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The Lexapro Marketing Plan Was Meant to Promote Marketing (Surprise?)

Last week, Gardiner Harris <a href="http://www.nytimes.com/2009/09/02/business/02drug.html">writing</a> for the NY Times noted that the US Senate Special Committee on Aging had made public part of Forest Laboratories' Fiscal Year 2004 Marketing Plan for the drug Lexapro (escitalopram oxalate), an anti-depressant. The document is available <a href="http://www.nytimes.com/packages/pdf/politics/20090831MEDICARE/20090831_MEDICARE.pdf">here</a>. Review of this plan revealed the marketing department's various activities, including activities that others might have believed were educational, scientific, or had some other high minded purpose. Continuing Medical Education Overall, one "promotional objective" was to "Maintain SRI category leadership in total number of medical education events (including CME symposia, speaker promotion, teleconferences, and peer selling programs)" One "critical issue" was to "increase Med Ed efforts: more sponsorships of CME, increased level of speaker programs, maintain level of teleconferences and peer selling." Under "Marketing Tactics" was a long section on "Continuing Medical Education." It covered various venues for CME such as internet/electronic CME, "sponsoring symposia at major meetings," "regional CME symposia" which would "serve a number of medical specialties," "sponsorhips of scientific sessions," etc Production of Scholarly Articles The "Publications" section of "Marketing Tactics" noted "publications will be geared toward psychiatrists, PCPs, .... Articles will appear in several formats, including original reports, review articles, and journal supplements." Thought Leaders and Consultants Under the "Continuing Medical Education" section of "Marketing Tactics," and then in the "Advisor Relations" section, there were numerous references to what "thought leaders" would do, including - "present new data" at "symposia at major meetings" - act "as advisors to Lexapro in order to obtain critical feedback and recommendations on educational and promotional strategies and tactics." - sit on the "Lexapro Exectuive Advisory Board" to "keep our advisors apprised of the commercial development ... of escitalpram." - sit on the "Primary Care Advisory Board" to "obtain critical feedback and recommendations on educational and promotional strategies and tactics...." Role of Medical Centers Under the CME section of "Marketing Tactics," we see that "academic health centers" would help develop "regional CME symposia." Under the "Sponsorship" section are plans to fund the "Professional Relations Group in their mission of establishing mutually beneficial long-term relationships with appropriate professionals and associations." Specific plans included funding the Department of Psychiatry and Behavioral Sciences at Emory Medical Societies The "Sponsorship section" also noted that these relationships "will also provide the basis for advocacy development and issues management, and will establish an appropriate environment for commercial and policy activities." Under the CME section of "Marketing Tactics, we see that "medical associations and professional societies" would help develop "regional CME symposia" Also in this section is the note that "smaller, more prestigious societis do not accept industry-sponsored symposia." So instead, "sponsorship of a study groups or plenary sessions is recommended. Marketing will work with the professional relations group regarding potential opportunities." Appendix VII, "Professional Associations of Priority" noted funding provided for guideline development by a "collaboration between APA, AAFP and ACP" for "chronic depression in primary care practice;" by AAGP for guidelines for late-life depression; multiple guidelines developed by AMDA; The appendix also noted that Forest supports ACNP "annual programming, and is a founding sponsor of it's newly created International College of Geriatric Pscyhopharmacology (ICGP)," is a "Corporate President's Circle Sponsor of AAFP," became a "corporate sponsor of ACP in FY03," became "a Corporate Sponsor of AMDA for the last few years," Also, it noted that Forest has "expanded its involvement" with APA for "lobbying of State Health Departments...." Disease Advocacy Organizations Also in Appendix VII, Forest was identified as a "Corporate Sponsor of NAMI," a "major Corporate Sponsor of NMHA," and a "major Corporate Sponsor of DBSA." Summary We have often heard from pharmaceutical, biotechnology, device and other health care corporations that they are only involved in education to disseminate accurate information for the good of society. We have often heard from physicians and academics who consult for such corporations that their advice is sought about clinical, scientific, and technical issues. We often hear from academic medical institutions, medical associations and disease advocacy groups that the money they get from such corporations does not influence the content of their educational and scientific work. Yet here we see, in considerable detail, that in the case of one drug company's promotional efforts for one drug, - The marketing plan from the marketing department paid for medical education as a "promotional objective," that is, to market, not to educate. - Thought leaders and consultants were again paid by marketing to market, and sometimes to provide opinions about "promotional strategies" and "commercial development." - Medical associations are funded by marketing "for commercial and policy activities." This suggests that health care corporations develop financial relationships with physicians, academics, academic institutions, medical and professional associations, and disease advocacy groups to support marketing first. This allows the corporations to advance marketing disguised as education, research, and other high-minded and apparently selfless activities by professionals, not-for-profit organizations, and dedicated inviduals. Such marketing, of course, is DECEPTIVE and DISHONEST. It also is in conflict with the professionals' ideals, and the missions of the medical and professional assocations and disease advocacy groups. The physicians, other health care professionals, and not-for-profit organizational leaders involved may rationalize these activities as consistent with their mission and professionalism, but such rationalizations are at best self-delusion. No one knows how representative the Lexapro marketing plans are of the marketing of other drugs, devices and health care services. The only way to find out would be to force many other corporations' marketing plans into public view. The Lexapro documents suggest that society would benefit if many more marketing plans were made public, but that such publication might generate a wave of revulsion about how deceptive marketing of health care goods and services has become, and the extent that health care professionals have betrayed their professional ideals, and academic medical institutions, professional and medical societies, and patient advocacy groups have betrayed their missions. I submit that we will not truly reform health care without making the marketing of health care goods and services honest, getting health care professionals to give up their financial relationships with health care corporations to reclaim their professionalism, and getting academic medical institutions, professional and medical societies, and patient advocacy groups to give up their financial relationships with health care corporations to reclaim their missions. See additional comments on how the marketing plan was meant to promote CME <a href="http://carlatpsychiatry.blogspot.com/2009/09/forests-promotional-objective-use-cme.html">by Dr Daniel Carlat</a> on the Carlat Psychiatry Blog.

The Lexapro Marketing Plan Was Meant to Promote Marketing (Surprise?)

Last week, Gardiner Harris writing for the NY Times noted that the US Senate Special Committee on Aging had made public part of Forest Labo...

