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Talking Points, Sans Original Thought, to Justify Million Dollar Hospital CEO Compensation

Generous pay given to health care leaders has become an area of interest in the media.  Some recent regional stories had a certain dreary sameness, however.  It seems that nearly everywhere in the US, million dollar CEOs have become commonplace at non-profit hospitals and health care systems.  Atlanta, Georgia Region In July, the Atlanta Journal Constitution <a href="http://www.ajc.com/news/atlanta/hospital-ceo-pay-has-997155.html">reported</a> on the compensation given to some regional hospital leaders.  It included the usual gaggle of million dollar CEOs: <blockquote>Edward Bonn of Southern Regional Health System, which operates Southern Regional Medical Center and two affiliated facilities, made $2,610,175 in fiscal 2009. Bonn left the system that year and received his pay of $421,822 plus $2.2 million from a retirement plan. Hospital CEOs commonly receive extra pay from retirement plans when they leave.</blockquote>and <blockquote>In fiscal 2009, John Fox of Emory Healthcare made $1,671,999 to manage Emory University Hospital and five associated institutions. Tim Stack of Piedmont Healthcare, who manages Piedmont Hospital and three others, made $1,340,974 the same year</blockquote> There were two other million dollar CEOs that the article did not name. The State of Georgia Last month, Georgia Health News published a <a href="http://www.georgiahealthnews.com/2011/08/high-ceo-pay-common-hospitals-statewide">story</a> on other highly paid hospital leaders. In general, <blockquote>Georgia Health News has found that executives at nine other Georgia nonprofit hospitals or health systems outside metro Atlanta received at least $1 million in total compensation during their organizations’ most recent fiscal year</blockquote> Some specifics: <blockquote>Ken Beverly, former CEO and president of Archbold Medical Center, a four-hospital system based in Thomasville, who received $6.2 million in fiscal 2009. The health system told Atlanta Unfiltered that most of that compensation related to Beverly’s retirement benefits, accumulated over many years of service.</blockquote>Also, <blockquote>The Gainesville [Northeast Georgia Health] system, which has 5,000 employees, paid CEO James Gardner $1.4 million in total compensation in fiscal 2009.</blockquote>Furthermore, <blockquote>** The Medical Center of Central Georgia paid Donald Faulk, its CEO, $1,003,412 in fiscal 2009. Faulk has been CEO of the Macon hospital since 1995, and has been employed there for 37 years.</blockquote><blockquote>** Larry Sanders, CEO of Columbus Regional Healthcare System, received compensation of $2.2 million in fiscal 2010, with $1 million of it a payout of a supplemental retirement benefit called a split-dollar life insurance policy. Sanders has worked in that system, which includes the Medical Center in Columbus, for 30 years. ** Jack Drew, with 29 years of service at Athens Regional Medical Center, received $1,185,902 in fiscal 2009.</blockquote><blockquote>** University Health in Augusta paid CEO Larry Read $3.5 million in fiscal 2009, with the majority coming as payment of his retirement benefit. Read retired last year. ** Joel Wernick, longtime CEO at Phoebe Putney in Albany, received $1.3 million, with part of it a one-time deferred compensation payment, in fiscal 2010. ** Kurt Stuenkel, CEO of Floyd Medical Center in Rome, received $1.35 million in compensation in fiscal 2010. ** At St. Joseph’s/Candler in Savannah, Paul Hinchey received $1,053,390 in total compensation in fiscal 2010.</blockquote> Madison, Wisconsin Region Madison.com <a href="http://host.madison.com/wsj/news/local/health_med_fit/article_c9e10fae-d174-11e0-93ad-001cc4c002e0.html">discussed</a> the area's highest paid hospital CEOs. They included: <blockquote>Javon Bea, CEO of Janesville-based Mercy Health System, made $3.6 million in total compensation in 2009 and $4.5 million the year before. The system has hospitals in Janesville, Lake Geneva and Harvard, Ill.</blockquote> Columbus, Ohio Region Columbus Business First <a href="http://www.bizjournals.com/columbus/blog/2011/08/hospital-ceo-pay-shows-wide-disparity.html">noted</a> compensation of regional hospital systems, including: <blockquote>By far the highest paid was Dave Blom, CEO of Columbus-based OhioHealth Corp ., at $1.8 million. About $675,000 of that total is deferred compensation. Among chiefs, he’s followed by Dr. Steve Allen of Nationwide Children’s Hospital at $1.2 million,...</blockquote> Furthermore, the justifications for these pay packages uncovered by reporters in different parts of the country also had a certain sameness.  They were actually so similar as to suggest they came from a common set of talking points generated by a common public relations effort.  We Pay What Everyone Else Pays In Atlanta, in general: <blockquote>Atlanta hospital boards have compensation committees of community leaders to ensure executive salaries meet Internal Revenue Service guidelines and are competitive with salaries offered by other medical facilities.</blockquote> Also, <blockquote>All of the tax exempt hospitals in the area issued statements asserting their CEO’s compensation is vetted by their boards and in line with industry standards....</blockquote> In Georgia <blockquote>Hospital boards 'have to pay market rates in order to attract talent,' said Glenn Pearson, Georgia Hospital Association executive vice president. CEO salaries in Georgia 'appear to be very much in line with national trends,' he said.</blockquote> In Columbus, Ohio <blockquote>Hospital trustees set compensation after studying comparable positions in both the nonprofit and for-profit sectors.</blockquote> CEOs Work Hard and are Brilliant, so They Deserve High Pay In Atlanta, in general: <blockquote>Industry representatives say these pay packages ensure communities get the best possible care by attracting the few people capable of administering these complex organizations.</blockquote> Also, <blockquote>Pay in excess of $1 million a year may seem high for an organization subsidized by taxpayers, but hospital executives and industry representatives said the public should think of these hospitals not as charities, but as complex, billion-dollar organizations. Georgia hospitals report to 27 state and federal agencies and engage in multimillion-dollar building projects. The larger hospital systems have billions in revenue and are among the largest employers in their communities. Many also operate for-profit subsidiaries. 