Big Door Keep Revolving - Our Latest Roundup About the Blurred Lines Between the Health Care Industry and the Government Bodies that are Supposed to Regulate and Make Policy Affecting It

The revolving door continues to turn connecting US government bodies that make health policy or regulate health care and the health care industry.  Sometimes these transitions are obvious, sometimes they are obscure.  The press sometimes makes the revolving door the subject, but more often it is just an aside.<br /><br />The latest roundup of transitions through the door includes, in chronological order of media attention...<br /><br /><b>Former White House Press Secretary to Consultancy Serving Health Care Corporations </b><br /><br />As <a href="http://www.washingtonpost.com/blogs/post-politics/wp/2014/04/06/pelosi-suggests-gibbss-obamacare-comments-due-to-business-ties/">reported</a> by the Washington Post in April, 2014, Robert Gibbs was White House Press Secretary until he departed for the private sector,<br /><br /><blockquote class="tr_bq">Since departing the White House in 2011, Gibbs has taken a path familiar to other former White House officials who use their ties to a president to enrich themselves and establish a new career. </blockquote><br />In particular, he<br /><br /><blockquote class="tr_bq">co-founded <a href="http://www.theinciteagency.com/">The Incite Agency</a>, a consulting and media relations firm that advises Fortune 500 companies, <i>including health-care firms</i>.</blockquote><br />The story was apparently generated after the Democratic House Minority Leader openly criticized someone who served in the Democratic President's White House, so the thrust of the story was about how Mr Gibbs has apparently changed his ideas on Obamacare since his White House days,<br /><br /><br /><blockquote class="tr_bq">House Minority Leader Nancy Pelosi (D-Calif.) suggested Sunday that former top Obama aide Robert Gibbs's <a href="http://www.washingtonpost.com/blogs/post-politics/wp/2014/04/03/top-former-obama-aide-obamacares-employer-mandate-wont-survive/">comment that the employer mandate portion of the Affordable Care Act won't survive</a> <i>might be related to Gibbs's business interests.</i><br /><br />'I don't know who his clients are or what his perspective is,' Pelosi told CNN's '<a href="http://sotu.blogs.cnn.com/">State of the Union</a>.' 'But we are celebrating the fact that we have over seven million who have signed up.'</blockquote><br />The Post also noted,<br /><br /><blockquote class="tr_bq">The speech Gibbs gave this past week in Colorado is consistent with how the Harry Walker Agency bills Gibbs as a potential paid speaker. <a href="http://www.harrywalker.com/speaker/Robert-Gibbs.cfm?Spea_ID=1474">On its Web site</a>, pitches Gibbs by noting that he '<i>played a major role in the daily White House policy debates over the shape of healthcare reform</i>.' It suggests that during such speeches, Gibbs 'articulates the future for the Patient Protection and Affordable Care Act.'<br /><br />The pitch concludes by stating that 'The future of Obamacare -- and how it will affect your business -- is yet to be seen, and <i>few are better prepared than Gibbs to guide you through that conversation</i>.'</blockquote>Again, note that this article seemed to be inspired by Rep Pelosi's direct criticism of a fellow Democrat, not by the revolving door transition per se.   <br /><br /><b>President of Global Government and Scientific Affairs at Natural Products Association to Director of the Division of Dietary Supplements at the FDA then Back to Natural Products Association as CEO</b><br /><br />This round trip through the door was noted rather obliquely in a New York Times <a href="http://well.blogs.nytimes.com/2014/04/30/why-dangerous-supplements-linger-on-shelves/">article</a> in late April, 2014, focused on how slowly the FDA has reacted to apparently dangerous "dietary supplements,"<br /><br /><blockquote class="tr_bq">Before joining the F.D.A. in 2011, Dr. [Daniel] Fabricant was a top executive at an industry trade group, the Natural Products Association.</blockquote><br />The article had previously identified Dr Fabricant as<br /><br /><blockquote class="tr_bq">the director of the division of dietary supplement programs in the agency’s Center for Food Safety and Applied Nutrition.</blockquote><br />But,<br /><br /><blockquote class="tr_bq">The F.D.A. <a href="http://www.nutraingredients-usa.com/Regulation/Fabricant-leaves-FDA-replaces-Shaw-as-head-of-NPA">recently announced</a> that Dr. Fabricant is leaving the agency this month to return to the trade group as its chief executive.</blockquote>While the NY Times article thus mentioned as an aside that a government official with major responsibility for regulating dietary supplements had these relationships with the dietary supplement industry, it did not question whether that relationship had anything to do with slow responses by the FDA to reports of toxic dietary supplements.  <br /><br /><b>Spokesman for the Speaker of the House of Representatives to Spokesman for America's Health Insurance Plans</b><br /><br />USA Today briefly but directly <a href="http://onpolitics.usatoday.com/2014/05/12/brendan-buck-health-insurance-lobby-ahip/">noted</a> this in mid-May, 2014,<br /><br /><blockquote class="tr_bq">House Speaker <i>John Boehner’s spokesman, Brendan Buck, has spent a lot of time over the years helping his boss and congressional Republicans criticize President Obama’s health care law</i>.<br /><br /><i>Now Buck is leaving Capitol Hill to be spokesman for America’s Health Insurance Plans</i>, the trade association that represents thousands of health insurance companies.<br /><br />'Brendan’s experience and skill set will allow him to hit the ground running on Day One,' said Karen Ignagni, president and CEO of AHIP. 'He’s an effective communicator who knows how to tackle complex policy issues and skillfully navigate an ever-changing health care and media environment.'</blockquote><br />What made this interesting seems to be how it represented a change of tune on Mr Buck's part.  Note that many people believe that commercial health insurers will benefit from all the new policy holders that Obamacare sends them, so<br /><br /><blockquote class="tr_bq">As the health insurance  industry’s trade group, AHIP supports the law’s mandate that individuals obtain health insurance. The trade group has praised the Affordable Care Act’s ability to expand insurance coverage.</blockquote><br />But never mind that the man in the government for whom Mr Buck previously worked, <br /><br /><blockquote class="tr_bq">Boehner likes to call Obamacare a 'train wreck.'</blockquote><br /><b>FDA Director of the Office of Medical Policy for the Center for Drug Evaluation and Research to Greenleaf Health Consultancy</b><br /><br />This so far has appeared only in a mid-May, 2014,  <a href="http://www.businesswire.com/news/home/20140519006244/en/FDA-Senior-Official---Dr.-Rachel-Sherman#.U30IqXaGee0">press release</a>.   It describe Dr Sherman's career at the FDA,<br /><br /><blockquote class="tr_bq">During her FDA tenure, Sherman was a driving force for innovation, new programs and policy. Sherman was responsible for spearheading and implementing the Sentinel Initiative, the Critical Path Initiative, biosimilars policy and the new Breakthrough Therapy Designation.<br /><br />As <i>Director of CDER’s Office of Medical Policy and Associate Center Director for Medical Policy Sherman was responsible for developing, coordinating, and implementing medical policy programs and strategic initiatives as well as establishing and chairing CDER's Medical Policy Counsel</i> [sic]. This included overseeing the regulation of prescription drug promotion and advertising. <br /><br />Sherman began her career with FDA in the Division of Antiviral Drug Products at CDER in 1989—first as a medical reviewer and then as a clinical team leader. In 1998, she was appointed Deputy Office Director for the Office of Drug Evaluation I. In 1999, she assumed the duties of Deputy Office Director for the newly established Office of Medical Policy in CDER. </blockquote><br />But now she will be "Principal, Drug and Biological Drug Products" for Greenleaf, described as,<br /><br /><blockquote class="tr_bq">Greenleaf Health is a<i> full service regulatory consulting firm that provides strategic guidance to companies regulated by the FDA</i> and those developing innovative solutions to pressing public health challenges around the globe</blockquote><br />Note that Greenleaf was already well populated with FDA officials who had previously transited the big revolving door,<br /><br /><blockquote class="tr_bq">Patrick Ronan, former FDA Chief of Staff and currently president of Greenleaf; Dr. Daniel Schultz, former Director of the Center for Devices ('CDRH') and Radiological Health and currently Greenleaf's Principal for Medical Devices and Combination Products; Michael Chappell, former Associate Commissioner for Regulatory Affairs, and currently Greenleaf's Principal for Regulatory Compliance; Heather Rosecrans, former Director of CDRH's 510(k) staff and currently Senior Vice President for Medical Devices and Combination Products; Linda Carter, formerly Associate Director of CDER's Office of Evaluation I and currently Vice President of Drug and Biological Drugs; and Taryn Fritz Walpole, former FDA Deputy Chief of Staff, and currently Chief Operating Officer and Senior Vice President for Regulatory Affairs</blockquote><br />So maybe it has become so routine for middle and upper level FDA managers to go to work for consultancies that help industry to deal with the FDA that no journalist found this revolving door transition interesting.<br /><br /><b>Summary</b><br /><br />Again, there appears to be constant traffic among health care corporations and the government bodies that regulate them and make policy that affects them.  The traffic may be so heavy and routine that it no longer appears to be news, unless accompanied by an ironic detail or two.<br /><br />However, as we have said many times before, the constant interchange of health care insiders among government, large health care corporations, and the consultancies, marketing, public relations, lobbying and legal firms which represent them certainly suggests that health care, like many other sectors, seems to be run by an amorphous group of insiders who owe allegiance neither to government nor industry.<br /><br />However, those who work in government are supposed to be working for the people, and those who work on health care within government are supposed to be working for patients' and the public health.  If they are constantly looking over their shoulders at potential private employers who might offer big checks, who indeed are they working for?<br /><br /><br /><div itemprop="articleBody"></div>Attempts to turn government toward private gain and away from being of the people, by the people, and for the people have no doubt been going on since the beginning of government (and since the Constitution was signed, in the case of the US).  However, true health care reform  would require curtailing the severe sorts of conflicts of interest created by the revolving door.<br /><br />Real heath care reform would require multi-year cooling off periods before someone who worked in the commercial world can get a job in a government whose work has direct effect on his or her previous employer or industry sector, and before someone who worked in government whose work had direct effect on a particular economic sector can accept a job for a company in that sector.    <br /><br />

Big Door Keep Revolving - Our Latest Roundup About the Blurred Lines Between the Health Care Industry and the Government Bodies that are Supposed to Regulate and Make Policy Affecting It

The revolving door continues to turn connecting US government bodies that make health policy or regulate health care and the health care industry.  Sometimes these transitions are obvious, sometimes t…

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Is this Any Way to Discuss Health Care Policy? - Television Advertising about US Health Care Reform Cost $445 Million from 2010 -2014

