine Right of CEOs"

We have frequently discussed the lack of <a href="http://hcrenewal.blogspot.com/search/label/accountability">accountability</a> of health care leaders, which we sometimes have described as CEO exceptionalism. We have noted how health care leaders almost never seem to need to take responsibility for their organizations' misbehavior and its outcomes, (look <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">here</a>) and in fact can command ever increasing <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">compensation</a>, no matter how badly they or their organizations do.  Some of the more recent examples of this phenomenon were: <div></div><div></div><ul><li>William Weldon, soon to retire as CEO of Johnson and Johnson, has commanded eight-figure yearly compensation despite severe manufacturing problems leading to 30 product recalls since 2009, and multiple ethical lapses leading to legal settlements and guilty pleas (see<a href="http://hcrenewal.blogspot.com/2012/02/semi-retirement-of-salesman-weldon-to.html"> this post</a>).</li><li>Non-profit hospital system CEOs got bonuses and raises, or departed with golden parachutes as their systems faced financial losses and laid off employees, or after their medical staff questioned their management (see <a href="http://hcrenewal.blogspot.com/2012/01/three-golden-parachutes-and-some.html">this post</a>).</li><li>A non-profit hospital CEO got a golden parachute ostensibly because he engineered a successful merger.  However, the merger never took place (see <a href="http://hcrenewal.blogspot.com/2011/11/new-low-hospital-ceo-got-golden.html">this post</a>.) </li></ul>Others examples can be found <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">here</a>.  Moreover, such executive compensation is almost never justified with anything approaching evidence or logic.  When health care organizations can be bothered to try to explain executive compensation, they revert to rote compliments (executives are called "brilliant" or "visionary") without further explanation, e.g., look <a href="http://hcrenewal.blogspot.com/2011/10/peer-benchmarking-lake-wobegone-effect.html">here</a> and <a href="http://hcrenewal.blogspot.com/2011/09/more-repeats-of-talking-points.html">here</a> and <a href="http://hcrenewal.blogspot.com/2011/09/talking-points-sans-original-thought-to.html">here</a>), or even fall back to <a href="http://hcrenewal.blogspot.com/search/label/logical%20fallacies">logical fallacies</a> (e.g.look <a href="http://hcrenewal.blogspot.com/2011/12/more-tales-of-hospital-ceo-compensation.html">here</a>). Why Does Unaccountable Leadership Persist Unchallenged? Why this absurd state of affairs persists and is getting worse, and why it is so little noticed outside of this blog, is a real question.  One explanation we just <a href="http://hcrenewal.blogspot.com/2012/03/golden-calf-explains-how-economism-lead.html">raised</a> is that society has gotten used to "the divine rights of CEOs," partially because of the success of an ideology that has been called "economism," that in turn is based on some old and now rarely accepted religious teachings that have somehow infiltrated what is supposed to be a science. The Family as a Supporter of the "Divine Right of CEOs" A related explanation comes from <a href="http://jeffsharlet.com/content/about-the-family/">The Family</a>, published in 2008, written by<a href="http://jeffsharlet.com/"> Jeff Sharlet</a>.  It suggests that such outmoded beliefs have been promoted by an extreme, nearly invisible, but influential religious sect called "The Family" that has been around since the 1930s.  The Family has powerfully promoted its fringe religious beliefs to influence policy and politics.  I strongly recommend reading the book for further details, or at least a summary article, <a href="http://www.harpers.org/archive/2003/03/0079525">Jesus Plus Nothing</a>, Shalet published in 2003 in Harpers. Let me summarize the relevant points.  Because many will seem far-fetched, I will provide quotes from the book to back each up, with page references from the Harper Paperback edition.  