'You can’t lose sight of the fact that it’s not an ice cream shop on the side of the street,' said Joseph Parker, president of the Georgia Hospital Association.</blockquote> In Georgia as a whole, <blockquote>GHA added that hospitals are accountable to 27 state and federal agencies, while dealing with tight Medicaid reimbursement and an increasing number of uninsured people.</blockquote> In Madison, Wisconsin, <blockquote>health care has become much more complicated than when Catholic nuns ran many nonprofit hospitals while taking vows of poverty, said [Integrated Healthcare Strategies vice president David] Bjork, the health care consultant. He said today's hospital executives struggle to keep their complex enterprises afloat, dealing with independent doctors who make many of the key financial decisions while being largely unable to predict when patients need services.</blockquote> High Pay is Needed to Attract and Retain Competent, If Not Brilliant People In Atlanta, <blockquote>The number of people who can manage these facilities is limited and recruitment is competitive, Parker said. Qualified leaders will gravitate to other fields over time if compensation for nonprofit CEOs is decreased, [Mercer Inc pay consultant Jose] Pagoaga said. The 'substandard leadership' that replaces them will degrade the quality of medical care for the community.</blockquote> In Georgia, <blockquote>The pay decision is made by community leaders who serve on hospital boards, Pearson said. Those board leaders want to make sure they 'have the person of the highest quality,' given the challenging financial times that hospitals face, he said.</blockquote>Furthermore, <blockquote>It’s a competitive market nationally for the top people, said Kevin Talbot, a vice president of the [Integrated Healthcare Strategies consulting] firm.</blockquote>Also, <blockquote>Boards of Georgia nonprofit health systems responded to GHN that the compensation is needed to attract and retain talented executives. </blockquote>In particular, <blockquote>'Establishing and maintaining competitive executive compensation is critical to our ability to ensure that we have a highly competent and effective leader at the helm, and it is a responsibility that our board does not take lightly,' said Mary Lynn Coyle, chairman of the board of Northeast Georgia Health System.</blockquote>Finally, <blockquote>'This is a field where there's a great demand for talent,' said Nancy Anderson, chairman of the board of the Medical Center of Central Georgia.</blockquote> In Madison, Wisconsin, <blockquote>But large hospitals such as those in Madison have to pay top dollar to attract people with the skills to manage them, said David Bjork, senior vice president of the Minneapolis-based consulting firm Integrated Healthcare Strategies. 'Running a hospital is probably the toughest management job that exists,' Bjork said.</blockquote> In Columbus, Ohio, <blockquote>'People who are running hospitals and hospital systems are running businesses that are literally saving people’s lives, so it’s really important to have a quality leader,' said Tiffany Himmelreich, spokeswoman for the Ohio Hospital Association</blockquote>And, <blockquote>'People with these types of leadership abilities could easily be snatched up by for-profit businesses,' she said.</blockquote>There was also a certain sameness in what the the reports did not say. Things Unsaid, and Questions Begged None of the news reports contained a response from a million dollar CEO.  Justifications of CEO pay came from hospital trustees, hospital spokespeople, or compensation consultants. None of the news reports explained why a particular CEO should be considered above average, much less brilliant.  None explained why a particular group of comparator hospitals were appropriate for a particular hospital and its CEO.  As we have discussed before, all CEOs cannot be above average, some CEOs must be below average.  Yet while the reports mentioned CEOs who made less than $1 million, none would dare characterize them as below average.  Some news reports noted reasons that particular hospitals or CEOs or CEOs ought not to be compared so favorably to their peers.  For example, Edward Bonn's Southern Regional Health System in the Atlanta area lost $12 million in 2009, Tim Stack's Piedmont Health "will cut 464 jobs," and Ken Beverly, of Archbold Medical Center, "was found guilty on six counts in a health care fraud case." (See <a href="http://hcrenewal.blogspot.com/2011/01/executive-compensation-at-non-profit.html">this post</a> on the latter.)However, nobody in the news reports dared to suggest that these CEOs might be below average in some sense, and hence might not be entitled to such high pay.    The report from Atlanta noted, "hospital executives and industry experts consider the examination of salaries a titillating issue for the public, but a subject lacking in substance."   However, they failed to explain why the incentives created by large salaries may not generate concerns of substance, or address the concern that "the 'rarified existence' of some nonprofit hospital CEOs may warp their financial decisions and blunt the charitable mission." Finally, if CEOs, most of whom are not health care professionals, are credited with "literally saving people's lives," why are the health care professionals who actually do save people's live not credited even more? Summary The extreme consistency of justifications for generous compensation given to hospital and health system CEOs, (and as <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">we have seen</a>, for such compensation given to other health care leaders) suggests that these justifications are talking points being generated by the leaders public relations flacks.  They may be using talking points because they know the real reason for the high pay is that the CEOs have become unaccountable, and able to set their own pay.  If the CEOs and their friendly boards cannot refute this contention, the latter do not deserve their pay, and the former do not deserve their positions of stewardship. Over and over, I say... Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior. If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