Every now and then, we get an anonymous comment criticizing our "lack of balance" or words to that effect, maybe because we criticized some action by a big, often but not always for-profit, health care organization.  We usually respond that we have no obligation to be balanced, since<br />- We publish opinion, not hard news<br />-  It is questionable that even hard news reporters must report all opinions on an issue, if some of those opinions are demonstrably less credible<br />-  There are far more voices extolling the wonderful "innovations" provided by our current "best health care system in the world," than providing our sorts of criticism.<br /><br />To expand on that last point - a recent news item suggests how much of the health care policy debate is paid marketing and public relations, rather than individual voices of citizens, health care professionals, or even health care policy experts.<br /><br />From the AP, <a href="http://www.seattlepi.com/news/article/Study-Political-TV-ads-on-health-law-total-445M-5483653.php">via the Seattle Post -Intelligencer</a>,<br /><br /><blockquote class="tr_bq">A new analysis finds the nation's health care overhaul deserves a place in advertising history as the focus of extraordinarily high spending on negative political TV ads that have gone largely unanswered by the law's supporters.<br /><br />The report, released Friday by nonpartisan analysts Kantar Media CMAG<a href="http://www.seattlepi.com/?controllerName=search&action=search&channel=news%2Fpolitics&search=1&inlineLink=1&query=%22Kantar+Media+CMAG%22"></a>, estimates <i><b>$445 million</b> was spent on political TV ads mentioning the law since the enactment of the Affordable Care Act in 2010</i>. Spending on negative ads outpaced positive ones by more than 15 to 1.</blockquote><br />In particular,<br /><br /><blockquote class="tr_bq">In the 2014 congressional races, 85 percent of the anti-Obama ads were also anti-'Obamacare' ads, the analysis found. In some competitive races, 100 percent of the pro-Republican TV ads aimed at Democrats contained anti-health law messages.<br /><br />Over the four years,<i> an estimated $418 million was spent on 880,000 negative TV spots focusing on the law, compared to $27 million on 58,000 positive spots</i>, according to the analysis. Nearly all of the spending was on local TV stations, in races ranging from state offices such as treasurer and governor to Congress and the presidential election.</blockquote><br />That is just amazing. <br /><br />My concern is not so much that much of this advertising is against "Obamacare."  We have not often written about the Affordable Care Act (ACA), aka "Obamacare," and what we wrote at best was mild praise.  As I <a href="http://hcrenewal.blogspot.com/2010/03/health-care-reform-bill-and-health-care.html">posted</a> back in 2009, very little of the law had anything to do with the issues we discuss on Health Care Renewal.  In my humble opinion, since the law went into effect, it has increased access to health insurance, especially for certain groups of people that commercial health care insurers previously spurned, e.g., older people and people with pre-existing diseases.  It also contained provisions that might increase disclosure of conflicts of interest, and foster comparative effectiveness research.  On the other hand, the law has done nothing to reduce <a href="http://hcrenewal.blogspot.com/search/label/concentration%20of%20power">concentration of power</a> in health care.  It has done nothing to make health care leaders more <a href="http://hcrenewal.blogspot.com/search/label/accountability">accountable</a>, especially for their organization's unethical or even <a href="http://hcrenewal.blogspot.com/search/label/crime">criminal</a> behavior, decrease their ability to <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">line their pockets</a> regardless of such behavior, and thus reduce their <a href="http://hcrenewal.blogspot.com/search/label/impunity">impunity.</a>  It will not obviously decrease <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest </a>affecting those who make decisions about patient care or health policy, lock the <a href="http://hcrenewal.blogspot.com/search/label/revolving%20doors">revolving door</a> between government and the health care industry, end <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulation of clinical research</a> to serve vested interests, or <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression of research</a> whose results offend such interests, etc, etc.  So there is plenty to discuss about health care reform and related matters of health care policy.<br /><br />Yet a major venue of US public discussion about health care policy, at least having to do with health care reform legislation, appears to be 15 -60 second paid television advertisements.  Often who pays for these ads are obscure, as certainly are the identities of the advertising or public relations firms that actually craft them.  Certainly, the ads do not explain who might profit were what they urge be implemented. The ads may appeal to emotion, or engage in logical fallacies.  And they appear in millions of peoples homes day in and day out.<br /><br />Such advertising, added to all the other billions of dollars worth of <a href="http://hcrenewal.blogspot.com/search/label/marketing">marketing</a> and <a href="http://hcrenewal.blogspot.com/search/label/public%20relations">public relations</a> that swirl around health care, make any sort of intelligent discussion very difficult.  The advertising frenzy renders the voices of individual citizens, health care professionals, and even health policy experts  whispers in comparison.<br /><br />While there are ostensible free speech advocates who defend these advertisements, and maybe who promote the free speech rights of corporations as the same as those of human citizens (without, of course, many of the responsibilities of citizens), none of these vocal self-proclaimed civil libertarians seem to be doing anything to defend the audibility of the voices of individuals in the health care policy debate.<br /><br />So we will continue to do what we can to bring some healthy skepticism about loud proclamations in health care made by people who stand to gain financially from their effects.  But is it any wonder that our voices create <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">so few echoes</a>? <br /><br />

Is this Any Way to Discuss Health Care Policy? - Television Advertising about US Health Care Reform Cost $445 Million from 2010 -2014

Every now and then, we get an anonymous comment criticizing our "lack of balance" or words to that effect, maybe because we criticized some action by a big, often but not always for-profit, health car…

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Marketing Bad Health Care Decisions as a New Form of Stealth Health Policy Advocacy

A remarkable set of video advertisements appeared a few weeks ago that seem designed to frighten people into making bad health care decisions.<br /><br /><b>The "Bad Uncle Sam" Advertisements </b><br /><br />As <a href="http://www.businessweek.com/articles/2013-09-20/the-creative-minds-behind-the-new-ghoulish-anti-obamacare-ads">described</a> by Businessweek,<br /><br /><blockquote class="tr_bq">In the first ad, dubbed '<a href="http://www.youtube.com/watch?v=R7cRsfW0Jv8">The Exam</a>,' a young woman who has signed up for Obamacare arrives at a medical facility and changes out of her clothes and into a flimsy hospital gown. Following the instructions of a doctor, she reclines on a hospital bed and spreads her legs into a pair of stirrups. The doctor leaves the room. Then, suddenly a mascot wearing a plastic Uncle Sam mask and sporting an unwavering grin—Creepy Uncle Sam!—pops up between her legs. As she screams, the ad pans out. 'Don’t let government play doctor,' reads the kicker.</blockquote><br />The final message, for some reason not described by Businessweek, was<br /><br /><blockquote class="tr_bq"><b>Opt out of ObamaCare</b></blockquote><br /><br /><iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/R7cRsfW0Jv8" width="420"></iframe> <br />Similarly,<br /><br /><blockquote class="tr_bq">A second spot, entitled '<a href="http://www.youtube.com/watch?v=BsN75nt1aUU">The Glove</a>,' follows a similar narrative arc. A young man sits in an examination room and tells a doctor that he’s signed up for Obamacare. 'I saw the ads and figured, why not?' he says. 'Okay,' says the doctor. 'Take your pants off.' The man drops his trousers, reclines on the hospital bed, and brings his knees to his chest. The doctor leaves the room. Behind the young man, Creepy Uncle Sam pops up, raises his hand into the air, snaps on a latex medical glove, and wiggles his fingers menacingly.</blockquote><br />Once again, the final message is<br /><br /><blockquote class="tr_bq"><b>Opt out of ObamaCare</b></blockquote><br /><iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/BsN75nt1aUU" width="420"></iframe> <br /><br /><b>The Ostensible Message of the Advertisements </b><br /><br />Again per Businessweek, the ads were sponsored by " <a href="http://generationopportunity.org/who-we-are/#axzz2fRyKxa6K">Generation Opportunity</a>, a Virginia-based conservative organization <a href="http://www.prwatch.org/news/2013/09/12247/breaking-new-list-dark-money-shell-game-groups-connected-kochs">funded</a> in part by Charles and David Koch,..."  According to an <a href="http://www.theatlanticwire.com/politics/2013/10/group-telling-young-people-opt-out-obamacare-still-working-math/70079/">article</a> on the Atlantic website, Generation Opportunity means to be<br /><br /><blockquote class="tr_bq">urging Millennials not to sign up for insurance on the health care exchanges created by the Affordable Care Act. It claims that paying the individual mandate's tax penalty and buying insurance that doesn't meet government coverage rules is a 'better deal' for young people.</blockquote><br />As many have noticed, that is not the implication of the visuals.  As an <a href="http://www.nationaljournal.com/politics/right-wing-ad-equates-obamacare-and-rape-20130919">opinion piece</a> in the National Journal put it,<br /><br /><blockquote class="tr_bq"> the message is that the government is trying to forcibly rape women with a blunt metal instrument.</blockquote><br />Furthermore, the final written message of both advertisements is not a nuanced one about where one should seek to go to buy health insurance.  It is simply "opt out of ObamaCare."<br /><br /><b>A Nonsensical Premise </b><br /><br />Also, the premise of the advertisements is nonsense, to put it politely.<br /><br />ObamaCare does require health insurance to pay for various kinds of preventive care without requiring patients to pay deductibles.  It does not make physicians and nurses provide these services.  Whether a patient gets, for example, a pelvic exam, is up to that patient and her doctor or nurse practitioner, not the government.  Of course, the legislation does not remotely suggest creepy government agents should perform pelvic or rectal exams.  <br /><br />Thus, the entire point of these advertisements seems to be to generate irrational fears that will drive young people away from health insurance now available through ObamaCare.<br /><br /><b>Stealth Health Policy Advocacy by Means of Marketing Bad Personal Health Care Decisions</b><br /><br />In the US, the Affordable Care Act, aka ObamaCare, still arouses a lot of controversy.  There are many people who have been critical of various aspects of the law.  (In fact, we <a href="http://hcrenewal.blogspot.com/2010/03/health-care-reform-bill-and-health-care.html">criticized </a>it for not addressing most of the issues about which we write on this blog.)  Furthermore, there is at least a large minority who want to repeal the law.  So there has been an ongoing barrage of persuasive messages meant to support or criticize various aspects of the law, and to support or discredit the entire law.<br /><br />However, the "Bad Uncle Sam" advertisements are different.  They do not urge people to vote for any particular person or initiative.  They do not urge people to express their own policy views.  They do not ask for contributions to political or advocacy organizations.<br /><br />Instead, they urge people to make particular health care decisions.  Despite the more nuanced messages espoused by Generation Opportunity when interviewed, their advertisements try to irrationally scare people away from purchasing health insurance made available by ObamaCare.<br /><br />They are aimed at young adults, who are less likely to have spare funds to pay for expensive health insurance, less likely to get sick or injured, and more likely to feel relatively invincible.  However, were an uninsured person, even a young one, to suffer a significant illness or injury, the resulting costs in our dysfunctional and extremely expensive health care system could drive them bankrupt.  This is all the more likely since the uninsured are likely to be charged "rack rates" for health care, while insurance companies negotiate discounts for their subscribers.  Furthermore, uninsured people may put off needed tests and treatments due to financial concerns, yet doing so may lead to worse health care results, or even death. <br /><br />An <a href="http://www.stltoday.com/business/columns/jim-gallagher/should-young-people-get-health-insurance/article_157c7d91-543b-5724-a560-c3f6eb34fae7.html">article</a> in the St Louis Post succinctly listed the costs associated with some unlucky outcomes for uninsured young people, for example,  <br /><br /><blockquote class="tr_bq">Suppose you twist your knee playing soccer. Without coverage, fixing it will be at least $20,000 to repair the ACL ligament, according to an estimate from <a href="http://health.costhelper.com/" title="http://health.costhelper.com/">Costhelper.com.</a><br /><br />Can’t pay it? Buy some crutches. They run about $30. You’ll also take on the <a href="http://www.nlm.nih.gov/medlineplus/ency/article/007208.htm" title="http://www.nlm.nih.gov/medlineplus/ency/article/007208.htm">risk of tissue damage and early arthritis</a>.</blockquote><br />Personal finance columnist Jim Gallagher concluded,<br /><br /><blockquote class="tr_bq"> although the vast majority of young adults stay healthy, serious trouble is not rare. Those without insurance are playing the odds. If they win, they’ve saved the insurance premiums. If they lose, they’re ruined.</blockquote><br />Generation Opportunity may <a href="http://generationopportunity.org/who-we-are/">claim to be</a><br /><br /><blockquote class="tr_bq"> a free-thinking, liberty-loving, national organization of young people promoting the best of Being American: opportunity, creativity and freedom. </blockquote><br />However, what it appears to be doing is urging bad health care choices  based on a false premise to serve an ideological agenda.<br /><br />Thus, its advertisements are a unique and uniquely bad mixture of marketing (of bad decisions) and <a href="http://hcrenewal.blogspot.com/search/label/stealth%20health%20policy%20advocacy">stealth health policy advocacy</a>.  If they want to publicly oppose ObamaCare, that is their right.  Fooling people into making bad decisions in the hopes that this will financially burden ObamaCare is completely unethical and amounts to <a href="http://hcrenewal.blogspot.com/search/label/disinformation">disinformation</a>, in my humble opinion.  The leadership and funders of Generation Opportunity ought to be ashamed of themselves. <br /><br />The US has many major health care problems.  They deserve discussion and debate.  Disinformation that tries to confuse people into making bad personal health care decisions is likely to make our health care dysfunction even worse.   <br /><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><br />