Italics were added for emphasis. Secrecy The Family, formerly the Fellowship, is secretive, and functions behind a variety of front organizations. <blockquote>The family has operated under many guises, some active, some defunct: National Committee for Christian Leadership, International Christian Leadership, National Leadership Council, the Fellowship Foundation, the International Foundation. (P 20-21)</blockquote> Extreme Theology While nominally Christian, the Family is at the far extreme of the spectrum, and embraces beliefs that many would find far-fetched, or worse. It discounts the Bible and the Holy Trinity, and hence is hardly fundamentalist in the usual sense of the word. The Family’s <blockquote>origins lie not in the New Testament, which is ultimately little more than a fabric from which the Family constructs contemporary realities....” (P 61)</blockquote><blockquote>Not Jesus plus scripture, since scripture, after all, contains a great deal besides Jesus. No burning bush, no voice in the whirlwind, no Daniel, no lions. (P 252).</blockquote> It discounts the Holy Trinity. <blockquote>[Current Family leader Douglas] Coe and his inner circle do believe in the trinity; a Washington fundamentalist activist told me,’ but they’ll given the Father and the Holy Ghost the weekend off. Because they clutter the conversation. Jesus is so easily presented. (P 252)</blockquote> Some call it a dominionist sect, that is, one that seeks a return to the very earliest Christianity, before any organized churches.   <blockquote>The Family’s beliefs appear closer to a more marginal set of theologies sometimes gathered under the umbrella term of dominionism, characterized ... by William Martin, a religious historian at Rice University, and Billy Graham’s official biographer.... Dominionist theologies hold the Bible to be a guide to every decision, high and low, from whom God wants you to marry to whether God thinks should buy a new lawn mower. Unlike neo-evangelicals, who concern themselves chiefly with getting good with Jesus, dominionists want to reconstruct early Christian society, which they believe was ruled by God alone. (P 44)</blockquote> (Note, however, that the emphasis on the Bible as guide appears to contradict the discounting of scripture above.) Links to the Powerful The Family has had ties to numerous powerful politicians. <blockquote>The Family is in its own words an ‘invisible’ association, although it has always been organized around public men. Senator Sam Brownback (R., Kansas), chair of a weekly off-the-record meeting of religious right groups called the Values Action Team (VAT) is an active member, as is Representative Joe Pitts (R., Pennsylvania),... Others referred to as members include senators Jim DeMint of South Carolina,...; Pete Dominici of New Mexico...; Chuck Grassley (R., Iowa); James Inhofe (R., Oklahoma); Tom Coburn (R., Oklahoma); John Thune (R., South Dakota); Mike Enzi (R., Wyoming); and John Ensign.... ‘Faith-based Democrats’ Bill Nelson of Florida and Mark Pryor of Arkansas,... are members.... (P18)</blockquote> Many other politicians, some very well known, from both major parties appear as Family members or friends in the book. Since the 1950s, the Family has supported the National Prayer Breakfast. (P 195).  The "Divine Right" of Leaders The Family believe that those who are powerful are those chosen by God to be powerful, and hence must obeyed. Family founder Abraham Vereide, better known as Abram <blockquote>“would become an exponent of religion for the elite - the ‘up and out,’ as he called them.... He termed this trickle-down faith the Idea, and it was really the only idea he ever had - the only one, he believed, God gave him. In one sense, it was nothing more than a defense of the status quo. It neither challenged power nor asked for anything from the powerful but their good intentions. ( P 91)</blockquote><blockquote>“Power lies in things as they are. God has already chosen the powerful, his key men. ( P 96)</blockquote><blockquote>‘We work with power where we can, build new power where we can’t.’ The words belong to Doug Coe, who seized the Fellowship’s top spot in a succession struggle following Abram’s death in 1969 and began transforming it into what I eventually encountered as the Family. ( P 121.)</blockquote> The "Divinely Chosen" Leaders Need Not be Accountable to Any Man The powerful, because they are chosen by God and are instruments of God’s will, need not be accountable, at least to any other humans. <blockquote>This, Abram decided, was what it meant to die to the self: to turn all responsibility over to God. That such a transfer meant the abdication of any accountability for one’s actions, that it provided justification for any ambition, did not occur to him. (P 125)</blockquote><blockquote>A Fellowship tract titled Studies for Public Men, 10,000 of which were printed up by a Chevron Oil executive, claimed that such abuses [refers to an Army General who worked with Coe and was subsequently jailed for selling surplus weapons to 'Third World gangs'] are inevitable, but not attributable to the piety with which such men cloaked their misdeeds. When pious men committed crimes, went the thinking, godlessness was to blame - ‘secularism in its worst form!’ In a Section titled ‘Accountablity,’ the tract explained why the Fellowship should not be held accountable for the actions of its individual members.... ‘Persisting in the accusation of collective guilt immobilizes a society,’ advised the tract. Perhaps, but the Fellowship denied the very concept of guilt for the powerful. That was a legalistic notion, an encroachment on God’s sovereignty.... (P 220)</blockquote><blockquote>We’re all sinners, and thus shouldn’t judge those whom God places in authority. (P 241)</blockquote> The "Divine Right" Extends Even to Dictators The Family’s support of powerful, unaccountable leadership is suggested by how it tolerated, and sometimes supported vicious dictatorships. <blockquote>Understand Abram’s weirdly ambivalent relationship with fascism.... (P 124)</blockquote><blockquote>In Frankfurt, Abram claimed, God personally revealed to Abram a key man to quietly help manage the internal affairs of Germany’s elite: Dr Otto Fricke, an austere German churchman with an uncomfortable past. ‘You are God’s man for this hour in Germany,’ Abram told him. Had Abram asked about Fricke’s role in Germany’s previous hour, Fricke would have begged off explaining his activities during the Third Reich. As a radio preacher, he’d been recruited by Goebbels to propagandize,.... (P 159)</blockquote><blockquote>Coe counseled a Haitian senator and then Haiti’s ambassador to the United States, easing both into commitments to a Christ-led nation, with the understanding the Christ Coe preached led not toward the socialism that tempts any bitterly poor people but toward an economics of ‘key men’ who would share their wealth as God instructed them. Senators Frank Carlson and Homer Capehart, both members of the Foreign Relations Committee, did the follow-up work, leading a Fellowship delegation of twelve businessmen to instruct the Haitian parliament in prayer cell politics. Francois ‘Papa Doc’ Duvalier, who would declare himself president for life but also the nation’s official ‘Maximum Chief of the Revolution’ and ‘Electrifier of Souls’ - he was the weirdest and most vicious dictator in the Western Hemisphere - impressed the senators with his spirituality.</blockquote><blockquote>Not only did South Korea hold a prayer breakfast, but its dictator, General Park Chung Hee, tried to use the Fellowship to channel illegal funding to congressional candidate’s of [President Richard] Nixon’s selection. (P 216)</blockquote><blockquote>In 1968, Abram declared [Indonesian dictator] Suharto’s coup a ‘spiritual revolution,’ and Indonesia under his rule an especially promising nation, hope for the future in Abram’s later years. (P 245)</blockquote> The family also had cordial relationships with South Vietnamese leader General Nguyen Van Thieu (P 248) and Filipino dictator Ferdinand Marcos (P 249)   Summary   Sharlet's book suggests how the Family's increasing influence has led to the infiltration into the general society of the notion that all current leaders, including and particularly corporate CEOs, have a "divine right," and can thus not be held accountable by mortal men, even though that notion, if expressed this clearly, would seem ridiculous to a vast majority of the population.  It is possible that the major reason that most health care leaders have become unaccountable is some sort of subconscious acquiescence to the notions of economism (as discussed <a href="http://hcrenewal.blogspot.com/2012/03/golden-calf-explains-how-economism-lead.html">here</a>), and promulgated by the Family.  However, this acquiescence then is largely by people who would likely reject the bizarre religious beliefs that underpin these notions if those beliefs and their origin were made clear.   All those who do not believe that all earthly leaders are divinely chosen need to challenge the leaders chosen by human to be accountable to humans.    As a society we need to wake up from our dazed acquiescence to ideas that border on crazy.  We need to challenge rote justifications and talking points for that which makes no sense, but serve to make the powerful more powerful.