Talking Points, Sans Original Thought, to Justify Million Dollar Hospital CEO Compensation

Generous pay given to health care leaders has become an area of interest in the media. Some recent regional stories had a certain dreary sa...

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New way to get kids interested in medicine: post confidential medical records on a homework site?

Was this a new way to get kids interested in medical careers? Or was it an accident due to the highest levels of negligence associated with lowest/cheapest standards in hiring for mission critical roles? <blockquote><a href="http://www.nytimes.com/2011/09/09/us/09breach.html?_r=1&hp">Patient Data Posted Online in Major Breach of Privacy </a> New York Times Sept. 8, 2011 Kevin Sack A medical privacy breach at <a href="http://topics.nytimes.com/top/reference/timestopics/organizations/s/stanford_university/index.html?inline=nyt-org" title="More articles about Stanford University" class="meta-org">Stanford University</a>’s hospital in Palo Alto, Calif., led to the public posting of medical records for 20,000 emergency room patients, including names and diagnosis codes, on a commercial Web site for nearly a year, the hospital has confirmed. Since discovering the breach last month, the hospital has been investigating how a detailed spreadsheet made its way from one of its vendors, a billing contractor identified as Multi-Specialty Collection Services, to a Web site called “Student of Fortune,” which allows students to solicit paid assistance with their school work. Gary Migdol, a spokesman for Stanford Hospital and Clinics, said the spreadsheet first appeared on the site on Sept. 9, 2010, as an attachment to a question about how to convert the data into a bar graph.<div id="articleBody"> </div></blockquote><div id="articleBody"> To teach the kids to be medical bean counters at an early age, perhaps? <blockquote>Even as government regulators strengthen oversight by requiring public reporting of breaches and imposing heavy fines, experts on medical security said the Stanford incident spotlights the persistent vulnerability posed by legions of outside contractors who gain access to private data. </blockquote> In the Oct. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/10/private-medical-records-offered-for.html">Private medical records offered for sale</a>" I wrote about how such data was for sale by onion-like layers contractors - cheap. <blockquote>The spreadsheet contained names, diagnosis codes, account numbers, admission and discharge dates, and billing charges for patients seen at Stanford Hospital’s emergency room during a six-month period in 2009, Mr. Migdol said. It did not include Social Security numbers, birthdates, credit-card accounts or other information used to perpetrate identity theft, he said, but the hospital is offering free identity protection services to affected patients. </blockquote> (Partial) luck prevailed - this time. <blockquote>The breach was discovered by a patient and reported to the hospital on Aug. 22, according to a letter written four days later to affected patients by Diane Meyer, Stanford Hospital’s chief privacy officer. The hospital took “aggressive steps,” [i.e., its CIO made a quick, panicky phone call - ed.] and the Web site removed the post the next day, Ms. Meyer wrote. It also notified state and federal agencies, Mr. Migdol said. </blockquote> Perhaps "aggressive steps" should have been taken before private medical data was published on a kid's homework site? <blockquote>“It is clearly disturbing when this information gets public,” he said. “It is our intent 100 percent of the time to keep this information confidential and private, and we work hard every day to ensure that.” </blockquote> Would "Master of the Obvious" (a favorite line of my early medical mentor, cardiothoracic surgeon/polymath <a href="http://www.facebook.com/pages/Dr-Victor-P-Satinsky/147849525268828">Dr. Victor P. Satinsky</a>, be too kind a response to this statement? <blockquote>Diane Dobson, of Santa Clara, Calif., said her “jaw dropped” on Saturday when she intercepted the letter from Ms. Meyer addressed to her 21-year-old son, who she said received emergency psychiatric treatment at Stanford in 2009. Ms. Dobson said it could have been disastrous if her son, who lives at home, had learned that his name was linked online to a diagnosis for psychosis. “My son, I can tell you, is fragile and confused enough that this would have sent him over the edge,” Ms. Dobson said. “Everyone with an electronic medical record is at risk, and that means everyone.” </blockquote> My sympathies go out to this mother and her son. Her concerns show that cavalier attitudes towards EMR's can lead to catastrophe beyond identity theft or career damage. <blockquote>The incident at Stanford, while egregious in its details, is far from rare. Records compiled by the Department of Health and Human Services reveal that personal medical data for more than 11 million people has been improperly exposed during the last two years alone ... The major breaches — a disconcerting log of stolen laptops, hacked networks, unencrypted records, misdirected mailings, missing files and wayward e-mails — took place in 44 states. </blockquote> I'm certain there is an increasing amount of critical medical data being withheld by patients as publicity about these breaches become more well-known. <blockquote>The breaches at Stanford reinforce that even the most prestigious medical centers are not immune to risk. <a title="Web site" href="http://www.massgeneral.org/"> Massachusetts General Hospital</a> in Boston, which trains Harvard medical students, agreed this year to pay a $1 million federal fine after an employee left paper medical records on a subway train while commuting to work. The pages contained the names of 192 patients, and diagnoses for about a third of them, including for H.I.V./AIDS. They were never recovered. </blockquote> I note these are both pioneers in electronic health records. Imagine what might be happening at Podunk Hollow General Hospital... <blockquote>Mr. Migdol said the hospital had concluded that “there is no employee from Stanford Hospital who has done anything impermissible.” He said he expected the federal Department of Health and Human Services to conduct its own investigation. Susan McAndrew, deputy director of <a href="http://topics.nytimes.com/top/reference/timestopics/subjects/h/health_information_privacy/index.html?inline=nyt-classifier" title="Recent and archival health news about health information privacy." class="meta-classifier">health information privacy</a> for the department’s Office of Civil Rights, said she could not discuss whether an investigation was in progress ... Bryan Cline, a vice president with the Health Information Trust Alliance, a nonprofit company that establishes privacy guidelines for health care providers, said that nearly 20 percent of breaches were perpetrated by outside contractors, accounting for more than half of all the records exposed. </blockquote> When you start to outsource mission critical data, you should probably be prepared to take responsibility for whomever you outsource it to. <blockquote>The vendor, identified by Mr. Migdol as Multi-Specialty Collection Services LLC, based in Los Angeles, could not be reached for comment. Mr. Migdol said the company created the spreadsheet as part of a billing-and-payment analysis for the hospital. He said the hospital immediately suspended its relationship with the contractor and received written certification that previous files would be destroyed or returned securely. </blockquote> Apparently someone there with access to the spreadsheet was less than careful about keeping it away from children. One wonders if they would have been more careful with pornography... <blockquote>“We’re still kind of caught in the pre-high-tech trust model instead of the insurance model,” Mr. Cline said. “Health care providers say, ‘I’m going to have some contract language and then just trust that you’ll protect my data because if you don’t I’m going to sue you.’ That just doesn’t work, as we can see. You have to do due diligence, something to assure yourself that the people you’re giving your data to can be trusted.”</blockquote> <div class="articleCorrection"> </div> </div> I'd say we're still in the stone age with respect to our irrational exuberance about health IT. See my series of articles on these issues at these query links: <a href="http://hcrenewal.blogspot.com/search/label/computer%20security">computer security</a>, <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy">medical record privacy</a>, <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20confidentiality">medical record confidentiality</a>. A fundamental set of rules in today's hire-on-the-cheap, keep-staffing-minimal environment is this: <blockquote>1. If you want information to be kept secure, don't place it on a computer. 2. If you place the information on a computer, don't place the computer on a network. 3. If you place the computer on a network, the information is no longer secure. </blockquote>In our current culture I do not believe these issues to be easily remediable, but hiring the truly best and brightest (after satisfactory scores in a very hard test in critical thinking skills) into IT roles - including design, implementation, and management - might be a start. -- SS