Marketing Bad Health Care Decisions as a New Form of Stealth Health Policy Advocacy

A remarkable set of video advertisements appeared a few weeks ago that seem designed to frighten people into making bad health care decisions.The "Bad Uncle Sam" Advertisements As described by Busines…

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Round and Round Spins the Revolving Door, Unimpeded by "Obamacare," Nor By Those Protesting "Obamacare"

On this day of government dysfunction in the US, it is time for our latest installment on the "<a href="http://hcrenewal.blogspot.com/search/label/revolving%20doors">revolving door</a>," the interchange of insiders among government legislative offices that affect health policy and agencies that implement it, and large health care corporations and the lobbyists and attorneys who represent them.  While we have been discussing this issue since March, 2011 (look <a href="http://hcrenewal.blogspot.com/2011/03/those-big-doors-keep-revolving.html">here</a>),  it got major media attention in the form of a New York Times <a href="http://www.nytimes.com/2013/09/18/us/politics/reaping-profit-after-assisting-on-health-law.html?pagewanted=all">article</a> two weeks ago.<br /><br />We have accumulated several other relevant stories since late August, 2013, which we will group by the type of government offices and agencies affected, and within them, by the date the story first came out..<br /><br /><b>Regulatory and Law Enforcement Agencies</b><br /><br /><u>Health Care Antitrust Leader at the Federal Trade Commission to Arnold & Porter</u> <br /><br /> From the MainJustice.com <a href="http://www.mainjustice.com/2013/09/09/ftc-senior-antitrust-attorney-joins-arnold-porter/">site</a>,<br /><br /><blockquote class="tr_bq">Peter J Levitas, a former senior antiturst attorney at the Federal Trade Commission, is joining Arnold & Porter LLP in Washington, D.C....<br /><br />Levitas has spent the past four years as deputy director of the FTC's Bureau of Competition and oversaw investigations and litigation for mergers and conduct cases in numerous industries.  </blockquote><br />So,<br /><br /><blockquote class="tr_bq">Levitas joins the firm's antitrust practice with experience3 addressing complex merger and conduct investigations, particularly in the healthcare, pharmaceutical and technology industries.</blockquote><br /><u>Leader of Health Care Fraud Enforcement for US Attorney New Jersey Office to Lowenstein Sandler </u><br /><br />From the ComplianceWeek.com <a href="http://www.complianceweek.com/former-health-care-fraud-chief-rejoins-lowenstein-sandler/article/311549/">site</a>,<br /><br /><blockquote class="tr_bq">Maureen Ruane, a former health care fraud chief at the U.S. Attorney's Office for the District of New Jersey, has rejoined the law firm Lowenstein Sandler to lead its new health care litigation, investigations and compliance practice.<br /><br />The new practice will help the firm's healthcare and life science clients strengthen their regulatory and compliance programs, as well as defend corporate and individual clients who become the subjects or targets of government investigations or enforcement actions.  <br /><br />Prior to rejoining Lowenstein Sandler, Ruane most recently served for more than three years as the Chief of the Health Care & Government Fraud Unit at the U.S. Attorney's Office for the District of New Jersey.</blockquote><br /><b>Health Policy Implementation</b><br /><br /><u>Counsel for Department of Health and Human Services to Sidley Austin</u><br /><br /><a href="http://www.nytimes.com/2013/09/18/us/politics/reaping-profit-after-assisting-on-health-law.html?pagewanted=all">Per</a> the NY Times,  <br /><br /><blockquote class="tr_bq">Dr. [Dora] Hughes, a former Obama administration official, has something Washington lawyers and lobbying shops covet: an insider’s understanding of the new health care law. After nearly four years as counselor to Health and Human Services Secretary Kathleen Sebelius, she left government last year to work for Sidley Austin, which represents insurers, pharmaceutical companies, device makers and others affected by the law. </blockquote><br />Previously,<br /><br /><blockquote class="tr_bq">she  began a decade ago, first as a health policy adviser to Senator Edward M. Kennedy, and later to Mr. Obama, then a senator. </blockquote><br /><u>Deputy Assistant Secretary of Department of Health and Human Services to Glover Park Group</u><br /><br />Also from the NY Times,<br /><br /><blockquote class="tr_bq"> Elizabeth Engel, who oversaw health legislation and served as a liaison to Congress when she was a deputy assistant health secretary under Ms. Sebelius, is now advising health care clients for the Glover Park Group. </blockquote><br /><u>White House to Avenue Solutions</u><br /><br /><a href="http://www.nytimes.com/2013/09/18/us/politics/reaping-profit-after-assisting-on-health-law.html">From</a> the NY Times,<br /><br /><blockquote class="tr_bq">Yvette Fontenot, a mother of three who began her Washington career in 1997, analyzing Medicare for the Office of Management and Budget. Ms. Fontenot worked on the health bill as a Finance Committee aide and later moved to the White House. Four months ago she joined Avenue Solutions, a boutique lobbying shop. </blockquote><br /><u>White House "Health Czar" and Deputy Chief of Staff to Consonance Capital, and CVS</u><br /><br />While we <a href="http://hcrenewal.blogspot.com/2013/08/the-door-revolves-again-former-white.html">noted</a> this in August, 2013, the NY Times reported in September as part of its larger article,  <br /><br /><blockquote class="tr_bq">   <a href="http://m.healthcarefinancenews.com/news/aca-architect-returns-private-equity">Nancy-Ann DeParle</a>, Mr. Obama’s former 'health czar' and later his deputy chief of staff, now guides health care investments as a partner in a new private equity firm, Consonance Capital, with colleagues from her pre-White House days. </blockquote><br />Actually, as we <a href="http://hcrenewal.blogspot.com/2009/03/meet-new-boss-same-as-old-boss-health.html">discussed</a> in 2009, Ms DeParle has been oscillating back and forth through the revolving door for a while.  She  was the administrator of the Health Care Financing Administration in the Department of Health and Human Services under President Clinton from 1997-2000.  She left to become managing director of a private equity firm, CCMP Capital.  She also served on the boards of directors of Boston Scientific, Cerner, and Medco.  Then she went back to the executive branch as noted by the the Times above.<br /><br />Furthermore, as reported by AP, <a href="http://news.providencejournal.com/breaking-news/2013/09/cvs-caremark-board-adds-former-white-house-adviser.html">via</a> the Providence Journal,<br /><br /><blockquote class="tr_bq">Drugstore chain CVS Caremark has added to its board of directors a former top adviser to President Barack Obama on the health care overhaul.<br /><br />The Woonsocket, R.I., company said Wednesday after markets closed that Nancy-Ann M. DeParle, 56, will be an independent director who serves on the board's audit committee.</blockquote><br /><u>White House to health care venture capital</u><br /><br />Also from the NY Times story,<br /><br /><blockquote class="tr_bq">Bob Kocher, a doctor, management consultant and former member of Mr. Obama’s economics team, is a California venture capitalist, helping finance health start-ups. </blockquote><br /><b>Legislative Offices</b><br /><br /><u>Senate Finance Committee Staff, then Department of Health and Human Services Staff to Avenue Solutions</u><br /><br />As <a href="http://thehill.com/business-a-lobbying/318577-architects-of-obamacare-reap-windfall-as-washington-lobbyists">reported </a>by The Hill bog,<br /><br /><blockquote class="tr_bq">The firm Avenue Solutions, for instance, recently hired Yvette Fontenot, a former staffer for both the Senate Finance Committee, which wrote ObamaCare’s tax-related provisions, and HHS's Office of Health Reform, which is assisting the implementation.<br /><br />Since her hire in April, the four-woman firm has picked up Health Care Service Corp. as a client, and Fontenot is now lobbying for the Blue Cross Blue Shield Association</blockquote><br /><u>Congress to Alston & Bird </u><br /><br />In the same report,<br /><br /><blockquote class="tr_bq">Former Rep. Earl Pomeroy (D-N.D.) joined Alston & Bird in 2011 after dealing with healthcare and tax issues as a member of the House Ways and Means Committee.<br /><br />Now Pomeroy and his one-time chief of staff, Bob Siggins, are lobbying on ObamaCare for clients such as clients such as Vision Service Plan, the National Coordinating Committee for Multiemployer Plans and Medicare — a health insurance provider.</blockquote><br /><u>Health Counsel for Senate Finance Committee from WellPoint, Now to Johnson & Johnson</u><br /><br />Note that we touched on part of this story back in 2010<a href="http://hcrenewal.blogspot.com/2010/04/pay-for-hypocrisy-for-health-insurance.html"> here</a>.  Now <a href="http://www.nytimes.com/2013/09/18/us/politics/reaping-profit-after-assisting-on-health-law.html?pagewanted=all">from</a> the New York Times,  <br /><br /><blockquote class="tr_bq"><div itemprop="articleBody">Liz Fowler, a onetime executive with WellPoint, the insurer, helped draft the legislation as the chief health counsel for the Senate Finance Committee and later joined the administration. Now she runs global health policy for Johnson & Johnson, the medical equipment and pharmaceutical giant, which strongly backed the health bill and stands to benefit from it. </div><div itemprop="articleBody"><br /></div><div itemprop="articleBody">Ms. Fowler is not a registered lobbyist, but she does provide in-house advice on the bill — work that has drawn criticism from publications like the British newspaper <a href="http://www.theguardian.com/commentisfree/2012/dec/05/obamacare-fowler-lobbyist-industry1">The Guardian</a> and the Web sites <a href="http://www.salon.com/topic/liz_fowler/">Salon</a> and <a href="http://www.huffingtonpost.com/bill-moyers/watch-washingtons-revolvi_b_2316245.html">The Huffington Post</a>, where the journalist Bill Moyers singled out Ms. Fowler, asserting that 'when push comes to shove, corporate interests will have the upper hand.'</div></blockquote><div itemprop="articleBody"><br /></div><div itemprop="articleBody"><b>Summary</b></div><div itemprop="articleBody"><br /></div><div itemprop="articleBody"> It's enough to make one's head spin: all that traffic through the revolving door reported just in the last five weeks.</div><div itemprop="articleBody"><br /></div><div itemprop="articleBody">As we have said many times before, the constant interchange of health care insiders among government offices, lobbying and legal firms, and large health care corporations certainly suggests that health care, like many other sectors, seems to be run by an amorphous group of insiders who owe allegiance neither to government nor industry.  The NY Times tried to explain this in a benign way,</div><div itemprop="articleBody"><br /></div><blockquote class="tr_bq"><div itemprop="articleBody">Yet the progression from government to the private sector is also predictable, a window into the peculiar rhythms of life in the capital. Young aides, often fresh out of college or graduate school, acquire highly specialized knowledge but eventually settle down, build lives and long for jobs that pay more and let them see their children at night. </div></blockquote><div itemprop="articleBody"><br /></div><div itemprop="articleBody">While the private sector may offer good pay, is it just for these poeples' skills and expertise?  Or are these offers only for those who while in government service evinced friendship to private vested interests?  Do government workers who think longingly of higher pay and shorter hours wonder what it would take to please those that might offer such opportunities?</div><div itemprop="articleBody"><br /></div><div itemprop="articleBody">Yet those who work in government are supposed to be working for the people, and those who work on health care within government are supposed to be working for patients' and the public health.  If they are constantly looking over their shoulders at potential private employers who might offer big checks, who indeed are they working for?</div><div itemprop="articleBody"><br /></div><div itemprop="articleBody">Attempts to turn government toward private gain and away from being of the people, by the people, and for the people have no doubt been going on since the beginning of government (and since the Constitution was signed, in the case of the US).  However, true health care reform  would require curtailing the severe sorts of conflicts of interest created by the revolving door.  This might require both improving pay and working conditions for government regulators, law enforcers, and legislative staffers; and specific laws to prevent immediate transitions from being a regulator, law enforcer, or legislator to handling corporate responses to or defenses against such regulation and enforcement. </div><div itemprop="articleBody"><br /></div><div itemprop="articleBody">That bit does not seem to be part of the current Affordable Care Act, yet it was hardly to enact such restrictions on conflict of interest that certain members of Congress have shut down the government.   </div><div itemprop="articleBody"><br /></div>