Why Health Care Leaders Remain Unaccountable: How the Family Invisibly Promoted the "Divine Right of CEOs"

We have frequently discussed the lack of accountability of health care leaders, which we sometimes have described as CEO exceptionalism. We...

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The Golden Calf Explains How Economism Lead to the Divine Right of CEOs

Our fellow blogger (on <a href="http://brodyhooked.blogspot.com/">Hooked: Ethics, Medicine and Pharma</a>), family physician and bioethicist Dr Howard Brody, has written a book on economic ideology that helps explain some of the issues we frequently discuss. Dr Brody's book, <a href="http://www.amazon.com/Golden-Calf-Economism-American-Policy/dp/1463762755">The Golden Calf</a>, is about how the social science of economics has been taken over by an ideology he and others call "economism."  Economism Economism consists of these major ideas: <ul><li>"'The economy' is a separate and distinct sphere of society."  This means that economic planning can be independent of consideration of the rest of society.</li><li>"Even if only a part of society, the economy is the primary part."  Thus economic planning, thinking, policies etc take precedence over other planning, thinking, policies, etc.</li><li>"People are, at core, economic beings.  The laws of the marketplace describe virtually asll of their behavior and the reasons for it.  People are beings of economic exchange, driven first to make money and then to spend on the goods obtainable in the marketplace."  So all other human thought, values, emotions, etc are less important.  The answer to the question, "what does love have to do with it?" is nothing.  Neither does honesty, morality, or ethics have to do with it.</li><li>"Economic calculation is the best way to understand, value, and manage human life.  It is appropriate that every aspect of our lives be thought of and analyzed in terms of economic calculations."  This essentially asserts that economists, economic thinking, and the marketplace should rule the world.  </li><li>"The economy, above all else, must be managed solely with an eye towards its own technical requirements - that is, what economists study.  There ought to be no interference from politicians, or policymakers, or moralists, or anyone else."  Thus, not only should greed be considered good, but greed ought to be enacted into law.  </li></ul>Economism's Prescription for Health Care Stated so baldly, economism may seem absurd.  However, it is easy to see its influence.  For example, Dr Brody explained how economism would state: <blockquote>what sort of health system the U.S. ought to have. It would be one that is governed by the laws of the market, and that treats all aspects of health care as consumer goods. How much any person 'needs' health care would be determined by one thing only - what that person is willing to pay on the open market. Anything else would be denounced as illegitimate interference with the market by politicians, policymakers, and other do-gooders.</blockquote> This, of course, corresponds very well with a lot that is said about health care by its current leaders. How often have we heard about the health care market, and how the only way to improve health care is market-based reforms? (Look <a href="http://hcrenewal.blogspot.com/2010/08/how-fallacy-of-perfect-health-care.html">here</a>).  How often have we heard leaders of hospitals refer to their "industry?" How often have we heard of patients as consumers, and doctors as providers? The list can go on. The problems are that economism does not provide good tools for prediction or management of the economy. Worse, <blockquote>If we want to live in a society that reflects basic human values, including acceptable moral rules, economism is a very poor guide. Yet economism is blind to its own deficiencies. it claims to be able to tell us the definitive answer to any problem in any aspect of human life, and accuse us of being irrational if we disagree with its proposals. If a powerful elite takes over control of a society, wedded to economism as their belief system, then the results for that society could be disastrous.</blockquote>The origins of economism provide an explanation for a phenomenon we have often seen in health care, the lack of <a href="http://hcrenewal.blogspot.com/search/label/accountability">accountability</a> of health care leaders, which we sometimes have described as CEO exceptionalism. We have noted how health care leaders almost never seem to need to take responsibility for their organizations' misbehavior and its outcomes, (look <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">here</a>) and in fact can command ever increasing <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">compensation</a>, no matter how badly they or their organizations do. The Religious Origins of Economism To understand this explanation, first note that Dr Brody suggested that economism is not a science. It did not arise out of an effort to use logic and reason to explain evidence. Instead, it seems to have come from two strains of religious thought that got translated into economic terms.  