New way to get kids interested in medicine: post confidential medical records on a homework site?

Was this a new way to get kids interested in medical careers? Or was it an accident due to the highest levels of negligence associated with ...

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Another Hospital Putting on the Ritz

The usual definition of a hospital is an institution which treats the sick and injured,.  That is a messy business, so some hospital executives seem to yearn to be doing something a little more - shall we say - upscale.  For example, the Chattanoogan <a href="http://www.chattanoogan.com/articles/article_207569.asp">reported</a>: <blockquote>Erlanger Health System will launch in October one of the most ambitious employee training initiatives in its 120-year history. All 4,500 employees will participate in a new service excellence program based on the legendary Ritz-Carlton service model. 'This is not a program. This is the beginning of long-term cultural transformation,' says Erlanger CEO James Brexler. 'Our board and leadership team believe this initiative is one of the most significant developments in the continued evolution of Erlanger.' The Erlanger Health System strategic plan, adopted by the board of trustees last year, identified service excellence as a priority. Funding for the initiative was approved in this year’s operating budget. The corporate university of Ritz-Carlton was selected to help take Erlanger’s patient experiences to the next level.</blockquote> A hospital, of course, provides services to patients. However, it seems glaringly obvious that the sort of services required by the sick and injured, especially the critically ill, are very different than those people who go to four-star hotels. Providing care to a patient on a ventilator (breathing machine), for example, hardly resembles providing spa services to a wealthy hotel guest. Furthermore, Erlanger Health System is a public, non-profit health system with a <a href="http://www.erlanger.org/body.cfm?id=38">mission</a> that involves service to the poor: <blockquote>To deliver excellence in medical care to improve the health status of our region, while providing vital services to those in need, and training to health professionals through affiliation with academic partners</blockquote> The Boston hotel in the Ritz-Carlton chain, its flagship property, <a href="http://www.ritzcarlton.com/en/Properties/BostonCommon/Rooms/Default.htm">boasts</a> that it: <blockquote>features hotel rooms and suites in Boston designed as sanctuaries of urban luxury. </blockquote> Where is the parallel to providing health care services to "those in need" who are acutely ill and injured? By the way, a few days after the Erlanger, Ritz-Carlton connection was announced, the Time Free Press <a href="http://timesfreepress.com/news/2011/aug/30/830-a1-erlanger-defends-ritz-bid-process">noted</a> questions about how the contract was awarded: <blockquote>Erlanger officials defended the no-bid procedure Monday, saying the hospital was correct in bypassing a competitive bid process and awarding a 'professional services' contract to Ritz-Carlton. 'Tennessee law says government entities do not have to bid professional services,' hospital spokeswoman Susan Sawyer said. Even early in the process, Whisman said, 'it was so clearly the Ritz going forward.' 'There was a lot of board support, executive-level support and steering committee support,' she said. 'Ritz had it all.'</blockquote> Furthermore, how well the money will be spent may be difficult to find out: <blockquote>In October, a Ritz-Carlton speaker is expected to lead several four-hour sessions, each of which will hold 400 employees, hospital officials said. The bill for those sessions is $288,000. On Thursday, Sawyer said Ritz-Carlton prohibited the media from attending the sessions because of proprietary information the hotel chain prefers to keep secret.</blockquote> It is not that the hospital system has money to burn, as the Chattanoogan just <a href="http://www.chattanoogan.com/articles/article_207569.asp">revealed</a>: <blockquote>Erlanger Health System officials reported a $1.3 million loss for July,...</blockquote> In addition, <blockquote>Admissions were under budget by 1.6 percent for the month and ahead of the previous year by 3.8 percent.</blockquote> So, in summary so far, a public hospital system that is currently experiencing budgetary challenges is spending hundreds of thousands of dollars for the Ritz-Carlton luxury hotel chain to train its employees in secret sessions about "service excellence," and the hospital system's management thinks this is a top priority. In my humble opinion, this illustrates a larger problem with the leadership of health care. Health care organizations are often lead by ultra <a href="http://hcrenewal.blogspot.com/search/label/generic%20managers">generic managers</a>, that is, managers trained in such fields as marketing, public relations, and finance, but without any experience or training in actually taking care of patients. (The supremacy of generic management is strange given that patient care itself has become so specialized.) The utter lack of gut feeling for what health care is really about seems to lead to managers thinking that hospitals are <a href="http://hcrenewal.blogspot.com/2005/09/reasoning-by-misanalogy-revisited-how.html">like automobile assembly plants</a>, or in this case, like luxury hotels. I cannot but help believe that such ultra generic managers, who do not appreciate the values of health care professionals, and do not understand the health care context, are going to make some very bad decisions, and are an important cause of health care dysfunction. I cannot help believe that the <a href="http://www.erlanger.org/body.cfm?id=191">Erlanger CEO</a>, Mr James Brexler, (whose most advanced degree was a "Masters of Public Affairs from North Carolina State University") was entirely off base when he was <a href="http://www.chattanoogan.com/articles/article_207720.asp">quoted</a>: <blockquote>'This is not a flavor-of-the-month thing,' continues CEO Brexler. 'This is a strategic priority and business imperative. We are committed to this. We are excited about it. Our staff is excited. Our physicians are excited. The results, we believe, will be evident to our patients and their families.'</blockquote> True health care reform would make sure health care leaders actually understand health care and uphold its values. PS - Long ago, we <a href="http://hcrenewal.blogspot.com/2006/03/putting-on-ritz.html">noted</a> the trustees of another hospital system who seemed to think that Ritz-Carlton experience was perfect background for hospital executives.