Round and Round Spins the Revolving Door, Unimpeded by "Obamacare," Nor By Those Protesting "Obamacare"

On this day of government dysfunction in the US, it is time for our latest installment on the "revolving door," the interchange of insiders among government legislative offices that affect health poli…

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What Sorts of People are "Most Influential in Healthcare?"

Modern Healthcare just put out their list of the <a href="http://www.modernhealthcare.com/article/20130824/INFO/130829987/100-most-influential-people-in-healthcare-2013-text-list">"100 Most Influential People in Healthcare"</a> for 2013.  A look at what sorts of people are on this list says a lot about who runs US health care, and raises questions about who should.<br /><br /><b>Some Health Care Professionals, Lots of Hired Managers</b><br /><br />I did some quick descriptive categorizations. (Counts were double checked but I am not guaranteeing accuracy.  Categorizations were sometimes difficult for highly diversified organizations.)<br /><br />First, less than one third of list members are physicians (31% by my count).  I did not see any other health professionals on it (although I confess I did not look up the biographies of all 100).<br /><br />Of these physicians, most are now functioning as hired managers, usually at the CEO level, of big health organizations.  I found only a few who could be characterized as somewhat academic: Dr Atul Gawande, professor at Harvard Medical School, Dr Eric Topol, chief academic officer at Scripps Health, Dr Harvey Fineberg, President, Institute of Medicine, Dr Brent James, chief quality officer and executive director, Institute for Health Care Delivery Research, Intermountain Healthcare,  and probably Dr Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine.  <br /><br />My counts of hired managers on the list included<br /><br />CEOs of For-Profit Health Insurers - 5%<br /><br />CEO of For-Profit Hospital Systems - 8%<br /><br />CEOs of Non-Profit Hospital Systems - 21%<br /><br />CEOs of Other For-Profit Care Delivery Corporations - 7%<br /><br />CEOs of Drug/ Device/ Medical Supply Corporations - 2%<br /><br />CEOs of Health Care Information Technology Corporations - 1%<br /><br />CEOs of Non-Profit Trade Associations - 14%<br /><br />CEOs and other Leaders of Professional or Medical Association - 5%<br /><br />CEOs of Health Care Charities - 4%<br /><br />CEOs of Other Non-Profit Organizations - 15%<br /><br />Elected Government Leaders - 6%<br /><br />Leaders of Government Agencies, Departments - 10%<br /><br />Union Leaders - 2%<br /><br /><b>People Whose Organizations Have Issues</b><br /><br />The list included quite a few people who lead organizations which have had issues of the sort we discuss on Health Care Renewal.  For example, the list included the following among its top 10 most influential, in order of listed influence -<br /><br />4.  Stephen Hemsley, CEO of <a href="http://hcrenewal.blogspot.com/search/label/UnitedHealth">UnitedHealth Group</a> - We have discussed concerns about his executive compensation and how it does not fit his organization's stated mission, or his organization's long list of ethical misadventures (most recently summarized <a href="http://hcrenewal.blogspot.com/2013/05/unitedhealth-ceo-continues-to-prosper_3.html">here</a>) <br /><br />6. Mark Bertolini, CEO, Aetna - We most recently discussed how Aetna's leaders' pontifications on health policy seem mainly based on self-interest (<a href="http://hcrenewal.blogspot.com/2012/07/fool-us-once-shame-on-you-fool-us-twice.html">here</a>)  We also <a href="http://hcrenewal.blogspot.com/search/label/Aetna">discussed</a> various other management, ethical and legal issues. <br /><br />7.  Richard Bracken, CEO, HCA - A long time ago, HCA was one of the first big health care corporations to have to make a billion dollar plus settlement for fraud, among other issues (look <a href="http://hcrenewal.blogspot.com/2010/05/how-did-ceo-who-presided-over-company.html">here</a>).  The company has had legal, ethical, and management issues <a href="http://hcrenewal.blogspot.com/search/label/HCA">since</a>. <br /><br />8.  Joseph Swedish, CEO, WellPoint - He is new as CEO, but under previous leadership, the company amassed a record of misadventures while making its leadership very rich (summarized <a href="http://hcrenewal.blogspot.com/2013/04/wellpoints-former-manager-queen-got-206.html">here</a>, and look <a href="http://hcrenewal.blogspot.com/search/label/WellPoint">here</a> for details.) <br /><br />The list also included many other people whose organizations have been frequent fliers on Health Care Renewal.  For example, the CEOs of <a href="http://hcrenewal.blogspot.com/search/label/EPIC">Epic Systems</a> (ranked 13),  <a href="http://hcrenewal.blogspot.com/search/label/Tenet">Tenet Healthcare</a> (18), <a href="http://hcrenewal.blogspot.com/search/label/CIGNA">Cigna</a> (20), <a href="http://hcrenewal.blogspot.com/search/label/McKesson">McKesson Corp</a> (24), <a href="http://hcrenewal.blogspot.com/search/label/Sutter%20Health">Sutter Health</a> (42), <a href="http://hcrenewal.blogspot.com/search/label/Johnson%20and%20Johnson">Johnson & Johnson</a> (46), <a href="http://hcrenewal.blogspot.com/search/label/PhRMA">Pharmaceutical Research and Manufacturers of America (PhRMA)</a> (48), <a href="http://hcrenewal.blogspot.com/search/label/HealthSouth">HealthSouth</a> (59),  <a href="http://hcrenewal.blogspot.com/search/label/UPMC">UPMC</a> (69), and  <a href="http://hcrenewal.blogspot.com/search/label/Steward%20Health%20Care">Steward Health Care System</a> (86).<br /><br />There are many other people on the list who lead organizations that have gotten unfavorable notice on this blog, and a few whose own extreme <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">executive compensation</a> garnered comment.  As my science professors used to say, I leave their identification as an exercise for those interested.<br /><br /><b>Who Is Not on the List</b><br /><br />It is interesting who is not on the list.  There are no physicians in private practice.   I would argue there are no physicians who are "pure" academics at the moment.  There are no other health care research, health policy research, or public health academics.<br /><br />I saw only one person on the list (Senator Charles Grassley - R, Iowa) who has been identified with the sorts of real health care reforms we discuss here.  (Senator Grassely has investigated many instances of alleged conflicts of interest and fraud, and sponsored the Sunshine Bill to disclose better physicians' conflicts of interest.)  I do not see anyone else who in my humble opinion is identified as a dissident within the current environment. <br /><br />Many of the media accounts we have noted include people identified as experts who decried such issues as excessive <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">executive compensation</a>, <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">mission-hostile management</a>, <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a>, ethical issues leading to <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">legal settlements</a>, or <a href="http://hcrenewal.blogspot.com/search/label/crime">crime</a> and <a href="http://hcrenewal.blogspot.com/search/label/health%20care%20corruption">corruption</a> in health care.  None of them save Senator Grassley  are on this list.  <br /><br /><b>Summary</b><br /><br />The Modern Healthcare list of 100 most influential people in health care demonstrates the enormous influence of hired managers in modern health care.  The vast majority of list members were hired managers.  While the list did include some physicians, most of them were currently working as hired managers. <br /><br />It also demonstrates the influence of the for-profit, industrial part of health care.  It included 5 for-profit insurance CEOs, 8 for-profit hospital corporation CEOs, 7 for-profit health care delivery corporation CEOs, 2 for-profit drug/device company CEOs, and 1 for-profit health care IT CEO, a total of 23.  It also included CEOs of multiple trade associations, some of which represent the for-profit side of health care (e.g., PhRMA, America's Health Insurance Plans).  While it included leadership of many <a href="http://hcrenewal.blogspot.com/search/label/non-profit%20organizations">non-profit organizations</a> as well, some of these organizations have clear financial links to the for-profit industrial side.  These ties may include significant financial support from industry, significant holdings of health care corporate stock, or managers or board members with their own relationships to industry.  (For example,  see <a href="http://hcrenewal.blogspot.com/2011/04/third-rail-that-no-one-wishes-to.html">this discussion </a>of conflicts of interest affecting the Gates Foundation, whose co-chair is 76 on the Modern Healthcare list.)  Many of the large, non-profit hospital systems, 21 of whose CEOs are on the list, have major<a href="http://hcrenewal.blogspot.com/search/label/institutional%20conflicts%20of%20interest"> institutional conflicts of interest</a>, and have many people with individual <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a> among their leadership and on their <a href="http://hcrenewal.blogspot.com/search/label/boards%20of%20trustees">boards of trustees</a>.<br /><br />As opposed to the influence of the for-profit industrial part of health care, the influence of government seems muted.  The list included only 6 politicians and 10 government managers.  Some of the politicians are notable proponents of smaller government, e.g. Senator Grassley, and specifically of a smaller role of government in health care, e.g., Governor Bobby Jindal, R, Louisiana.    Nor do unions have much influence.  Only two union leaders were on the list.  There was little counterweight provided to industrial influence from academia, and an almost complete absence of those who might question the current US status quo of dominance of health care by commercial interests.  <br /><br />So here is the latest evidence that US health care is dominated by commercial interests (in an era of <a href="http://hcrenewal.blogspot.com/search/label/regulatory%20capture">regulatory capture</a>, <a href="http://hcrenewal.blogspot.com/search/label/revolving%20doors">revolving doors</a>, and <a href="http://hcrenewal.blogspot.com/search/label/financialization">financialization</a>) and professional, if often generic managers.  This suggests why our health care system seems more about revenue (and thus is very expensive), and less about improving patients' and the public's health.  True health care reform would require increasing the influence of people who have different priorities than the currently most influential.  <br /><br />