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A Solution To Pharma's Repeated Drug Offenses: Incarceration

Some straightforward common sense follows. No spin, no indirection, no excuses: Pfizer has recently paid a $2.3 billion dollar settlement on civil and criminal charges that potent drugs were being improperly promoted (i.e., pushed onto unsuspecting physicians and patients) for uses not approved by the regulatory agencies responsible for such matters. What is the real world meaning of these charges? The meaning is that patients - the final consumers - were ingesting drugs that were not only not indicated, but held possibilities of harming the drug taker. We have seen negative outcomes from these practices before in the form of, for example, children in whom improperly pushed antidepressants caused suicidal thoughts and actual suicide (the teenage daughter of a friend of my mother hanged herself after starting such drugs, resulting in a lawsuit that the parents ultimately won). It demonstrates reckless and malicious disregard for others to tamper with people's lives in this fashion. Perhaps sociopathy is an apt description of such behavior. One wonders about the adverse consequences to patients of this latest round of pharma fraud. Ultimately, those engaging in these practices (usually at the group director or VP level) are doing the following: They are gambling with the lives and well-being of countless patients. In some of these cases, patients will have been harmed; in others, patients will have died. In the former case, the perpetrators of the fraud are facilitators of the injury. In the latter case, the perpetrators are accessories to murder. Fining a corporation is a nearly useless exercise, as ultimately the conversation in the executive offices and Wall Street will be about the <a href="http://www.investors.com/NewsAndAnalysis/Article.aspx?id=505405">cost of doing business</a>, not about crimes or morals. Terminating perpetrating individuals is also not extremely effective in motivating reform, even if terminated with prejudice, if those terminated have already made their fortune. <div>(The $2.3 billion could have been used, in fact, as a war chest to reduce the need for layoffs during economic downturns, like our current one, were it not wasted in paying fines due to the behaviors of unscrupulous executives.)</div><div> The solution to this problem is straightforward. Deal with the individuals involved in the following manner: <div style="text-align: center;"><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMJeiV3peuzXP_OVWQdui0uhnqmvF77W2w9YkrOlwTAFpOgZ9L16lt8mnOwhfGPydqmuM4YnvnbxQu5Yr5KMQng-WL4EobGpr1BDf2w693deGnPiADvBmVLukn2dkZ2F6BM6pF2G1vqnhL/s1600-h/Jail_doors.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5379191722950654450" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMJeiV3peuzXP_OVWQdui0uhnqmvF77W2w9YkrOlwTAFpOgZ9L16lt8mnOwhfGPydqmuM4YnvnbxQu5Yr5KMQng-WL4EobGpr1BDf2w693deGnPiADvBmVLukn2dkZ2F6BM6pF2G1vqnhL/s320/Jail_doors.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 214px;" /></a>Where the executives behind these abuses belong: jail </div> Time in jail for these executives is a needed remedy. The following, however, is the situation we have: <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlM3HQADphppCKx0jG-iHRaW9hyphenhyphenga4rcXPGJOIBqUhJdISSbTmVZX_L6SYtMVzzzS2tMoVwQcy-TlEt1YXNlQSfsEhoXOkVvhs399U-u3LghBgleIELg-MTreXqqLXLhIkQrYYKovW7TGM/s1600-h/get_out_of_jail_free.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5379192350058766658" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlM3HQADphppCKx0jG-iHRaW9hyphenhyphenga4rcXPGJOIBqUhJdISSbTmVZX_L6SYtMVzzzS2tMoVwQcy-TlEt1YXNlQSfsEhoXOkVvhs399U-u3LghBgleIELg-MTreXqqLXLhIkQrYYKovW7TGM/s320/get_out_of_jail_free.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 246px; height: 144px;" /></a> This is inexcusable. Healthcare advocacy groups and relatives of those injured need to lobby for the solution proposed in the first picture: long, stiff sentences for those committing medical fraud and quackery by proxy in the form of these industry abuses. Finally, the Pfizer scenario causes me to ask: Is the leadership of this company competent to manage its operations? Or, is that leadership - for instance a CEO lacking science and biomedical education and experience - an "enabler" of the creative marketing for drugs -- creative advertising campaigns being seen as a virtue in his <a href="http://hcrenewal.blogspot.com/2006/07/pfizer-brings-life-to-my-if-youve-run.html">prior industry</a>? -- SS</div>

A Solution To Pharma's Repeated Drug Offenses: Incarceration

Some straightforward common sense follows. No spin, no indirection, no excuses: Pfizer has recently paid a $2.3 billion dollar settlement o...

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Five million students going back to school are "going Google"

(Cross-posted on the <a href="http://googleforstudents.blogspot.com/2009/09/five-million-students-going-back-to_08.html">Google Students Blog</a>) It's always tough to bid farewell to summer and hit the books again, but for a few million students this back-to-school season, things are looking up. As of this fall, over five million students at thousands of schools in more than 145 countries have "<a href="http://googleblog.blogspot.com/2009/08/going-google-with-google-apps.html#utm_campaign=gonegoogleuni&utm_medium=blog&utm_source=en-ogblog-na-us-edugogoogle_0908">gone Google</a>" and are actively using <a href="http://www.google.com/a/help/intl/en/edu/index.html#utm_campaign=gonegoogleuni&utm_medium=blog&utm_source=en-ogblog-na-us-edugogoogle_0908">Google Apps Education Edition</a> on campus. Since this time last year the number of students using Google Apps on campus has increased by 400%. Because more schools sign up for Apps everyday, we wanted to celebrate the start of the 2009 school year by launching a<a href="http://www.google.com/a/help/intl/en/edu/appsatschool.html#utm_campaign=gonegoogleuni&utm_medium=blog&utm_source=en-ogblog-na-us-edugogoogle_0908"> </a><a href="http://www.google.com/a/help/intl/en/edu/appsatschool.html#utm_campaign=gonegoogleuni&utm_medium=blog&utm_source=en-ogblog-na-us-edugogoogle_0908">new site</a> that shows off some of these schools, provides product tips and tricks, introduces a community discussion forum and more. <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://www.google.com/appsatschool#utm_campaign=gonegoogleuni&utm_medium=blog&utm_source=en-ogblog-na-us-edugogoogle_0908"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5379161785424650018" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYwTy48MYcc1IUzcdpoPJ_OjT2stbUI8QzmjjszckLeyZssxcKokoEmpQgyHvpwoVm9mLDyEr1Gs2dpS2vm-8g9Ob4YTPG-cVrCElsdAMpTTKBWyh20U_aig4OOn1GA1CEDKH9URdY84Vs/s400/cf25nc3h_48ccrqm6fk_b.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 174px;" /></a><div style="text-align: center;">A snapshot of some of the thousands of schools "going Google" this fall. Every location in green indicates Apps users. </div> When you visit the site, you'll also find an interactive map packed with interesting trivia. For example, in addition to the 70,000 students using Apps at Temple University, their 5,000 staff and faculty were given a choice between Gmail and alternative vendor, and over 90% chose to go Google. Or when Kent State first deployed, they saw more than 700 students migrating each hour. And a single admin at Montana State successfully deployed over 30,000 accounts in less than 90 days. Or as we learned in the <a href="http://www.youtube.com/watch?v=PuteocMftek#utm_campaign=gonegoogleuni&utm_medium=blog&utm_source=en-ogblog-na-us-edugogoogle_0908">recent webinar</a> from another school on the map — Notre Dame — they saved $1.5 million by switching to Apps. You can hear their full story in this video: <object height="344" width="425"><param name="movie" value="http://www.youtube.com/v/PuteocMftek&hl=en&fs=1&"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/PuteocMftek&hl=en&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" height="344" width="425"></embed></object> We hope more schools will continue to go Google and bring Apps to their campuses in an effort to improve communication and collaboration while cutting costs and resources. In the meantime, check out <a href="http://www.google.com/a/help/intl/en/edu/appsatschool.html#utm_campaign=gonegoogleuni&utm_medium=blog&utm_source=en-ogblog-na-us-edugogoogle_0908">our site</a> and find out what Apps has done for other schools and what Apps can do for your school — and if you're already a part of the movement, <a href="https://spreadsheets.google.com/a/google.com/viewform?hl=en&formkey=dElDTTBzTjJBejgzUXZFcVJGbHZLT1E6MA#utm_campaign=gonegoogleuni&utm_medium=blog&utm_source=en-ogblog-na-us-edugogoogle_0908">add yourself to the map</a>!<div> Posted by Miriam Schneider and Jason Cook, Google Apps Education Edition team</div>