Another Hospital Putting on the Ritz

The usual definition of a hospital is an institution which treats the sick and injured,. That is a messy business, so some hospital executi...

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Yet more health IT articles based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y"

The article "Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method" by Greenhalgh, Potts, Wong, Bark and Swinglehurst at University College London appeared in the Dec. 2009 <a href="http://www.milbank.org/quarterly.html">Milbank Quarterly</a>. I wrote about it extensively and quoted it at <a href="http://hcrenewal.blogspot.com/2009/12/healthcare-it-as-cybernetic-miracle.html">this post</a>. A key statement: <blockquote>... This review has also identified some areas where more research does not appear to be needed ... [including] simplified experimental studies based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y?” or variations thereof ... the circumstances in which they add value are more limited than is often assumed. We [also] believe that surveys of attitudes of patients or staff towards ‘the EPR’ or ‘computerization’ which are not adequately contextualized have almost no enduring value.</blockquote> So guess what was just published in the NEJM? An article based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y." In a special article entitled "Electronic Health Records and Quality of Diabetes Care", NEJM August 31, 2011 (<a href="http://healthpolicyandreform.nejm.org/?p=15235&query=TOC">link</a>), a study was performed in which the researchers: <blockquote>... compared EHRs with paper-based records in a long-term regional collaborative that seeks to improve care and outcomes for patients with chronic conditions. </blockquote> They found that: <blockquote> ... EHR sites were associated with higher levels of achievement of and improvement in regionally vetted standards for diabetes care and outcomes. Our findings focus on composite standards, although the results were similar for virtually all component standards. </blockquote> This is not really news. I had the same results in a more limited EHR data-based study of diabetics ... in 1997. As I've often written, health IT can be of great benefit...but only if done well. (I have to frequently repeat that there is massive, perhaps <a href="http://en.wikipedia.org/wiki/Wicked_problem">wicked</a> complexity behind those simple two words "done well.") When not done well, disaster can strike. There are no statistics in in the NEJM article regarding complications, "close calls", patient injuries, or patient deaths due to the implementation of health IT. I sincerely doubt the incidence was zero. Their dismissal or lack of mention is common in the medical and health IT literature and seems to reflect an amoral, pervasive paternalism in medicine. The amoral paternalism in turn seems to be a repeat of the attitudes towards experimentation that led to the many human subjects protections that apply everywhere else in biomedicine (<a href="http://ohsr.od.nih.gov/guidelines/index.html">link</a>) - except computing - e.g.: <a href="http://ohsr.od.nih.gov/guidelines/45cfr46.html"></a><blockquote><a href="http://ohsr.od.nih.gov/guidelines/45cfr46.html">45 CFR 46</a> Protection Of Human Subjects <a href="http://ohsr.od.nih.gov/guidelines/GrayBooklet82404.pdf">Guidelines for Conduct of Research Involving Human Subjects at NIH (Gray Booklet) (pdf file)</a> <a href="http://ohsr.od.nih.gov/guidelines/belmont.html">The Belmont Report</a> Ethical Principles and Guidelines for the Protection of Human Subjects of Research <a href="http://ohsr.od.nih.gov/guidelines/nuremberg.html">Nuremberg Code</a> Directives for Human Experimentation <a href="http://ohsr.od.nih.gov/guidelines/helsinki.html">World Medical Association Declaration Of Helsinki</a> </blockquote> To their credit, the NEJM authors did issue several caveats: <blockquote>... we compared sites that had sophisticated EHR systems with paper-based organizations that, as safety-net practices, care for a vulnerable patient population and may have fewer quality-related resources than other paper-based practices ... Our results, showing accelerated improvement in care and outcomes, should encourage those concerned that the quality of ambulatory care may fail to improve with increased adoption of EHRs [per numerous past studies - ed.] ... our study did not determine changes in achievement after the conversion from paper to electronic records, which would provide more compelling evidence of the benefits of EHRs.</blockquote> One might wonder how the tens or hundreds of millions of dollars spent on EMR's might compare, with regard to disease management, with the results achieved by hundreds of dedicated people who could be hired for that purpose for far less money. In other words, the ROI issues of the health IT investment vs. alternatives are not addressed (they rarely are), and truly robust RCT's were not performed comparing the two alternatives. Greenhalgh et al. also wrote in the aforementioned Milbank article: <blockquote>... as a cross-cutting theme in all the above areas, the realpolitik of EPR projects within and between organizations and interest groups should be more explicitly explored ... Orlikowski and Yates have called for more research on the “messy, dynamic, contested, contingent, negotiated, improvised, heterogeneous, and multi-level character of ICTs [information & communications technologies - ed.] in organizations” (page 132) (Orlikowski and Yates 2006). We suggest that sponsors and publishers eschew sanitized accounts of successful projects and instead invite studies of the EPR in organizations that “tell it like it is” – perhaps using the critical fiction technique to ensure anonymity (Winter 1986).</blockquote> There's no trace of that in the new NEJM article. Where health IT is concerned, that's where the money is (no pun intended) in learning how to "do health IT well." -- SS

Yet more health IT articles based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y"

The article " Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Met...