What Sorts of People are "Most Influential in Healthcare?"

Modern Healthcare just put out their list of the "100 Most Influential People in Healthcare" for 2013.  A look at what sorts of people are on this list says a lot about who runs US health care, and ra…

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The Door Revolves Again: the Former White House Health Reform Czar Goes to Private Equity Firm Looking for Investments Created by Health Reform

Round and round it goes, and when it will stop, nobody knows.<br /><br /><b>Background: The Former Health Care Reform Czar's Past Career </b><br /><br />It appears that Ms Nancy DeParle, formerly a White House Deputy Chief of Staff, and before then, from 2009 - 2011, the Director of the White House Office of Health Care Reform, has gone through the revolving door again.<br /><br />We raised concerns about Ms DeParle's strong ties to the commercial side of health care at the time she was put in charge of getting health care reform legislation passed (look <a href="http://hcrenewal.blogspot.com/2009/03/meet-new-boss-same-as-old-boss-health.html">here</a>.)  Specifically, her background for shepherding this legislation included being on the boards of directors of three large health care corporations, Boston Scientific, a medical device company, Cerner, a vendor of health care information technology, and Medco, and pharmacy benefits company.   She had previously been on the boards of DaVita, a commercial kidney dialysis care delivery company, and Triad Hospitals, a for-profit hospital system.  At the time, I wondered whether this set of relationships with multiple  health care corporations would lead to "health care reform" that was more about the interests of big health care corporations and their top executives than about us, the people.<br /><br />As it turned out, there is a case to be made that a lot of the health care reform legislation that eventually passed was in the interests of big corporations.  It enabled for-profit <a href="http://hcrenewal.blogspot.com/search/label/health%20insurance">health care insurance</a> companies to continue to dominate the insurance market, and created no "public option" that could have competed with them.  It fostered the development of "accountable care organizations," (ACOs), and thus fostered a wave of <a href="http://hcrenewal.blogspot.com/search/label/concentration%20of%20power">consolidation </a>in the hospital market favoring ever larger hospital systems, including for-profit ones, and the rise of the <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">corporate physician</a>.  It pushed the use of commercial health care information technology without requiring these devices' effects on patients to be rigorously assessed, and with no obvious concerns about the <a href="http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20dangers">risks</a> posed by these systems.  It did nothing to stop concentration of power in health care, nothing to support small private practices, small non-profit hospitals, or non-profit health insurance.  While it required more disclosure of <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a> affecting physicians, it did nothing to reduce them, or to combat <a href="http://hcrenewal.blogspot.com/search/label/deception">deception</a> in health care <a href="http://hcrenewal.blogspot.com/search/label/marketing">marketing</a> and <a href="http://hcrenewal.blogspot.com/search/label/public%20relations">public relations</a>, or to reduce <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulation</a> or <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression</a> of clinical research to serve commercial vested interests, or even to combat blatant <a href="http://hcrenewal.blogspot.com/search/label/health%20care%20corruption">health care corruption</a>. <br /><br /><b>A Brief Stop at a Think Tank</b> <br /><br />At any event, Ms DeParle left the government early this year.  She did not immediately go back to the commercial world, however.  Instead, as <a href="http://thehill.com/blogs/blog-briefing-room/news/276789-obama-policy-deputy-nancy-ann-deparle-to-exit-for-brookings-post">reported</a> by The Hill, she went to a think tank.<br /><br /><blockquote class="tr_bq"><div class="p1">Nancy-Ann DeParle, a White House deputy chief of staff and the president's point person on his signature health care law, is leaving the West Wing to <i>join the Brookings Institution</i>. </div><div class="p1"><br /></div><div class="p2">Brookings president Strobe Talbott announced in a post on Twitter that the longtime Obama staffer would work as a <i>guest scholar</i> for the think tank.</div></blockquote><div class="p2"><br /></div><div class="p2"><b>Through the Revolving Door to Private Equity </b></div><br /><br />That position did not last long, however.  A few days ago, a Wall Street Journal blog <a href="http://blogs.wsj.com/privateequity/2013/08/07/obamas-health-czar-joins-consonance-capital/">announced</a> she was moving again,<br /><br /><blockquote class="tr_bq">As <i>health care-focused private equity firms</i> navigate the nuances of the Affordable Care Act, one such shop, Consonance Capital, has decided to go straight to the source, hiring Nancy-Ann DeParle, the former director of the White House Office of Health Reform.</blockquote><br />So now she will be with private equity, and in particular, with a private equity firm specializing in, of course, health care:<br /><br /><blockquote class="tr_bq">Consonance has been out targeting between $350 million and $450 million for its debut fund.<br /><br />The fundraising effort appears to have gained traction in recent months. LBO Wire reported in February that the firm had raised $30.3 million for Consonance Private Equity PV LP.  According to a person familiar with the fundraising, the vehicle has gathered as much as $200 million so far from investors including Ohio Public Employees Retirement System, Travelers Insurance and LGT Group.<br /><br />The fund is earmarked for <i>buyouts and recapitalizations of health-care providers, payors, pharmaceutical and specialty distributors and device manufacturers</i> with between $20 million and $150 million in annual revenue.</blockquote><br />Finally, it seems Ms DeParle will be suited to this new employment opportunity since she knows so much about how the new supposed health care reform will create investment opportunities,<br /><br /><blockquote class="tr_bq"> Ms. DeParle said the <i>changing regulatory environment will give rise to a host of new investment opportunities.</i> 'There’s a lot that’s changing in health care,' said Ms. DeParle. 'There will be millions of new customers for hospitals and health care providers, much stronger demand for health care services....'</blockquote><br /><b>Summary </b><br /><br />So to recapitulate, Ms DeParle came from roles as a steward of multiple large health care corporations to lead the health care reform efforts of the executive branch.  In that capacity, she helped to create and enact legislation that she would later say created many "new investment opportunities."  Now, as the legislation is going into operation, she has spun over to private equity to take advantage of these opportunities.<br /><br />This seems to be a great example of why the revolving door is bad for government, health care, and the American public.  People in responsible government positions, in which they are supposed to represent all the people, may be constantly thinking about impressing those who might employ them in the private sector when they leave government service.  What better way to impress these potential employers than to take actions which may later improve these companies'  commercial prospects, whatever effect they may have on us, the people?<br /><br />I am no political scientist, but in my humble opinion, there should be multi year cooling off periods before someone who worked in the commercial world can get a job in a government agency whose work has direct effect on his or her previous employer or industry sector, and before someone who worked in a government agency whose work had direct effect on a particular economic sector can accept a job for a company in that sector.  Now that would be a real reform. 

The Door Revolves Again: the Former White House Health Reform Czar Goes to Private Equity Firm Looking for Investments Created by Health Reform

Round and round it goes, and when it will stop, nobody knows.Background: The Former Health Care Reform Czar's Past Career It appears that Ms Nancy DeParle, formerly a White House Deputy Chief of Staff…

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Is the Patient Centered Outcomes Research Institute Really More Industry-Centered?