Five million students going back to school are "going Google"

(Cross-posted on the Google Students Blog ) It's always tough to bid farewell to summer and hit the books again, but for a few million s...

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Pfour Legal Settlements for Pfizer - Why is the Company "Recidivist?"

We recently posted about Pfizer's $2.3 billion dollar settlement with the US government (<a href="http://hcrenewal.blogspot.com/2009/09/pfizers-2300000000-settlement-no-longer.html">here</a>), which we first mentioned six months ago (<a href="http://hcrenewal.blogspot.com/2009/02/pfizer-settles-for-mere-2300000000.html">here</a>). It is worth reviewing what we know about this settlement. We will start with quoted from the article by Gardiner Harris writing <a href="http://www.nytimes.com/2009/09/03/business/03health.html">in the New York Times</a>. We will also use quotes from other articles listed below: A Big Settlement (from the NYT) <blockquote>The pharmaceutical giant Pfizer agreed to pay $2.3 billion to settle civil and criminal allegations that it had illegally marketed its painkiller Bextra, which has been withdrawn. It was the largest health care fraud settlement and the largest criminal fine of any kind ever. </blockquote>The penalties include a very large criminal fine, an even larger civil fine, and a corporate integrity agreement (from the NYT). <blockquote>Under the agreement with the Justice Department, Pfizer will pay a $1.3 billion criminal penalty related to Bextra and $1 billion in civil fines related to other medicines. In addition, a Pfizer subsidiary, Pharmacia and Upjohn, will plead guilty to violating the Food, Drug and Cosmetic Act for its promotion of Bextra. The company has agreed to sign another corporate integrity agreement that requires senior company executives to annually certify legal compliance and mandates that Pfizer post on its Web site many of its payments to doctors. </blockquote>For Specific Unethical and Illegal Activities The activities for which Pfizer incurred the penalties included marketing drugs for "off-label" indications for which the company did not have US Food and Drug Administration (FDA) approval, and other deceptive marketing practices (from the NYT). <blockquote>The government charged that executives and sales representatives throughout Pfizer’s ranks planned and executed schemes to illegally market not only Bextra but also Geodon, an antipsychotic; Zyvox, an antibiotic; and Lyrica, which treats nerve pain. [Acting US Attorney for Massachusetts] Mr. Loucks, the prosecutor, accused Pfizer of aggressive marketing tactics. 'Among other things, Pfizer did the following: Pfizer invited doctors to consultant meetings, many in resort locations. Attendees expenses were paid; they received a fee just for being there,' he said. Such weekend getaways for doctors are still common throughout the drug and medical device industries. </blockquote>Also, <a href="http://www.nj.com/news/ledger/jersey/index.ssf?/base/news-14/1251938706305590.xml&coll=1">per the Newark Star-Ledger</a>, <blockquote> The government said the company promoted four prescription drugs, including the pain killer Bextra, as treatments for medical conditions different from those the drugs had been approved for by federal regulators. Authorities said Pfizer's sales representatives often created phony doctor requests for medical information in order to send unsolicited information to doctors about unapproved uses and dosages. The civil settlement covered Pfizer's promotions of Bextra, blockbuster nerve pain and epilepsy treatment Lyrica, schizophrenia medicine Geodon, antibiotic Zyvox and nine other medicines. The agreement with the Justice Department resolves the investigation into promotion of all those drugs, Pfizer said. The government said Pfizer also paid kickbacks to market a host of big-name drugs: Aricept, Celebrex, Lipitor, Norvasc, Relpax, Viagra, Zithromax, Zoloft and Zyrtec. </blockquote> Pfizer's Previous Unethical Behavior Pfizer has previously been charged with unethical conduct, and the penalties it paid for this conduct did not seem to deter it (from the NYT). <blockquote>It was Pfizer’s fourth settlement over illegal marketing activities since 2002. 'Among the factors we considered in calibrating this severe punishment was Pfizer’s recidivism,' said Michael K. Loucks, acting United States attorney for the Massachusetts district. Much of the activities cited Wednesday occurred while Pfizer was in the midst of resolving allegations that it illegally marketed Neurontin, an epilepsy drug for which the company in 2004 paid a $430 million fine and signed a corporate integrity agreement — a companywide promise to behave. </blockquote> Some more details of these settlements, <a href="http://www.philly.com/philly/business/homepage/20090903_FDA__Pfizer_ignored_warnings__gets_record_fine.html">from the Philadelphia Inquirer</a>, <blockquote>Repeat Offender: Previous Pfizer Settlements April 2007: Pfizer agreed to pay $34.7 million in fines to settle Department of Justice allegations that it improperly promoted the human growth hormone product Genotropin. The drugmaker's Pharmacia & Upjohn Co. subsidiary pleaded guilty to offering a kickback to a pharmacy-benefits manager to sell more of the drug. May 2004: Pfizer agreed to pay $430 million to settle DOJ claims involving the off-label promotion of the epilepsy drug Neurontin by subsidiary Warner-Lambert. The promotions included flying doctors to lavish resorts and paying them hefty speakers' fees to tout the drug. The company said the activity took place years before it bought Warner-Lambert in 2000. October 2002: Pfizer and subsidiaries Warner-Lambert and Parke-Davis agreed to pay $49 million to settle allegations that the company fraudulently avoided paying fully rebates owed to the state and federal governments under the national Medicaid Rebate program for the cholesterol-lowering drug Lipitor. </blockquote> On Health Care Renewal, we have posted about other instances of unethical behavior by Pfizer. Most recently, these included producing allegedly misleading direct to consumer (DTC) advertising about Lipitor (see post <a href="http://hcrenewal.blogspot.com/2008/02/rower-mis-impresses-pfizer-ends-its.html">here</a>), and conducting unethical research in Africa (see post <a href="http://hcrenewal.blogspot.com/2009/08/pfizer-settles-trovan-case-with-kano.html">here</a>). So it appears that Pfizer is, as the prosecutor put it above, recidivist. Why has the company repeatedly behaved unethically? One argument is that company executives have learned that the rewards of unethical behavior exceed its costs (thus, are responding to a form of perverse incentives.) Perverse Incentives Favoring Unethical Behavior The fines paid by Pfizer were not that large for a company of Pfizer's size (from the NYT). <blockquote> While the government said the fine was a record sum, the $2.3 billion fine amounts to less than three weeks of Pfizer’s sales. </blockquote> In lieu of other punishments, the company's managers may just look upon paying fines as the cost of doing business. <a href="http://abcnews.go.com/Health/PainManagement/story?id=8476391">Per ABC News</a>, <blockquote> Industry insiders say drug companies often forgo legal considerations in favor of profit. If companies, people or entities 'are able to make that decision and determine that there's an economic incentive to break the law, they'll break the law,' said Reuben Guttman, attorney for Glen Demott, a former Pfizer drug representative. Change in a financially driven industry depends on whether a few billion dollars of penalty will affect the company's net profits or share costs. In 2008, Pfizer earned $48.3 billion in revenue. </blockquote> Bloomberg