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Millions for tribute, but not one cent for defense: If hospitals cannot afford to legally defend EMR mishaps, should they be investing in them?

<div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;">Imagine an airline going out and buying new multimillion-dollar jets with increased fuel efficiency and that produce less pollution. However, they knowingly buy them under conditions of not being able to afford to perform complete diagnostics/forensics for the FAA when something goes awry and a plane malfunctions or crashes. Absurd? Apparently not in the domain of healthcare IT. The hospital where my mother was injured (now of blessed memory as a result) has still refused to substantively answer EMR-related questions, after a motion by my mother's attorney to compel discovery. As part of their legally sworn-truthful response they write:</div> <div dir="ltr" style="font-family:arial;"> </div> <blockquote style="margin-right: 0px; font-weight: bold;font-family:arial;" dir="ltr"> <div dir="ltr"> "The burden and expense of more detailed responses would put a substantial drain on the hospital's limited resources."</div></blockquote> <div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;"> If this is true, perhaps hospitals (which generally do have limited resources) should not be spending tens or hundreds of millions of dollars on electronic medical records, a still-experimental technology (<a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html">link</a>). It also causes concern about the maintenance state of the current technology. The general point of which this is a specific example is this: If hospitals cannot afford to defend/produce forensics for the technology when mishaps inevitably occur (such as in the Feb. 2010 FDA internal memorandum on health IT related mishaps, <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">link</a>, which the director of CDRH states are likely the "tip of the iceberg, <a href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html">link</a>), then perhaps hospitals need to rethink the initial investment and ongoing maintenance/upgrading costs until the technology is more mature. Should the motto of hospitals be "Millions for IT tribute, but not one cent for defense?" Finally, in the same brief claiming poverty, I, now representing my deceased mother was referred to as a "self-described expert in computerized medical records" and "critic of use of computerized medical records in hospitals" (as opposed to the reality of my being a critic of misuse of computerized medical records, especially deficient ones, in hospitals). </div> <div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;">Just to further nail that point down as to my being a health IT amateur and Luddite, they also included as an attachment to their brief my entire CV and publications history -- 17 pages long - as retrieved from <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=about" target="_blank">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=about</a>, picture included. (Perhaps I should send the hospital a thank-you note for introducing me to the judge, without my having to lift a finger.) Also issued were subpoenas for another fifteen or so doctors and practices that saw my mother, in addition to many others in past subpoenas. These records, mostly paper, will need to be reviewed. This will likely be a very profitable piece of work with many billable hours for the retained defense firm's lawyers. All this was more than one month after the state's Medicare Quality Improvement Organization found my mother's care "did not meet applicable professionally accepted standards of healthcare", and the deficiencies led to the catastrophic "subsequent medical complications" that she filed a complaint about while still lucid. Medicare also set up a monitoring program at the facility "for several quarters" as a result. (This was not mentioned in the defendant's brief to the court.) In effect, for probably $300+ per hour for legal services in the attempt to defend a case Medicare itself found not to have met applicable professionally accepted standards of healthcare, the hospital seems to have plenty of money. Again, the general point here is this: I believe this type of behavior is not atypical for hospitals today, and is likely another unfortunate manifestation of the medical leadership deficiencies and ethical gaps (e.g., at <a href="http://hcrenewal.blogspot.com/search/label/leadership">link</a>, <a href="http://hcrenewal.blogspot.com/search/label/Mismanagement">link</a>) commonly noted on this blog. -- SS </div>

Millions for tribute, but not one cent for defense: If hospitals cannot afford to legally defend EMR mishaps, should they be investing in them?

Imagine an airline going out and buying new multimillion-dollar jets with increased fuel efficiency and that produce less pollution. How...

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Smart ALEC's Strange Bedfellows