One of the biggest reasons our health care system seems so dysfunctional is that clinicians and patients have great difficulty determining what might be the appropriate management of particular clinical problems.  Due to endless and sometimes <a href="http://hcrenewal.blogspot.com/search/label/deception">deceptive</a> marketing,<a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest"> conflicts of interest</a> affecting health care professionals and academics, and <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulation</a> and <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression </a>of clinical research, making truly evidence based decisions that put individual patients interests first has become very difficult.  Instead, we may end up using excessively expensive, relatively ineffective, and more dangerous than anticipated drugs, devices, and diagnostic and therapeutic strategies, thus leading to poor patient outcomes and high costs.<br /><br /><b>Background - the Patient-Centered Outcomes Research Institute (PCORI)</b><br /><br />One lingering hope has been that better clinical research, particularly focusing on the outcomes that are most important to patients (patient-centered outcomes), and comparing clinical strategies that may be widely used but poorly evaluated (<a href="http://hcrenewal.blogspot.com/search/label/comparative%20effectiveness%20research">comparative effectiveness research</a>) would help dissipate the fog.  An attempt to promote such research in the US appeared in our recent health reform legislation, the Affordable Care Act.  It authorized the creation of the <a href="http://www.pcori.org/">Patient Centered Outcomes Research Institute </a>(PCORI).<br /><br />However, as we <a href="http://hcrenewal.blogspot.com/2010/03/health-care-reform-bill-and-health-care.html">observed</a>, how good a solution this would be would depend on the details.  Our concerns were that PCORI, which is an independent although government sponsored institute, not a government agency, might be too beholden to "stake-holders" including the large organizations, device and pharmaceutical companies, insurance companies, hospital systems, etc, that already dominate health care and may promote their and particularly their executives' interests ahead of patients.<br /><br />Recently, Merrill Goozner, the editor of Modern Healthcare, <a href="http://www.modernhealthcare.com/article/20130427/MAGAZINE/304279990">raised similar concerns</a>,<br /><br /><blockquote class="tr_bq">there is the law's requirement for stakeholder boards to set PCORI research priorities. They must include representatives of researchers, clinicians, patients, providers, insurers, employers and industry. <i>The interests of those groups are not the same. Priority-setting by stakeholder boards could turn into a prescription for steering clear of the most controversial, and therefore most significant, questions.</i></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br />So,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq">There is no shortage of drug and device firms, specialty hospitals and medical specialty societies with a vested interest in leaving certain questions unasked or muddying the waters with methodological quibbles. <i>They shouldn't be allowed to hijack or soften the agenda.</i></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div></div><br />PCORI is now in operation, but has seemingly not gotten a lot of scrutiny. What scrutiny it has received as not allayed these concerns.<br /><br /><b>The PCORI Advisory Panels</b><br /><br />Recently, the publication of the membership of four key advisory panels for PCORI got the attention of  Michael Millenson, <a href="http://thehealthcareblog.com/blog/2013/04/05/why-the-pcori-picks-matter/">blogging on</a> the Health Care Blog.  He noted that initially the members of the panels were identified only by name and city of residence, without any information on their other affiliations or characteristics.  He suggested,<br /><br /><blockquote class="tr_bq"> PCORI isn’t a church, where all are created equal in the eyes of God, but <i>a politically created, politically governed, controversial dispenser of a very large amount of money that a host of interest groups would like to control.</i> PCORI staff chose the panel members in part by looking at their affiliations, and those connections (or lack of them) should be an immediate part of the public record when the appointments are announced. <i>By being vague, PCORI obfuscates political and power relationships and makes it more difficult for the public and industry stakeholders to either approve of or criticize those choices.</i></blockquote><br />Eventually, PCORI did release somewhat more information on membership of these panels, on <a href="http://www.pcori.org/get-involved/pcori-advisory-panels/advisory-panel-on-addressing-disparities/">Addressing Disparities</a>, <a href="http://www.pcori.org/get-involved/pcori-advisory-panels/advisory-panel-on-assessment-of-prevention-diagnosis-and-treatment-options/">Assessment of Prevention, Diagnosis, and Treatment Options</a>, <a href="http://www.pcori.org/get-involved/pcori-advisory-panels/advisory-panel-on-improving-healthcare-systems/">Improving Healthcare Systems</a>, and <a href="http://www.pcori.org/get-involved/pcori-advisory-panels/advisory-panel-on-patient-engagement/">Patient Engagement</a>.  Mr Millenson was able to review the membership of one panel, and noted some strange anomalies in a comment to his original blog post. <br /><br />One panel member who supposedly represents "patients, caregivers, and patient advocates" had a full time position with a pharmaceutical company.  Another worked for a big consumer organization which is heavily funded by the pharmaceutical industry. <br /><br />This raised concerns that PCORI may get guidance from people whose interests are actually different from those they are supposed to represent. <br /><br />Therefore, I attempted to review the stated affiliations of all PCORI advisory panels.<br /><br />Review of the what was made public about the membership of the advisory panels revealed several additional important anomalies.  Members said to be representing "patients, caregivers, and patient advocates" appeared to have positions working for organizations who might have their own, and different interests from the group they were supposed to be representing.  <br /><br />Let me summarize the apparent anomalies by advisory panel.  In each case, in alphabetical order by panel,  I will list the panelists name, supposed representation, and affiliation, with my comments.  <br /><br /><u>Addressing Disparities</u><br /><br />Monique Carter MS - Dallas, TX<br />representing: patients, caregivers, and patient advocates<br />affiliation: <i>Senior Research Scientist, AROG Pharmaceuticals Inc</i><br /><br />So this person would appear to be more of an industry (pharmaceuticals) representative.<br /><br />Venus Gines, MA, P/CHWI - Manvel, TX<br />representing: patients, caregiver, and patient advocates<br />affiliation: <i>Instructor, Chronic Disease Prevention and Control Research Center, Department of Medicine, Baylor College of Medicine</i><br /><br />So this person appears to be more of a clinician, or health system representative<br /><br />Doriane C Miller MD - Chicago, IL<br />representing: patients, caregivers, and patient advocates<br />affiliation: <i>Director, Center for Community Health and Vitality, University of Chicago Medical Center</i><br /><br />So this person also appears to be more of a clinician, or health system representative.<br /><br />Carmen E Reyes, MA - Whittier, CA<br />representing: patients, caregivers, and patient advocates<br />affiliation: <i>Center and Community Relations Manager, Los Angeles Community Academic Partnership in Research in Again, UCLA</i><br /><br />So this person appears to be more of a health system representative.<br /><br />Mary Ann Sander, MHA, MBA, NHA - Pittsuburgh, PA<br />representing: patients, caregivers, and patient advocates<br />affiliation: <i>Vice President, Aging  and Disability Services, UPMC Community Provider Services</i><br /><br />So this person appears to be more of a health system representative<br /><br />Deborah Steward, MD, MBA - Jacksonville, FL<br />representing: clinicians<br />affiliation: <i>Florida Blue</i><br /><br />So in summary, this panel included five people who ostensibly represent patients, caregivers, and patient advocates but who actually work for large academic medical centers or health systems, and one who was there to ostensibly represent patients, caregivers, and patient advocates who works for a pharmaceutical firm.  (In addition, one person supposedly representing clinicians apparently works full time for a health insurance company.)<br /><br /><u>Assessment of Prevention, Diagnosis, and Treatment Options</u><br /><br />Karen Chesbrough, MPH - Annandale, VA<br />representing: patients, caregivers, and patient advocates<br />affiliation: <i>Scientific Program Administrator, Foundation for Physical Therapy.</i><br /><br />Note that the <a href="http://foundation4pt.org/get-involved/about/">stated mission</a> of the Foundation for Physical Therapy is that it "supp<span style="font-size: small;"><span>orts the physical therapy profession’s research needs," and the foundation is funded in part by companies that make physical therapy devices and supplies  (look <a href="http://foundation4pt.org/get-involved/partners/">here</a>).  Therefore, this person appears to be more of a representative of clinicians, or perhaps industry (devices).</span></span><br /><br /><span style="font-size: small;"><span>Bettye Green RN - South Bend, IN</span></span><br /><span style="font-size: small;"><span>representing: patients, caregivers, and patient advocates</span></span><br /><span style="font-size: small;"><span>affiliation: <i>Community Outreach Nurse and Associate Director of Advocacy, Alliance for Clinical Trials in Oncology, Saint Joseph Regional Medical Center</i></span></span><br /><br /><span style="font-size: small;"><span>So this person appears to be more of a health system representative.</span></span><br /><br /><span style="font-size: small;"><span>Debra Madden - Newtown, CT</span></span><br /><span style="font-size: small;"><span>representing: patients, caregivers, and patient advocates</span></span><br /><span style="font-size: small;"><span>affiliation:<i> Clinical Applications Systems Analyst, Associated Neurologists</i></span></span><br /><br /><span style="font-size: small;"><span>So this person appears to be more of a clinician representative.