commentator Ann Woolner <a href="http://www.bloomberg.com/apps/news?pid=20601039&sid=ahodmf54hyPA">said</a> one reason the penalties have not been stiffer is that somehow the government views the company as too big to fail. <blockquote> So how does Pfizer get away with civil settlements given its history? The penalties have ranged from hand slaps to a light punch in the gut, none of which have hurt the company enough for things to change. Last year Pfizer earned $8.1 billion on sales of $48.3 billion. The New York-based company repeatedly winds up as the target of government accusations. Its misdeeds cost federal and state programs hundreds of millions of dollars, says the Justice Department, not to mention the human suffering that comes with taking the wrong drug in the wrong dosage. But Pfizer is the pharmaceutical equivalent of insurance giant American International Group Inc., which was too interwoven into the global economy to be allowed to fail. Likewise, if Pfizer were convicted of a crime, it would face debarment from federal programs. And that would mean that Medicaid and Medicare patients would have to either somehow pay pocket for vital medicines the company produces or go without. 'You have to balance the desire, an appropriate desire, to punish the company against the harm to patients,' says attorney Kelton. </blockquote> This begs the question about why no people, save for two relatively low level managers, no individuals paid any penalties. The unethical behaviors listed above must have been implemented by scores of line personnel, lead by mid-level managers. They, in turn, were acting at the behest of a hierarchy of managers and executives, culminating in "C-level" officers, lead by the CEO. Finally, these executives all reported, in theory at least, to the board of directors. So almost none of the people responsible for the unethical activities paid any penalty. No individuals had to pay fines, or even lose their jobs, much less face criminal proceedings. Maybe the apparent ability of company personnel, starting with those in the trenches, all the way up through levels of management to the CEO, and thence to the board of directors to act with impunity has lead to a culture of amorality. A Culture of Amorality Some evidence that the culture of the company is pathologic comes from former Pfizer insiders charged that the comany's culture promotes unethical behavior (from the NYT). <blockquote> John Kopchinski, a former Pfizer sales representative whose complaint helped prompt the government’s Bextra case, said that company managers told him and others to dismiss concerns about the Neurontin case while pushing them to undertake similar illegal efforts on behalf of Bextra. 'The whole culture of Pfizer is driven by sales, and if you didn’t sell drugs illegally, you were not seen as a team player,' said Mr. Kopchinski </blockquote> Also, per ABC News, <blockquote>'At Pfizer, I was expected to increase profits at all costs, even when sales meant endangering lives,' Kopchinski said, in a statement. 'I couldn't do that.' </blockquote> In light of the list of unethical behaviors documented above, that company leaders deny any big problems itself becomes a problem (from the NYT). <blockquote>Amy W. Schulman, Pfizer’s general counsel, said that Pfizer had reformed — again. 'The reasons to trust Pfizer are because, as I have walked the halls at Pfizer, you would see that the vast majority of our employees spend their lives dedicated to bringing truly important medications to patients and physicians in an appropriate manner,' she said. </blockquote>Note that the majority of Pfizer employees may be ethical, but all it takes to accomplish unethical behavior is a few people in key leadership positions willingo to direct unethical activities to increase sales and profits, and for their subordinates to be willing to just follow orders. Also, per a <a href="http://www.bloomberg.com/apps/news?pid=20601087&sid=aFFALMOwjfrg">report in Bloomberg News</a>, Ms Schulman added, <blockquote> This gives us a very important opportunity to put final closure on the universe of material open items involving our U.S.-based operations. This is a significant opportunity because it allows Pfizer to return its attention to the things that really should matter most to a biopharmaceutical company, which is the practice of developing innovative medications and bringing them to market in an appropriate fashion. </blockquote> Summary: What is to be Done? So will even a $2,300,000,000 settlement and yet another corporate integrity agreement make Pfizer or any other health care corporation act more ethically? I doubt it. Remember, Pfizer may be a corporation, and thus be before the law a sort of pseudo-person. However, it is not really a person. In this settlement, like others before it, it was people who implemented the behavior, made the decisions which lead to the behavior, and condoned the behavior. The people involved ranged from those in the trenches, through layers of management, to C-level executives, to the board of directors. In my humble opinion, until the people responsible for the bad behavior experience negative consequences from that behavior, they will continue to perform, direct, and condone bad behavior. Finally, I say again that we cannot improve health care until we address this sort of unethical behavior. As reported by ABC News, <blockquote> 'It won't make a dent if the conduct that led to the settlement is not addressed as part of health care reform,' said [Harvard Medical School faculty member Dr Jon]Abramson, who was the expert consultant for the plaintiff attorneys in the Bextra case in 2007. 'The real problem is this behavior is not isolated to Bextra nor Pfizer but in essence is the way the pharmaceutical industry expands the sales of its drugs,' Abramson said. 'Unless health care reform can address misrepresentations, withholding science and control claims made to consumers, Americans will continue to pay too much for health care that is not as effective and is expensive.' </blockquote> PS - According to Bloomberg commentator Ann Woolner, one of the whistle-blowers in this case was a physician who noticed that a Pfizer drug representative was pushing him to use drugs off-label, <blockquote>Pfizer Inc. sales folks had one tough customer in psychiatrist Stefan Kruszewski. He didn’t buy their pitch to prescribe the anti-psychotic drug Geodon to children, a use that hadn’t been approved by federal regulators. Nor did he go for the so-called off-label uses they suggested, such as treating dementia in the elderly. Kruszewski didn’t just say no. He went and checked the research and saw Geodon could have serious cardiac side effects not mentioned by the salesmen, who boasted of its relative safety, according to his lawyer, Brian Kenney. And he noticed that Pfizer was paying his peers to promote the drug to other psychiatrists. But the worst for Pfizer was that Kruszewski didn’t keep it to himself. He found a lawyer, Kenney, who specializes in whistleblower cases, and they took what they had to the government. </blockquote> So to all you physicians out there, this shows that you can succesfully blow the whistle on unethical practices by health care organizations. And you may even make some money doing so. Apparently several of the whistle-blowers in this case will get sizable payments under the US False Claims Act. ADDENDUM (8 September, 2009) - See also comments <a href="http://alison-bass.blogspot.com/2009/09/pfizers-23-billion-fine-is-only-tip-of.html">by Alison Bass </a>on the Alison Bass Blog, and <a href="http://brodyhooked.blogspot.com/2009/09/pfizer-assessed-record-fine-why-we-need.html">by Dr Howard Brody </a>on the Hooked: Medicine, Ethics and Pharma blog.