Dr Brody suggest that while it may make sense to think of economism as an ideology, it functions more like a religion, so that viewing economics ruled by economism as a social science would be a very big mistake. The first strain was the Protestant evangelism found in England in the 18th century. Evangelicals of that time <blockquote>regarded poverty as part of a divine program. Evangelicals interpreted the mental anguish of poverty and debt, and the physical agony of hunger or cold, as natural spurs to prick the conscience of sinners. They believed that the suffering of the poor would provoke remorse, reflection, and ultimately the conversion that would change their fate [in the afterlife]. In other words, poor people were poor for a reason, and helping them out of poverty would endanger their mortal souls.</blockquote>Thus, people who fail in the marketplace of life are sinners. Markets should not be regulated to prevent such failure, because doing so would prevent their still possible salvation. On the other hand, the Puritanism of the 17th and 18th centuries, and its 19th century evolution in the US <blockquote>was creeping up on the idea, not only that material wealth and worldly success was a good thing in the eyes of God, but that seeing oneself become successful and wealthy was the strongest possible sign of God's grace and one's status among the Elect.</blockquote> Things then got more extreme. <blockquote>The moderate idea that those who enjoy material wealth in the earthly life may have been especially favored by God seems gradually to have morphed into the extreme idea that God wishes us to bestow on the super-rich our adulation and unquestioning allegiance.</blockquote> So, <blockquote>For example, Reverend Russell Cornwell's lecture called 'Acres of Diamonds' proved so popular after he first wrote it in 1870 that he was called upon to give it six thousand times over the next quarter century. He preached: 'I say you ought to get rich, and it is your duty to get rich.'</blockquote> Thus, <blockquote>We have been conditioned to believe that wealth is an infallible sign of God's favor.</blockquote> Here is the religion behind CEO exceptionalism, lack of CEO accountability, outrageous CEO compensation, the imperial CEO. CEOs can become extremely wealthy, and "wealth is an infallible sign of God's favor," generating the notion of the divine right of CEOs. Summary No wonder that we have yet to see any logic or evidence to support CEO exceptionalism. Instead, we have seen logical fallacies used to support <a href="http://hcrenewal.blogspot.com/2011/05/logical-fallacies-to-defend-ceos-from.html">lack of CEO accountability</a> and <a href="http://hcrenewal.blogspot.com/2010/09/logical-fallacies-in-defense-of-million.html">immense CEO compensation</a>. The wealth of our leaders cannot be addressed with logic and evidence if it is a sign of God's favor. Thus, anyone whose religious beliefs are perfectly compatible with 18th century English evangelism and 17th through 19th century British and American Puritanism and its aftermath might be happy with the divine right of CEOs, and with economism in general. However, Dr Brody makes the powerful point that economism functions like a religion, and at best is an ideology, not scientific paradigm. Anyone who is uncomfortable with the religious beliefs that underlie it ought to be very uncomfortable with its precepts, as should anyone who believes that economics or health care should be based on evidence and logic. Specifically, in health care and in the larger economy, anyone who does not believe that rich CEOs are especially favored by God should question why they should be so rich, and why they should be so unaccountable. Dr Brody has written a powerful and important book which goes a long way to explain the irrationality that has infected health care. People of all, or of no religious beliefs should pay attention.

The Golden Calf Explains How Economism Lead to the Divine Right of CEOs

Our fellow blogger (on Hooked: Ethics, Medicine and Pharma ), family physician and bioethicist Dr Howard Brody, has written a book on econom...

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