</span></span><br /><br /><span style="font-size: small;"><span>Daniel Wall - Spencer, WI</span></span><br /><span style="font-size: small;"><span>representing: patients, caregivers, and patient advocates</span></span><br /><span style="font-size: small;"><span>affiliation: <i>Analyst, Biomedical Informatics Research Center, Marshfield Clinic Foundation</i></span></span><br /><br /><span style="font-size: small;"><span>So this person appears to be more of a clinician or health system representative</span></span><br /><br /><span style="font-size: small;"><span>So in summary, this panel included four people who ostensibly represent patients, caregivers, and patient advocates but who actually work for health systems or clinician organizations, and one of the latter organizations appears to be heavily funded by the medical device and supplies industry.</span></span><br /><br /><span style="font-size: small;"><u><span>Improving Healthcare Systems</span></u></span><br /><br /><span style="font-size: small;"><span>Susan Diaz MPAS, PA-C - Jacksonville, FL</span></span><br /><span style="font-size: small;"><span>representing patients, caregivers, and patient advocates</span></span><br /><span style="font-size: small;"><span>affiliation: <i>Physician Assistant in Liver Transplant, Mayo Clinic in Florida</i></span></span><br /><br /><span style="font-size: small;"><span>So this person appears to be more of a clinician, or health system representative.</span></span><br /><br /><span style="font-size: small;"><span>Anne Sales PhD-  Ann Arbor, MI</span></span><br /><span style="font-size: small;"><span>representing: patients, caregivers, and patient advocates</span></span><br /><span style="font-size: small;"><span>affiliation: <i>Professor, School of Nursing, University of Michigan</i></span></span><br /><br /><span style="font-size: small;"><span>So this person appears to be more of a clinician, or health system representative.</span></span><br /><br /><span style="font-size: small;"><span>Jamie Sullivan MPH - Silver Spring, MD</span></span><br /><span style="font-size: small;"><span>representing: patients, caregivers, and patient advocates</span></span><br /><span style="font-size: small;"><span>affiliation: <i>Director of Public Policy, COPD Foundation.</i></span></span><br /><br /><span style="font-size: small;"><span>Note that the COPD Foundation receives support at least from "</span>Boehringer-Ingelheim/Pfizer Inc. and Grifols" (look <a href="http://www.copdfoundation.org/Home/AboutUs/PartnersSponsors.aspx">here</a>).  .</span><br /><br /><span style="font-size: small;">So this person appears to be at least somewhat an industry (pharmaceutical) representative. </span><br /><br /><span style="font-size: small;">So in summary, this panel includes three people who ostensibly represent patients, caregivers, and patient advocates, two of whom actually work for large health system, and one who works for a foundation with significant pharmaceutical industry support.  </span><br /><br /><span style="font-size: small;"><u>Patient Engagement</u></span><br /><br /><span style="font-size: small;">Stephen Arcona MA PhD - East Hanover, NJ</span><br /><span style="font-size: small;">representing patients, caregivers, and patient advocates</span><br /><span style="font-size: small;">affiliation:<i> Executive Director, Outcomes Research Methods & Analytics, Department of Health Economics and Outcomes Research, Novartis Pharmaceuticals Corporation</i></span><br /><br /><span style="font-size: small;">So this person appears to be more of a researcher, and industry (pharmaceutical) representative. </span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">Marc Boutin JD - Washington, DC</span><br /><span style="font-size: small;">representing patients, caregivers, and patient advocates</span><br /><span style="font-size: small;">affiliation: <i>Executive Vice President and Chief Operating Officer, National Health Council </i></span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">Note that while the National Health Council <a href="http://www.nationalhealthcouncil.org/pages/page-content.php?pageid=53">claims</a> to be an advocate for people with chronic disease and disability, its core membership includes "<span><span style="font-family: Verdana;"><span style="font-family: Times,"Times New Roman",serif;">major pharmaceutical, medical device, health insurance, and biotechnology companies</span>." </span></span>and it receives considerable industry support.  For example, it <a href="http://www.nationalhealthcouncil.org/pages/corporate-partners.php">disclosed</a> contributions in the $100,000 - $300,000 range from Amgen, Astra-Zeneca, Eli Lilly, Novartis, Pfizer, and the Pharmaceutical Research and Manufacturers of America (PhRMA), and smaller but still significant contributions from other pharmaceutical companies and other industry associations.  So this person appears to be at least somewhat of an industry (pharmaceutical) representative.</span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">Charlotte W Collins JD - Elkridge, MD</span><br /><span style="font-size: small;">representing patients, caregivers, and patient adovcates</span><br /><span style="font-size: small;">affiliation: <i>Vice President of Policy and Programs, Asthma and Allergy Foundation of America</i></span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">Note that while the Asthma and Allergy Foundation of America claims to be a patient advocacy organization, it <a href="http://www.aafa.org/display.cfm?id=10&sub=27&cont=250">disclosed</a> financial support from many pharmaceutical, device, and health insurance companies, and from major health care systems</span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">So this person appears to be at least somewhat an industry, health insurance, and/or health system representative.</span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">Amy Gibson, RN MS - Washington, DC</span><br /><span style="font-size: small;">representing patients, caregivers, and patient advocates</span><br /><span style="font-size: small;">affiliation: <i>Chief Operating Officer, Patient-Centered Primary Care Collaborative (PCPCC)</i></span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">Note that the PCPCC has an <a href="http://www.pcpcc.net/executive-members">executive committee</a> that includes multiple pharmaceutical, device, and health insurance companies, and health systems.  So this person appears to be at least somewhat an industry, health insurance, and/or health system representative.</span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">Julie Ginn Moretz - Augusta, GA</span><br /><span style="font-size: small;">representing patients, caregivers, and patient advocates</span><br /><span style="font-size: small;">affiliation: <i>Associate Vice Chancellor, Patient- and Family-Centered Care, University of Arkansas for Medical Sciences</i></span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">So this person appears to be more of health system representative.</span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">Sara Triagle van Geertruyden - Washington, DC</span><br /><span style="font-size: small;">representing patients, caregivers, and patient advocates</span><br /><span style="font-size: small;">affiliation: <i>Executive Director, Partnership to Improve Patient Care (PIPC)</i></span><br /><span style="font-size: small;">(Note: this affiliation appears incomplete.  Sara van Geertruyden is <a href="http://thornrun.com/contact">listed</a> as <i>a <a href="http://thornrun.com/sara-van-geertruyden">current partner </a>of Thorn Run Partners,</i> a <a href="http://thornrun.com/">lobbying firm</a>, with a major <a href="http://thornrun.com/practice-areas">practice area</a> in health care, boasting, "Thorn Run Partners offers one of Washington, DC’s most comprehensive, competent and effective health policy practices."</span><br /><br /><br /><span style="font-size: small;">Note also that PIPC has <a href="http://www.improvepatientcare.org/pipc-member-list-0">membership</a> that includes many specialty physician societies, and a <a href="http://www.improvepatientcare.org/steering-committee">steering committee</a> that includes the Biotechnology Industry Organization, and PhRMA.  </span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;"><span>So this person appears to be more of an industry (pharmaceutical and biotechnology) representative.</span></span><br /><br /><span style="font-size: small;"><span>So in summary this panel includes six members who ostensibly represent patients, caregivers, and patient advocates, but who work for either patient advocacy organizations that get considerable industry support, or a health system, or a pharmaceutical company.  One person whose affiliation was listed as a patient advocacy organization also somehow appears to be a full-time lobbyist.   </span></span><br /><br /><span style="font-size: small;"><span><b>Summary </b></span></span><br /><span style="font-size: small;"><span><br /></span></span><span style="font-size: small;"><span>While PCORI has set up advisory panels that seem to strongly emphasize representation of patients, caregivers, and patient advocates, a substantial fraction of the people who are supposed to provide this representation seem to work for patient advocacy groups with considerable industry support, or directly for industry or health care systems.  Some of them may work as clinicians or researchers, but many appear to have high level executive positions with these organizations.  One appears to be a full-time lobbyist at a firm that has a strong health care practice.  </span></span><br /><span style="font-size: small;"><span><br /></span></span><span style="font-size: small;"><span>Thus it appears that PCORI advisory panels actually may be as much about the interests of big health care organizations, including pharmaceutical and device companies, health insurance companies, and large hospital systems, as they are about patients, caregivers, or patient advocates.  </span></span><br /><span style="font-size: small;"><span><br /></span></span><span style="font-size: small;"><span>I am afraid my and Merrill Goozner's original fears that PCORI may end up being more about industry-centered interests than patient-centered outcomes may not be paranoid.  I do hope that PCORI leadership manages to put improving patients' and the public's health ahead of making industry executives happy.  </span></span><br /><span style="font-size: small;"><span><br /></span></span><span style="font-size: x-small;"><span style="font-size: small;">by Roy M. Poses MD, for Health Care Renewal</span></span>