A number of articles in the Nation, plus posts by some of our blogging colleagues discussed the American Legislative Exchange Council (ALEC) and its role in policy, including health policy advocacy.  The <a href="http://www.thenation.com/article/161978/alec-exposed">lead article</a>, "ALEC Exposed," in the Nation, characterized ALEC as: <blockquote>a critical arm of the right-wing network of policy shops that, with infusions of corporate cash, has evolved to shape American politics. Inspired by Milton Friedman’s call for conservatives to 'develop alternatives to existing policies [and] keep them alive and available,' ALEC’s model legislation reflects long-term goals: downsizing government, removing regulations on corporations and making it harder to hold the economically and politically powerful to account. Corporate donors retain veto power over the language, which is developed by the secretive task forces. The task forces cover issues from education to health policy.</blockquote>ALEC and Health Care Reform Wendell Potter contributed an <a href="http://wendellpotter.com/2011/07/alec-exposed-sabotaging-healthcare/">article</a> about ALEC's position on health care reform. First, <blockquote>ALEC crafted the Freedom of Choice in Health Care Act, which, despite its Orwellian name, was written to deny the citizens of any state that passed it the freedom to set up such a system. By declaring that Congressional attempts to regulate health insurance at the federal level would be unconstitutional, it would effectively ban not only a federal single-payer proposal but also a federally created health insurance exchange and a federally operated public insurance option. </blockquote> ALEC <blockquote>adopted a strategy to shape rather than stop reform. Its top five goals became: § Keeping single-payer proposals off the table; § Ensuring that the final bill contain a clause requiring all Americans not eligible for an existing federal program to buy coverage from a private insurance company; [note that thus the "mandate" that pseudo-conservative groups like the Tea Party hate seems to have been pushed by big commercial insurance firms, and by some of the Tea Party's backers, not by the "big government" the Tea Party also loves to hate] § Preventing the new law from establishing a government-run plan (the 'public option') that would compete with private insurers; § Making sure that the reform law is implemented primarily at the state level, to keep the federal government from assuming any significant new oversight of private insurers’ business practices; and § Keeping any new regulations and consumer protections to a minimum. Insurers achieved their first four goals, with ALEC playing a key role in a well-coordinated effort to keep the most progressive proposals from being enacted at the state or federal level. </blockquote>Corporate Funders and Influencers The articles in the Nation suggest that ALEC's health policy advocacy is shaped only by commercial health care insurance. However, it appears that ALEC is supported by a much broader spectrum of health care corporations and other corporations whose products affect health care. It's <a href="http://www.alec.org/AM/Template.cfm?Section=Private_Enterprise_Board&Template=/CM/HTMLDisplay.cfm&ContentID=15992">"Private Enterprise Board"</a> includes Mrs Sandra Oliver, First Vice Chairman, Bayer Corp; Mr John Del Giorno, Second Vice Chairman, GlaxoSmithKline; Mr David Powers, Treasurer, Reynolds American; and Board Members Mr Don Bohn, Johnson and Johnson, Mr Jeffrey Bond, PhRMA, and Mr Michael Hubert, Pfizer. A PRWatch <a href="http://www.prwatch.org/news/2011/07/10887/cmd-special-report-alecs-funding-and-spending">special report</a> on its funding noted: <blockquote>98% of ALEC's funding comes from corporations like Exxon Mobil, corporate 'foundations' like the Charles G. Koch Charitable Foundation, or trade associations like the pharmaceutical industry's PhRMA and sources other than 'legislative dues.'</blockquote> In more detail, <blockquote>Other current ALEC corporate leaders have given an undisclosed sum to ALEC this year and before. These companies include: CenterPoint 360 (a firm that helps companies 'manage legislation'), Altria (formerly Phillip Morris tobacco), the American Bail Coalition (the trade group for for-profit bail bonds), AT&T, Bayer (aspirin), Coca-Cola, Diageo (Crown Royal and other liquor), Energy Future Holdings (Texas electricity), ExxonMobil, GlaxoSmithKline (Tums and other brands), Intuit (Quickbooks), Johnson & Johnson (lotion), Koch Industries (Georgia Pacific paper products and other brands), Kraft Food (Macaroni and Cheese dinners), Peabody Energy (the largest private coal company in the world), Pfizer (Viagra), PhRMA (the pharmaceutical trade group), Reed Elsevier (Lexis/Nexis legal research), Reynolds American (tobacco), Salt River Project (energy), State Farm Insurance, United Parcel Service, and Wal-Mart (world's largest retailer).</blockquote> So ALEC supporters include some very strange bed fellows. Commercial Insurance in Bed with Pharma ALEC has championed health care positions that seem designed to favor commercial health insurance.  However, it is supported by many corporations with which commercial health insurance ostensibly negotiates at arms length, and whose prices commercial health insurance ostensibly wants to lower.  These include pharmaceutical companies, Bayer, GlaxoSmithKline, and Pfizer, and pharmaceutical/ biotechnology/ device conglomerate Johnson and Johnson, all represented by PhRMA.  It is very curious, to say the least, that such companies are helping to fund a set of policy objectives all designed to further the interests of commercial insurance companies as listed above.  Perhaps the leaders of drug companies think that commercial insurers are likely to be easier negotiators than would be some future hypothetical "public option," (government run insurance company).  Perhaps the leaders of commercial insurance companies realize that they can more plausibly raise their administrative costs, and the amounts they pay to top executives, when overall health care costs, fueled by pharmaceutical and device prices, are rising. A UK Company in Bed with American State Legislators ALEC is supposed to be directed at American state legislatures, and be a membership organization for American state legislators.  It literally includes a graphic of a waving American flag on its <a href="http://www.alec.org/AM/Template.cfm?Section=Home">home page</a>.  However, it is supported by at least one foreign (UK) pharmaceutical company, GlaxoSmithKline.  It is very curious that a British company seems to be seeking to influence the US state legislative process. The appropriateness, and the legality of a British company seeking to influence American state legislatures I leave to be judged by others.  Pharmaceutical Companies (Including Those that Make Smoking Cessation Products) in Bed with Tobacco Companies ALEC is supported by pharmaceutical companies that all promise to improve health care.  These particularly include those that make or sell products that are designed to improve health by aiding smoking cessation, (GlaxoSmithKline, Johnson and Johnson, and Pfizer).  However,by their side stand two tobacco companies, Reynolds America and Altria, whose products the pharmaceutical companies' products are designed to counter.  It is very, very curious that smoking cessation product manufacturers would team up with tobacco companies.  Perhaps cynics among the leadership of the drug companies realize that the market for smoking cessation products increases with tobacco sales.  Perhaps cynics among the leadership of tobacco companies think that the knowledge that there are treatments, albeit not very effective ones, to aid in smoking cessation may encourage people to start or continue smoking (an interesting but rarely discussed example of the "moral hazard" that free market economists love to otherwise discuss).   Summary So in my humble opinion, the strange bedfellows among health care related corporations funding ALEC suggest 1) how little the health care system functions like anything resembling an ideal free market; and 2) how top organizational leaders may have feel they have more in common with each other than they do with their more lowly employees, customers, clients, and the public at large. True health care reform would require decreasing the size and power of large health care organizations, and ensuring that their leaders put their mission, and their patients' and the public's health ahead of their personal enrichment. Hat tip to Naomi Freundlich's <a href="http://www.healthbeatblog.com/2011/08/alec-the-industry-sponsored-group-behind-state-efforts-to-sabotage-health-reform.html">post</a> on the Health Beat blog.

Smart ALEC's Strange Bedfellows

A number of articles in the Nation, plus posts by some of our blogging colleagues discussed the American Legislative Exchange Council (ALEC...