Pfour Legal Settlements for Pfizer - Why is the Company "Recidivist?"

We recently posted about Pfizer's $2.3 billion dollar settlement with the US government ( here ), which we first mentioned six months ag...

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Hood to Coast 2009

This past Monday, when my co-workers asked me what I did over the weekend, I casually mentioned that I ran a 197 mile race. Thankfully, <a href="http://www.hoodtocoast.com/">Hood to Coast</a> is a relay, so I finished with my legs intact after journeying from <a href="http://maps.google.com/maps?source=s_q&hl=en&geocode=&q=mount+hood&vps=1&jsv=174d&sll=37.0625,-95.677068&sspn=32.80241,80.419922&ie=UTF8&hq=mount+hood+loc:&split=1">Mount Hood</a> to Seaside, Oregon with 11 other Googlers. Team Google One was comprised of Googlers from the AdSense, AdWords and engineering groups. We competed against more than 1,000 other teams, including blazing fast running shoe companies and other tech companies. We kicked off the first leg near the top of Mount Hood at 6:45 pm last Friday, as our first runner barreled down 4,000 feet of elevation. During the relay, each team member ran three legs, varying in distance from three to eight miles. At exchanges, the current runner handed off a snap bracelet baton and cheered on his swiftly departing teammate. When not running, we wolfed down PB&J's, and slept in the vans or in massive congregations of sleeping bags along the road. We started with the sun setting over dramatic gray-blue mountains and ran through the night as reflective vests became fireflies flickering down country roads. We finished at 2:25 pm Saturday afternoon in 19 hours and 40 minutes on the beach where a funk band was laying down some grooves. The time earned us eighth place overall and second place in the corporate division, according to the still <a href="http://www.hoodtocoast.com/documents/HTCresults09.pdf">unofficial results</a> (PDF). In addition to medals, we walked away with sore legs, cross-office friendships and some great stories. <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVQR2v-_BtdJGjNdmXukcN42cpCaqSm8zAnoIlgljlGlzGpD0czR6EfRNoZVSot6DyFrPKLfaFZ-7CLmF21Rg3MtCcxEzJzFV9M2Vjt7lHRx2GnI1CbH4O_vIQuHU-Ul7CU9Kj6_q5SJXz/s1600-h/htc.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5377652440144649474" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVQR2v-_BtdJGjNdmXukcN42cpCaqSm8zAnoIlgljlGlzGpD0czR6EfRNoZVSot6DyFrPKLfaFZ-7CLmF21Rg3MtCcxEzJzFV9M2Vjt7lHRx2GnI1CbH4O_vIQuHU-Ul7CU9Kj6_q5SJXz/s400/htc.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 266px;" /></a>Team Google One pauses for a moment as we prepare to descend Mount Hood Posted by Matt Kane, Associate, Consumer Operations

Hood to Coast 2009

This past Monday, when my co-workers asked me what I did over the weekend, I casually mentioned that I ran a 197 mile race. Thankfully, Hood...

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Captains Outrageous for Cape Anne's Health Care System