Is the Patient Centered Outcomes Research Institute Really More Industry-Centered?

One of the biggest reasons our health care system seems so dysfunctional is that clinicians and patients have great difficulty determining what might be the appropriate management of particular clinic…

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Why Did the "Dean of Health Care Economics" Urge Reforms that "Appeal to Some Special Interests?"

We have often discussed, some would say belabored, the importance of the "<a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>" in health care.  Particular issues which would make those who benefit the most from our current dysfunctional health care system uncomfortable are often considered not to appropriate for polite conversation.  <br /><br />A prominent recent article in JAMA provided a great example of  how there are certain topics that health care, services, and policy experts avoid discussing.<br /><br /><b>Summary of the Article </b><br /><br />The article was by Victor R Fuchs, who has been <a href="http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html">called</a> the" dean of health care economics."  His topic was why US health care is so expensive compared to those in other countries, but provides little additional value for the extra expense.  [Fuchs VR. How and why US health care differs from that in other OECD countries.  JAMA 2013; 309: 33-34.  Link <a href="http://jama.jamanetwork.com/article.aspx?articleid=1555142">here</a>.]<br /><br />His explained the differences as follows:<br />-  "US individuals appear more distrustful of government...."  Thus presumably they shun government operation of health systems, which can lead to lowering administrative costs, and more effective negotiating "with drug companies and physicians and to control investment in hospitals and equipment."<br />-  "reluctance to achieve more equal outcomes for the population through redistributive public policy."  He attributed this to attitudes stressing personal responsibility for success, and the heterogeneity of the population leading to decreased sympathy to those who are unfortunate but "whose identity may differ greatly from one's own."<br />- "the opposition [to health care reform] of 'special interests,' such as pharmaceutical and device manufacturers, physicians (especially those in high-income specialties), and hospitals."  He noted that other countries have special interests, but attributed the power of US special interests to the country's system of government, especially "checks and balances," which provide "'choke points' for special interests to block or reshape legislation."<br /><br />He ended with three policy prescriptions for more and better health care reform:<br /><br /><br />-  "government's role should be limited to what is necessary, not just desirable."<br />-  "provision of basic coverage for all should not require equality for obtaining additional coverage."<br />-  "reform should have features that would appeal to some special interests, or to some elements within each special interest group (for example, some physicians or some health plans."<br /><br /><br />I believe this essay, because it is in a prominent journal and by the supposed dean of US health care economists, provides a good example of some of the things that ail the discussion of health care policy. First, the author made rather cavalier use of evidence to support his points.  Second, he avoided even mentioning any of the unpleasant issues we discuss on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>.  Third, he not only failed to challenge any of those who benefit the most from the current system, but also suggested further appeasement at least of some of them.<br /><br /><b>Cavalier Use of Evidence</b><br /><br />Prof Fuchs' justification for the role of distrust of government was based on a rather casual review of American history, and a single survey.  In fact, the proportion of people who appear to trust the government appears to depend on who asks the question and how it is asked.<br /><br />For example, <a href="http://www.gallup.com/poll/157700/trust-state-local-governments.aspx">Gallup polling</a> from 1998 to 2012 showed from 65% to 80% of people expressed “a great deal/ fair amount of trust in state and local government.” <a href="http://www.gallup.com/poll/157673/americans-trust-government-handling-problems.aspx"> Gallup polling</a> from 1997 to 2012 showed from 51% to 83% of people had “a great deal” or “fair amount” of “trust in federal government to handle international problems.”  On the other hand, the <a href="http://www.people-press.org/2010/04/18/public-trust-in-government-1958-2010/">Pew Research Center for the People and the Press</a> showed public trust in government peaking at nearly 80% during the administration of President Johnson, then precipitously declining, rarely exceeding 50% over the ensuing years, and now around 20%. Furthermore, although Prof Fuchs argued that distrust of government is uniquely American, he provided no data comparing such poll results from the US with those from elsewhere.<br /><br />Nor did he compare results of polls about trust of the government with those about trust of other organizations involved in health care.  However, while people in the US may be distrustful of government, polling shows even bigger distrust of health care special interests (like pharmaceutical companies and health insurance).    While <a href="http://trust.edelman.com/trust-and-health/">Edelman</a> marketing showed relatively constant trust in the pharmaceutical industry at around 50% from 2009-2012), a <a href="http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/648/ctl/ReadCustom%20Default/Default.aspx">Harris Interactive 2010 poll</a> showed that only about 10% of people thought the pharmaceutical industry was honest and trustworthy from 2003 to 2010, while health insurance companies and managed care companies were trusted by even fewer.<br /><br /><b>Avoiding Unpleasant Issues</b><br /><br />While Prof Fuchs acknowledged the role of "special interests," he avoided mentioning how these special interests might negatively affect health care, and thus how their role could be altered or countered.<br /><br />Some issues we discuss on Health Care Renewal, but which he ignored were:<br /><br /><a href="http://hcrenewal.blogspot.com/search/label/concentration%20of%20power">Concentration of Power</a><br /><br />We have frequently discussed how health care organizations have grown ever larger, increasing their market power, and hence their ability to command revenue.  Although we often hear arguments that larger organizations are more efficient, this historic excuse of monopolists has little evidence in support.  In fact, large organizations seem mainly efficient in extracting money for the benefit of their insiders.  For a recent discussion of the push toward monopolies that has some health care angles, see <a href="http://www.nakedcapitalism.com/2013/01/lazy-corporate-monopolies-are-why-america-cant-have-nice-things.html">this pos</a>t on Naked Capitalism.    <br /><br /><br /><u>Commercialization of Health Care </u><br /><br />The US seems to be unique in that it allows a larger role for private, for-profit corporations in health insurance and the actual provision of health care.  In the US, many health insurance companies, some hospitals and hospital systems, and many other types of health care providers, like hospices and dialysis centers, are now for-profit.  Furthermore, the physicians who provide direct patient care are more frequently employed by corporations (rather than being in solo or small group practice), and these corporations are increasingly for-profit  (look <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">here</a>).<br /><br />This increase in the provision of health insurance and direct health care by for-profit corporations is a historical change.  Through the 1970s, the American Medical Association declared "<i><b>the practice of medicine should not be commercialized, nor treated as a commodity in trade." </b></i>(Look <a href="http://hcrenewal.blogspot.com/2009/06/why-did-us-physicians-give-up-their.html">here</a>)   In most states, the corporate practice of medicine used to be banned.<br /><br /><br /><u>Commercialization in an Age of</u> <a href="http://hcrenewal.blogspot.com/search/label/financialization">Financialization</a> -<br /><br />This commercialization took place in an era in which economists were advocating that corporate leaders ignore all goals other than increasing "shareholder value" (look <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">here</a>).  This de facto meant increasing short-term stock price and/or revenue.  Clearly focusing only on short-term revenue increased the risk of management that ignored or was even <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">hostile</a> to the health care mission.  The focus on short-term revenue lead to strong incentives for employees to "make their numbers," that is, to achieve financial goals, no matter what it took (see examples <a href="http://hcrenewal.blogspot.com/2011/01/making-their-numbers-examples-of.html">here</a>).  This likely lead to many examples of unethical behavior.  Furthermore, physicians were not immune to such requirements (look <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">here</a>). <br /><br /> <u>Abandonment of Government Regulation </u><br /><br />As was noted in the comments on <a href="http://www.nakedcapitalism.com/2013/01/lazy-corporate-monopolies-are-why-america-cant-have-nice-things.html">the post</a> on Naked Capitalism,enforcement of anti-trust law that could prevent concentration of power has generally been abandoned by recent US administrations.  Furthermore, as we have discussed <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">here</a>, enforcement of laws against fraud, kickbacks, etc have lead to numerous legal settlements, but almost never any penalties against individuals who authorized, directed or implemented such actions within large health care organizations.  Thus, the leaders of health care organizations, particularly large health care corporations, have experienced<a href="http://hcrenewal.blogspot.com/search/label/impunity"> impunity</a>.  In some cases, there has been outright <a href="http://hcrenewal.blogspot.com/search/label/regulatory%20capture">regulatory capture.</a>  Conflicted regulators have proliferated, often through the mechanism of the <a href="http://hcrenewal.blogspot.com/search/label/revolving%20doors">"revolving door."</a><br /><br /><a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">Executive Compensation</a>  <br /><br />Thus protected by such impunity, executives of large health care organizations often have become rich, and seem to be able to do so without any accountability for their organizations' actions.  As noted above, their incentives push them to put short-term financial goals ahead of the health care mission.  Furthermore, another currently fashionable business school doctrine is that health care managers may and perhaps should be <a href="http://hcrenewal.blogspot.com/search/label/generic%20managers">generic</a>, and thus need not know anything about health care, have experience caring for patients, or have sympathy for health care values.  All this has lead to health care management that ignores or even is <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">hostile</a> to the health care mission.  <br /><br /><u>Deception Undermining Clinical Research and Education </u> <br /><br />Furthermore, this impunity and lack of accountability has been correlated with a rising tide of unethical behavior.  In particular, corporations that make drugs and devices have taken over clinical research meant to evaluate their own products.  They have often <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulated</a> research to favor their products, and <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppressed</a> research that even when manipulated does not favor these products.  Thus they have corrupted the clinical research base on which physicians and patients rely to make the best possible health care decisions.  Marketers have launched <a href="http://hcrenewal.blogspot.com/search/label/stealth%20marketing">stealth campaigns</a> that have also included corruption of medical education.  In particular, they have paid influential health care professionals, called <a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">key opinion leaders</a>, to support marketing under the guise of medical education.  Thus distorting health care and medical research and education decision making has distorted decision making, likely leading to increased costs and decreased quality.   <br /><br />Other examples of poor, that is ill-informed, unaccountable, self-interested, conflicted and corrupt leadership are strewn around Health Care Renewal.  He have also shown how the governance of health care organizations often lacks accountability, integrity, transparency, and honesty.  All these problems can lead to increased costs, and decreased quality and access.  Yet almost never do any of these issues make it into polite discussion within health care research and policy circles.<br /><br /><b>Appeasement of Special Interests</b><br /><br />Over eight years of  effort by a few dedicated academic researchers, health care professionals, investigative reporters, whistle-blowers, and watch dog organizations,  chronicled to some extent on this blog and by other bloggers and commentators, has shown bad leadership and governance of, and resulting unethical behavior by health care "special interests."  Yet, the example essay by Prof Fuchs failed to deal with any of these issues.  Instead of discussing how they might be approached, he suggested continuing appeasement of special interests, which would likely make our problems even worse.  Why he ignored all the privileges the leaders of special interest have, and felt the need to treat them even more nicely, remains unclear.  <br /><br />Thus it appears that the anechoic effect is leading to failure to grapple with the real reasons for health care dysfunction, thus ensuring that health care costs will continue to rise while access and quality fall. <br /><br />Real health care reform will first require honest, unflinching consideration of what has gone wrong.  As long as the conversation seeks to avoid offending those who benefit the most from the current system dysfunction, that dysfunction will only get worse.  <br /><br />US President Theodore Roosevelt had the courage to <a href="http://en.wikiquote.org/wiki/Theodore_Roosevelt">challenge the "malefactors of great wealth" </a>who engineered the first gilded age, at the expense of the public at large.  During this second gilded age, will we have the courage to take on the new malefactors of great wealth, including those who benefit from health care's dysfunction?

Why Did the "Dean of Health Care Economics" Urge Reforms that "Appeal to Some Special Interests?"

We have often discussed, some would say belabored, the importance of the "anechoic effect" in health care.  Particular issues which would make those who benefit the most from our current dysfunctional…

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Where is the risk?

That’s the question Thomas Cox, an RN with insurance experience and expertise, says should be asked about any health care financing mechanism.<br /><br />The whole idea of insurance is distributing risk widely so that it can be shared over a wide group of people and thus become manageable. That’s why people need insurance at all, and that’s also why schemes that put too much of the onus on individuals are a very bad idea – as has happened in recent years to a number of people,  the “insured” individual can incur costs that are more than he or she can bear.<br /><br />In general, insurance is most solid when it’s over a larger group. Each major increase in group size distributes the risk further and makes the healthcare financing system stronger. Cox has an <a href="http://www.afn.org/~sfcommed/JSM2011PaperFinal.pdf" target="_blank">interesting paper on this</a> which he presented at an American Statistical Association meeting.<br /><br />In general, large insurers are an order-of-magnitude more sound than small ones, and nationwide insurance systems (such as Medicare) have a distinct actuarial edge over state-based insurance (think, for example, California earthquake). For this reason, it’s a shame that the Affordable Care Act (ACA) has state exchanges as its primary mechanism rather than one single federal exchange; risk dispersal is inferior. <br /><br />Looking at the risk question, there’s a real problem with affordable care organizations (ACOs), which are one of the primary ways the ACA aims to keep down future costs. Essentially, ACOs are a form of capitation, and (Cox maintains and I think he’s right) capitation is essentially a mechanism to push risks down from the insurer or from Medicare to providers. <b><i>Pushing risks to smaller groups is a terrible idea</i></b> and will worsen the system. With ACOs having  smaller covered populations, they are far more subject to being the victim of events they can’t control, whether that’s having a large number of huge-cost, high-needs patients in a single year or having a large number of patients affected by an epidemic or natural disaster.<br /><br /><i><b>Providers are not trained or qualified to manage risk well, nor do they have the financial reserves to do so.  </b></i>Cox calls this <a href="http://www.biomedcentral.com/1472-6939/5/3/comments" target="_blank">“professional caregiver insurance risk.”</a>  Burdening providers with a task they are very ill-suited for is a truly bad idea. As Cox comments:<br /><br /><blockquote class="tr_bq">Pushing risks elsewhere removes the only real function we are paying insurance companies for.  If insurance companies are pushing down their risks elsewhere, we are paying them money for nothing of value. Insurance companies don’t provide healthcare – if they don’t manage risk either, what good are they? Of course, if they can sit there and siphon off profits without taking risks, it may not trouble profit-making insurers . . . but it should trouble the public [if they are] issuing policies, passing the insurance risks on to health care providers, and walking off with guaranteed profits year after year.</blockquote><br />And (particularly for the ACO that has been “unlucky” and has incurred larger-than-expected costs), <b><i>the financial risk can be a force for corruption</i></b>, pushing organizations toward denying care and undertreatment.<br /><br />Of course, with the <u>enormous</u> amount of unnecessary care and overtreatment in the US medical system today, some ACOs may indeed manage to give really good care for quite a while provided they are reasonably lucky. But this is a strategy with diminishing returns (as unneeded care dwindles in amount). At root, pushing down insurance risk to smaller entities is, Cox has persuaded me, a fundamentally flawed direction. <br /><br />And I’ll never look at a health care financing proposal in future without asking myself: <i><b>“Where is the risk?”</b></i>

Where is the risk?

That’s the question Thomas Cox, an RN with insurance experience and expertise, says should be asked about any health care financing mechanism.The whole idea of insurance is distributing risk widely so…

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