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Say It Ain't So - Howard Dean Runs Through Revolving Door to Become Biotechnology Booster

The revolving door now accommodates the whole political spectrum.  A Salon <a href="http://www.salon.com/news/politics/war_room/2011/09/01/howard_dean_paid_advocate">article</a> documented the transit of one Howard Dean, former darling of the left-wing of the Democratic party: <blockquote>Howard Dean has long cultivated an image as the plainspoken doctor who speaks for the left wing of the Democratic Party, a role he still plays as a pugnacious pundit on TV. But since his term as chairman of the Democratic National Committee ended in January 2009, Dr. Dean has taken on a less-noticed role: paid advocate for interest groups that would find few fans among the progressive voters once energized by Dean's 2004 presidential bid. Dean may not be the worst of the 'buckrakers,' those prototypical capital characters who exploit their name and connections without regard for principle. But his recent political forays seem to have diverged from his trailblazing left-liberal past. As senior strategic advisor at McKenna Long & Aldridge, a heavyweight Washington lobbying firm, Dean played a prominent role representing the biotech industry during the healthcare bill debate, staking out a position on biopharmaceutical drugs that was decried by consumer groups. 'Gov. Dean was very helpful to us,' biotech CEO Jim Greenwood told a trade publication 'As a physician clearly focused on healthcare, a Democrat leader and clearly to left of center, his efforts were impactful.' Greenwood is the head of the Biotechnology Industry Organization (BIO), a trade group that lobbies for the industry in Washington.</blockquote> In particular, <blockquote>Dean arrived in the comfortable K Street offices of McKenna Long & Aldridge shortly after his term as DNC chair ended in January 2009. He had been passed over by President Obama for the secretary of health and human services Cabinet post, and he needed a paying job. In announcing his appointment, the firm said Dean would 'provide guidance to clients, particularly in the areas of healthcare and alternative energy resources.' Dean has been careful not to register as a lobbyist, a designation that would prompt legal disclosure requirements. Both McKenna and the governor's spokeswoman declined to reveal which clients he has worked for. Dean took on a very public role during the 2009 healthcare reform battle, specifically going to bat for the biotech industry -- whose trade association is a client of McKenna. At stake was how the government would regulate a growing class of drugs called biologics or biopharmaceuticals and their generic competitors. The industry argued for a longer period -- at least 12 years -- in which expensive brand-name biologics would face no competition from less costly generics. Consumer groups argued that, to keep costs down, the period of exclusivity should be just five years. Dean jumped into the fight on the side of the industry, writing an Op-Ed in the Hill in 2009 arguing that a 'commonsense and fair approach' would be to bar generics for 'at least 12 years.' 'If we discourage investment, we jeopardize the development of the next generation of breakthrough medicines and cures,' he wrote, echoing a key industry talking point.</blockquote> Dr Dean also apparently did some paid health policy advocacy on behalf of other clients: <blockquote>In January, he waded into another high-stakes healthcare fight, this one being waged in New York state between foreign medical schools and their American competitors. The issue was whether foreign-trained doctors would have access to hospitals in New York for their residencies. Dean wrote an Op-Ed in the Albany Times-Union, 'N.Y. needs its foreign-trained doctors,' that repeated talking points of foreign medical schools, which, Dean's bio blurb noted, are clients of McKenna Long & Aldridge. While the firm won't say whom Dean has worked for, his bio page on McKenna's website offers some clues.</blockquote> Dean also took on a few other jobs for corporate health care. For example, <blockquote>He currently serves on the board of advisors at Vatera Health Partners, a New York-based venture capital fund whose mission is 'to support and grow emerging biopharmaceutical companies.' It's not clear from the public record how long he has served in the position. But his presence on the Vatera board indicates that he has a personal financial stake in the biopharmaceutical industry.</blockquote> Also, he is now <blockquote>serving on the board of Extendicare, a Canadian long-term care company.</blockquote> Dr Dean's new job did not sit well with a former colleagues on the left side of the US political spectrum who had a distinctly different position on the issue of biologic exclusivity: <blockquote>'It was devastating to have him involved because of his reputation,' says James Love, director of Knowledge Ecology International, a public interest group that fought for a shorter period of exclusivity. 'He's considered to be independent of industry and on the left, so it was really shocking to us when we first saw this. But there it was.'</blockquote> The Salon article ended on this disillusioned note: <blockquote>Dean is indeed uniquely positioned: Between his former followers and his current clients, between his idealist liberal past and the cynical culture of K Street, between independence and cooptation.</blockquote> We have discussed how other government officials and political leaders transited the revolving door to work for corporate health care (e.g., starting <a href="http://hcrenewal.blogspot.com/2010/12/former-nih-director-spins-trhough.html">here</a>, and more lately <a href="http://hcrenewal.blogspot.com/search/label/revolving%20doors">here</a>). However, this most recent case seems to present the most vivid contrast between previous reputation and later employment.  Actually, while Dr Dean was clearly an advocate for changing health care, he was not a supporter of some ideas usually labeled left-wing," such as a single payer system (see <a href="http://www.ontheissues.org/2008/Howard_Dean_Health_Care.htm">here</a>).  However, the Washington Times <a href="http://www.washingtontimes.com/news/2004/jan/5/20040105-103754-1355r">reported</a> that when he was running for President in 2004, the Club for Growth Political Action committee ran an television advertisement calling him the proprietor of a: <blockquote>tax-hiking, government-expanding, latte-drinking, sushi-eating, Volvo-driving, New York Times-reading … Hollywood-loving, left-wing freak show </blockquote> The transformation of Dr Howard Dean from a target of the Club for Growth to a paid helper and talking points echoer of the Biotechnology Industry Organization illustrates that nowadays the revolving door accommodates all kinds of politicians. The door remains legal, but its continuing rapid spin raises more and more concern that even the ostensibly most left-wing politicians may act to avoid offending any future lucrative corporate employer. So the coziness between government and the medical-industrial complex is increasingly revealed, and the ability of current government officials and politicians to represent the people rather than corporate CEOs is increasingly in doubt. True health care reform would have to somehow reduce the resultant corporatism.

Say It Ain't So - Howard Dean Runs Through Revolving Door to Become Biotechnology Booster

The revolving door now accommodates the whole political spectrum. A Salon article documented the transit of one Howard Dean, former darlin...

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