While on a brief vacation on lovely Cape Anne, Massachusetts, one of my daily automated Google searches provided an article of local interest. The person nominated to be CEO of the local hospital system had been at the center of controversy while in his previous position as leader of a hospital system in Cincinnatti, Ohio. When I got back, I put some relevant terms into Google, and lo and behold, came up with one of the more complicated and colorful, if unhappy stories about problems with health care leadership and goverance I have seen lately. So, to the tune of "lions and tigers and bears, oh my...." Let me start with some background, and then to try to tell this story chronologically, noting issues as they came into public view. <a href="http://www.beverlyhospital.org/">Northeast Health System </a>is a regional hospital system in northeast Massachusets. It includes Addison Gilbert Hospital in Rockport, BayRidge Hospital in Lynn, and Beverly Hospital. Now bear with me through the amazing details. Leadership Lacking in Transparency The system's leadership seems to have recently inspired more than its share of controversy. Hints about the nature of the leadership problem appeared in <a href="http://www.gloucestertimes.com/puopinion/local_story_108062014.html?keyword=secondarystory">an editorial </a>in the Gloucester (MA) Daily Times in April, 2008. <blockquote> Once again, Northeast Health System, the Beverly-based corporation that owns Gloucester's Addison Gilbert Hospital, is trying to have it both ways. When it wants public support — including public money — it casts itself as serving the public. When it doesn't want the public looking into its affairs, it retreats behind the 'private corporation' wall. That is not acceptable. The latest example is Northeast's refusal to provide statistics on its diversion rate of patients from Addison Gilbert to Beverly Hospital during the past three years. </blockquote> Although the editorial allowed that the diversion statistics might not prove to be that alarming, but <blockquote> If there is not a problem here, the corporation is simply creating needless concern about it by its failure to be forthcoming. Unfortunately, this is a continuing pattern for Northeast CEO Stephen Laverty, who apparently sees no problem with accepting subsidies of $500,000 from the state for two years running — subsidies secured in part through Tarr's efforts — but then ignoring reasonable requests for information about the corporation's operations, specifically as it pertains to Addison Gilbert. Statistics on diversions should not be high-level trade secrets. Laverty must make Northeast more transparent. </blockquote> Doctors Vote No Confidence The pot really started to boil in May, 2008. At that point, as <a href="http://www.boston.com/business/healthcare/articles/2008/05/15/mds_vote_to_rebuff_hospitals_executive/">reported by the Boston Globe</a>, its medical staff voted "no confidence" in CEO Stephen R Laverty: <blockquote> In a private meeting, doctors at Beverly Hospital have taken a vote of no confidence in its chief executive, Stephen R. Laverty, citing frustration with his management. The unusual step, made three weeks ago and acknowledged by hospital officials this week, was prompted by Laverty's alleged lack of communication and support in recent years, said several doctors who attended the April 29 meeting at the hospital. 'There's been a lot of cumulative dissatisfaction with how the physicians have been dealt with over a period of years in a variety of departments,' said Dr. Harriet A. Bering, an oncologist who was at the meeting. 'People had the same frustrations with incidents in which they hadn't been included in the decision-making process.' </blockquote> A vote of no confidence, oh my. The article was not very specific about what lead to such an unusual step, but did note that doctors "accumulated grievances during Laverty's tenure. For instance, they said they were not properly consulted a few years ago when Beverly Hospital ended a successful cancer treatment program with North Shore Medical Center...." So this part of the story points to a hospital system management that does not see the need to communicate with and be transparent to dedicated health care professionals. The Pregnancy Pact In June, 2008, a story about a high school's unexpectedly high pregnancy rate and allegations that girls there entered into a "pregnancy pact" got international attention. The latter allegation was not proven, and although initial coverage did locate the story in Gloucester, MA (e.g., see the <a href="http://www.time.com/time/world/article/0,8599,1815845,00.html">story</a> in Time), the role of Northeast Health System was more obscure. Later we learned, in October, 2008, as <a href="http://www.gloucestertimes.com/punews/local_story_274224500.html?keyword=topstory">reported</a> in the Gloucester Times, <blockquote> Addison Gilbert Hospital risked losing the state grant that pays for the operation of the Gloucester High School Health Center this spring when hospital leaders were reluctant to allow confidential access to birth control at the clinic, according to its former staff. Debate about prescribing contraceptives erupted within a health center advisory board working on a response to the rise in teen pregnancies in Gloucester this year and turned public when the medical director and nurse practitioner resigned because representatives of Northeast Health Systems, the company that owns Addison Gilbert and runs the clinic, would not consider adding confidential prescription of contraceptives to the care offered. </blockquote> A pregnancy pact, oh my. But this part of the story speaks to system management that seems unsympathetic to the concerns of its health professionals. Nurses Vote No Confidence, and Allege a Punitive Culture and Intimidation; Vice President Accused of Art Theft Also in October, 2008, the nurses also voted no confidence, again <a href="http://www.gloucestertimes.com/permalink/local_story_300223052.html">per the Gloucester Times</a> in an editorial that provided more hints about the nature of the system's leadership problems, <blockquote> Conflicts between Northeast Health System CEO Stephen Laverty and his subordinates are, unfortunately, nothing new. By now, in fact, they have taken on a weary familiarity. After persistent rumors of unrest, a group of subordinates goes public with their frustration and resentment of the CEO. This past week, it was the nurses union, with members at both Beverly Hospital and Gloucester's Addison Gilbert Hospital, that took a 'no confidence' vote in Laverty. The union is now trying to pressure the board of trustees to fire him, saying Laverty has created a 'punitive organizational culture (with) ... oppressive management practices.' And a 2005 Beverly Hospital citation by OSHA, which surfaced along with the nurses' discontent, gives credence to that claim. The nurses, of course, are not alone. This past April, it was doctors who took a no confidence vote. In 2006, the Massachusetts Nursing Association filed a formal complaint against Laverty for entering operating rooms unannounced to observe surgeries. Yet, the response from Laverty is always the same — no response. And his spokespeople offer little more than vague references to 'challenges' and 'competing agendas,' concluding with how proud they all are of themselves. </blockquote> The editorial allowed, "It's also true that, in any large business, especially one as competitive as health care, there are sure to be conflicts between management and labor." However, <blockquote> Still, it has to concern the Northeast trustees that every time there is trouble or unrest, Laverty is at the center of it. It should concern them that morale continues to sink under his style of leadership, which most subordinates agree is a mix of arrogance and intimidation. Effective leaders don't assert their authority by demeaning their subordinates. They lead by building people up, not tearing them down. They lead by inspiring, not breeding resentment. The truth is, Northeast still inspires shaky confidence among Cape Ann residents for a variety of reasons, including the corporation's out-and-out refusal to share numbers regarding the number of ambulance transport "diversions" from Addison Gilbert to Beverly — and, more recently, Northeast's stewardship over Addison Gilbert's wonderful endowment of artwork. The recent arrest of a former Beverly Hospital associate vice president — a reported friend of Laverty — on charges of stealing donated art and antiques worth more than $200,000 from the hospital, hardly inspires confidence. And public confidence is one of the most important assets any health care institution has, since its patients are entrusting their health and livelihoods to it. At times like this, when the public starts asking questions about problems, Northeast officials tend to retreat behind the 'private corporation' wall. It is true that Northeast is not part of the public sector. But it regularly seeks donations from the public. It has received at least $1.5 million in state money, supposedly to support its services to the public, but somehow still finds enough money to pay Laverty well more than $600,000 a year. The trustees surely should not take the nurses vote as the only credible word on Laverty. But they need to take it, along with other continuing conflicts, very seriously. </blockquote> Another no confidence vote, a punitive organizational culture and oppressive management, arrogance and intimidation, and art theft, oh my. So here we have much more detail about bad management, punitive, oppressive, arrogant, and ruling by intimidation. We also have allegations of criminal behavior by top managers. Wait, what was that, a vice president of the system arrested for stealing art from it? In November, 2008, the <a href="http://www.boston.com/business/articles/2008/11/05/beverly_hospital_chief_may_step_down/">Boston Globe suggested </a>Laverty's imminent departure, and added more about the art theft. <blockquote> The current situation comes after years of increasing resentment between Laverty and hospital staff. His internal relationships at the hospital were also damaged by his longstanding association with Paul G. Galzerano, Beverly's former associate vice president for support services. Galzerano sometimes argued with staff members, according to longtime employees, and often threatened them based on his close association with Laverty, according to former nurses. Galzerano, who left the hospital last year, was arrested in October by Groveland police, who alleged he stole paintings, a grandfather clock, and furniture from Beverly Hospital. The items were found in his home, according to police, who alleged they were stolen when the hospital was undergoing renovations. Galzerano could not be reached for comment yesterday. </blockquote> Threats by allegedly an art thief, oh my. Birthing Center Threatened with Closure But Laverty's departure did not end the controversy. Also in November, 2008, the Boston Globe <a href="http://www.boston.com/news/health/articles/2008/11/14/birth_centers_possible_demise_ignites_protest/">reported</a>, <blockquote> A proposal to cease all deliveries at the North Shore Birth Center in Beverly - one of only two hospital-affiliated centers statewide that offer natural birth options - has ignited a passionate protest from women across the region. With a debate and potential vote by Beverly Hospital's board of trustees expected Tuesday morning, women have been picketing the hospital, circulating fliers, writing letters to board members, blogging and organizing on Facebook, where more than 500 members have already signed on to the campaign. </blockquote> Service cuts, oh my. After the art work was stolen, the system decided to cut costs by reducing an apparently very popular service. Specialty Service Cuts, Bed Cuts, and Board Conflicts An eloquent <a href="http://www.wickedlocal.com/gloucester/news/opinions/letters/x403281115/Letter-Trying-to-keep-AGH-alive">letter to the Cape Anne Beacon in January, 2009, </a>(and an abbreviated version <a href="http://www.gloucestertimes.com/puopinion/local_story_025224217.html">in the Gloucester Times</a>) by Ms Beverly Quint of Drumlin Road, Rockport, provided much more detail about the legacy of the leadership and governance problems at Northeast Health Systems: <blockquote> Since November, I’ve heard a number of people say on line at the market, or greeting one another for coffee or waiting for a movie to start, 'Thank goodness he’s gone. Now we can get somewhere without the worry.' At first I thought they might be talking about the presidential election, but it became clear that most of them felt that anyone leading the country at this time was not expected to perform feats of magic. Then I wondered if they were talking about Father Time, himself, the old guy with the flowing robe and the long beard. It has, in fact, been a year of plunging confidence and quiet desperation. No, people were talking of neither of these; people were and are talking about the exit of Stephen Laverty, the much-criticized CEO of Northeast Health Systems, the corporation that 14 years ago merged with Addison Gilbert Hospital, our community hospital. I wish I could share my neighbors’ rejoicing at Mr. Laverty’s exit, but I am more worried than ever about the potential loss of our hospital, the lifeline for Cape Ann citizens, isolated as we are from the mainland, connected by two not-always-reliable bridges. Here’s why I’m more worried than ever: When NEHS announced its merger with AGH, it declared that the merger would benefit both parties. Almost immediately, NEHS began to dismantle AGH, service by service. Nor has NEHS ever made available to the community a detailed accounting of its use of $2 million given by the state Department of Public Health for the protection of emergency surgical and anesthesiologist services at AGH. Here it should be added that NEHS has never given a detailed accounting to the community of other sums taken from AGH, in the form of income from investments, real estate and an art collection estimated at $4 million. Having downsized AGH’s bed capacity by refusing to use the beds on Steele Two and having sent patients to Beverly for every or no reason and having closed several departments, what remains in Gloucester is a shell. Even as such, we can still call it our community hospital so long — and only so long — as it provides eight services all under one roof, eight services essential for retaining its license. Now even that status for AGH is at risk. And that is why I am more worried than ever. If those eight services go, we lose all — and now they are being plucked at by NEHS. We are at the tipping point, with or without Stephen Laverty. Let me give you a few examples. One of the eight services essential to our hospital’s survival is the availability of a surgeon 24/7. Instead, NEHS, without announcing it, sends any patient whom they think might need surgery to Beverly Hospital. Till Jan. 1 of this year, we had only one general surgeon based on Cape Ann. Now, again without publicizing it, he will not be available on call for emergency services. The same is true of anesthesiologists. Without publicizing it, NEHS has not recruited anesthesiologists for AGH, even as it has not recruited surgeons for AGH. This, despite the previously mentioned $2 million received from DPH for bolstering those specialties. Availability of hospital beds is another of the eight essential services required for AGH to stay alive, but NEHS refuses to open medical-surgical beds on Steele Two, sending patients away from their families, over the bridge instead. NEHS has also not made an effort to insist that specialists, such as pulmonologists, see hospitalized patients at AGH, but are insisting that patients, instead, be moved to Beverly. As a by-product, this means that patients’ family members — many elderly, many handicapped, many who do not drive —are deprived of a closeness, something that can be emotionally important to patients’ recovery. For starters, the present board of trustees needs to be questioned on the very high percentage of trustees who are physicians and executives employed by NEHS. </blockquote> Cuts in surgical and anesthesia services, cuts in beds, shifting of medical sub-specialty services, and conflicted board members, oh my. So whatever the management is doing, it is not increasing services. Also, Ms Quint's letter suggested that conflicted governance may be enabling bad management. Can It All Be Blamed on the Previous CEO? In <a href="http://www.gloucestertimes.com/puopinion/local_story_238214020.html/resources_printstory">another letter </a>published only last month, in August, 2009, Ms Quint suggested that things had not changed much under an interim CEO, <blockquote> Not only has the Board of Directors of Northeast ignored a petition by 8,000 Cape Ann residents begging Northeast to disclose its plans and make a commitment in writing. Not only has Northeast ignored a petition by Rockport residents at Town Meeting to be more interactive in commitment to this issue. Not only has it ignored Rockport selectmen's request to report at regular meetings to which the public could have input. Not only has it snubbed overtures by state Sen. Bruce Tarr to meet regularly with his Task Force, it has systematically downsized, downsized, downsized Addison Gilbert. Some of this has been ascribed to the particularly tyrannical nature of former Northeast CEO Stephen Laverty. Yet here is a most recent example that belies Mr. Laverty's personality as the supreme cause of the problems. On July 28, Dr. Henry Ramini, interim replacement for Mr. Laverty, spoke to Rockport selectmen on the status of Addison Gilbert. Did you know Dr. Ramini would be there? Nobody seemed to know. Even the selectmen — one of whom, I understand, had been on vacation — seemed unprepared to publicize Dr. Ramini's appearance. What I later learned from people who happened to hear Dr. Ramini was that he is a much kinder, gentler appearing person than his predecessor. However, the content of his presentation was not particularly reassuring: He urged the town of Rockport to be nice to any future doctors who might deign to seek employment here. </blockquote> Again, the suggestion is that there are systemic problems with governance and leadership "An Ugly Set of Facts" And that will bring us up to the story that my automated search produced. The candidate to be the new Northeast Health System CEO also has his issues. Per <a href="http://www.gloucestertimes.com/punews/local_story_242224712.html">the Gloucester Times</a> from August, 2009, <blockquote> The man in line to become the next CEO of Northeast Health System is leaving behind a crumbling hospital system in Ohio that has been plagued by lawsuits and controversy. Supporters of Kenneth Hanover say he does not deserve blame for the breakup of the Health Alliance, a $1.4 billion corporation that he served as president and chief executive officer. But in two court decisions, judges ruled that the Health Alliance and Hanover failed to live up to a legal obligation to act for the benefit of two of its hospitals, improperly used 'enormous sums' of money to fight the lawsuit and gave bonuses to doctors to prevent them from working at those hospitals. 'The record is replete with evidence that the Alliance breached its fiduciary to (The Christ Hospital),' Judge Ralph Winkler wrote in his decision last year for the Ohio Court of Appeals. Considering the turmoil surrounding Laverty's tenure at Northeast Health System, it might seem surprising that the organization would replace him with a man with such a controversial background of his own. The breakup of the Health Alliance became so acrimonious that the Ohio attorney general's office stepped in. In July 2007, in the midst of the legal battle, the chairman of Christ Hospital wrote a letter calling for Hanover to be replaced. Monica Rimai, the interim president at the University of Cincinnati and a former Health Alliance board member, acknowledged that the lawsuit and the breakup constitute 'an ugly set of facts and we lost.' Robert Weigel, chairman of Fort Hamilton Hospital, which is in the processing of withdrawing from the Alliance, said Hanover is "one of the smartest men I know." He also said Hanover has a forceful manner than can rub some people the wrong way. "I have a lot of respect for his abilities and his thinking, but he can be tough to deal with," said Weigel.... </blockquote> An ugly set of facts about the new CEO, oh my. One wonders if the NEHS board had investigated its new CEO candidate's previous performance. On the other hand, maybe the board is most comfortable with CEOs that are "tough [for others] to deal with." Pregnancy pacts, art theft, no confidence votes, punitive corporate culture, threats and intimidation, closed wards and clinics, slashed services, oh my. You just can't make this stuff up. On a slightly more sober note, the curious case of Northeast Health Systems is a good example of how governance and leadership can go wrong, and the downstream effect on health services. Reorganizing the colorful facts above, we seem to start with poor governance, possibly by a conflicted board (per Ms Quint). That board seems most comfortable with aggressive leaders who seem more intent on imposing their will on dedicated, professional staff, rather than working collaboratively, and hiding behind a veil of corporate secrecy, rather than providing the transparency appropriate for a not-for-profit organization whose mission is to to serve the community. Meanwhile, services of all kinds decline, while the community that once supported the organization now regards it with suspicion and alarm. The current debate about health care reform has focused - to the extent it has focused on anything - on financing and insurance. As we have said many times before, we cannot fix the health care crisis simply by changing financing mechanisms or money flows. We can only improve health care by improving the leadership and governance of health care organizations, and by rethinking the size and scope of health care organizations. The most crucial part of health care is what goes on between individual health care professionals and individual patients. Yet our system is composed of endlessly enlarging bureaucracies run by self-interested, often clueless, and sometimes dishonest, if not criminal leaders. This must change, unless we want this crisis to get much, much worse. The title of this post is a weakly satirical bow to the Rudyard Kipling novel set partially in Gloucester, MA.

Captains Outrageous for Cape Anne's Health Care System

While on a brief vacation on lovely Cape Anne, Massachusetts, one of my daily automated Google searches provided an article of local interes...

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Helping create responsible digital citizens

With more and more kids going online, whether to connect over social networking sites, mingle in chat rooms or play games, it's become increasingly important for families, schools and service providers to work together to ensure that the younger generation understands their responsibilities while they explore the virtual world. A few weeks ago, Google participated in the <a href="https://www.cacconference.org/">21st Annual Crimes Against Children Conference</a> in Dallas, where over 3,500 members of law enforcement, child advocacy groups, the tech industry and the <a href="http://www.missingkids.com/">National Center for Missing and Exploited Children</a> (NCMEC) convened to share ideas, discuss strategies and explore new technologies designed to combat the many and varied forms of crimes against children. We had the opportunity to describe some of the positive steps Google is taking to <a href="http://googlepublicpolicy.blogspot.com/search/label/Child%20Safety">educate and safeguard minors</a> who use our products and services, as well as the unique ways we support the individuals on our staff who do child exploitation-related work. According to a recent NCMEC study in patterns and trends in online child victimization, the past few years have seen a 6% increase in reports of kids providing images and videos of themselves when asked by online acquaintances; sending naked photos of themselves through text messages ("sexting"); and cyber-bullying. This new trend underscores the need to <a href="http://googlepublicpolicy.blogspot.com/2009/07/best-practices-for-online-child-safety.html">educate</a> our younger users, their families and teachers on ways to create and enjoy safe online experiences. We're doing our part by working with child safety organizations and law enforcement around the globe to spread positive messages about life online. For example, in mid-September, we're launching a global training program on YouTube to help teens teach other teens about these issues. This is just one step among many that we're taking to help create a generation of responsible digital citizens. Posted by Alice Wu, Policy Specialist, YouTube

Helping create responsible digital citizens

With more and more kids going online, whether to connect over social networking sites, mingle in chat rooms or play games, it's become i...

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