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Health Care's "99 Percenters"

As Occupy Wall Street has gone from an obscure protest covered only on blogs and social media to a national phenomenon, the apparent parallels between the issues it is raising and the issues we have been raising in health care grows. 99 Percenters A growing number of protesters are calling themselves the "99 Percenters," (Alter, Jonathan.  Why Occupy Wall Street Should Scare Republicans.  Bloomberg, October 6, 2011.  Link <a href="http://www.bloomberg.com/news/2011-10-07/occupy-wall-street-should-scare-republicans-commentary-by-jonathan-alter.html">here</a>) referring to those who are not in the top 1% of earners.  (The top 1% of income is clearly greater than $250,000/ year [see 2009 census data on US household income <a href="http://www.census.gov/compendia/statab/2012/tables/12s0693.pdf">here</a>], and likely around $380,000 a year [based on the distribution of income reported on tax returns <a href="http://www.financialsamurai.com/2011/04/12/how-much-money-do-the-top-income-earners-make-percent/">here</a>.])  In health care, nearly all who are paid more than $380K/ year are either proceduralists (some medical sub-specialist physicians, and some surgeons, again mainly sub-specialist), or managers and executives of health care organizations. Health Care's 1%  We have been discussing since 2007 how the inequality among physicians' incomes favoring those who do procedures over primary care and other "cognitive" physicians has been driven not by the market, but by regulatory capture.  The fees paid for all physicians services by Medicare, a fee schedule adopted without question or major changes by nearly all insurers, are set through the Resource Based Relative Value System (RBRVS) by the US Center for Medicare and Medicaid Services (CMS).  CMS, in turn, gets virtually all its input on these fees from the <a href="http://hcrenewal.blogspot.com/search/label/RUC">RBRVS Update Committee (RUC),</a> a private committee of the American Medical Association (AMA), made up largely of proceduralists, whose deliberations are secret, and whose membership has been secret until recently.  See here for most recent posts.  Note that the CMS' peculiar relationship with the RUC is now subject of a lawsuit that accuses this relationship of violating the Federal Advisory Committee Act (Klepper B, Kibbe D. A legal challenge to CMS' reliance on the RUC.  Health Affairs Blog, August 9, 2011.  Link <a href="http://healthaffairs.org/blog/2011/08/09/a-legal-challenge-to-cms-reliance-on-the-ruc">here</a>)  The real top earners in health care, however, are not physicians, but executives of big corporations, non-profit and especially for profit.  We have <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">discussed</a> endlessly how huge their compensation may be, and how it seems unrelated to any aspect of their own or their organizations' performance, especially not to how much they benefit patients' or the public's health.  Furthermore, we have noted how executives have prospered even when their management seems overtly <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">hostile to the health care mission</a>, when it leads to ethical missteps requiring <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">legal settlements</a>, or even guilty pleas or verdicts to <a href="http://hcrenewal.blogspot.com/search/label/crime">criminal charges</a>.  So health care's "99 percenters" ought to be angry at the top 1%. The Power of Finance Furthermore, the Occupy Wall Street protesters are not merely upset with the upper 1%, but particularly outraged by those in the financial sector, which "with regulators and elected officials in collusion, inflated and profited from a credit bubble that burst, costing millions of Americans their jobs, incomes, savings and home equity."  Then, "the initial outrage has been compounded by elected officials' hunger for campaign cash from Wall Street, a toxic combination that reaffirmed the economic and political power of banks and bankers, while ordinary Americans suffer.  Extreme income inequality is the hallmark of a dysfunctional economy, dominated by a financial sector that is driven as much by speculation, gouging and government backing as by productive investment." (Anonymous. Protesters against Wall Street.  NY Times, October 8, 2011. Link <a href="http://www.nytimes.com/2011/10/09/opinion/sunday/protesters-against-wall-street.html">here</a>) In another report, the protesters "unite around a common theme: bankers are ripping off America.  Two secondary themes also emerge....  One is that the super rich own the politicians.  The other is that the news media, almost across the board, view events through the eyes of the super rich." (Johnston DC. Occupy Wall Street.  Reuters Blogs, October 7, 2011.  Link<a href="http://blogs.reuters.com/david-cay-johnston/2011/10/07/occupy-wall-street/"> here</a>.) Finance's Links to Health Care We have <a href="http://hcrenewal.blogspot.com/2011/08/now-mainstream-notion-profit-seeking.html">noted</a> parallels between the effects of Wall Street and health care on the economy.  Furthermore, we have noted active ties among Wall Street and health care organizations. (Look <a href="http://hcrenewal.blogspot.com/search/label/finance">here</a> for examples.)  Top executives and board members of some of the financial firms most obviously responsible for the global economic collapse/ great recession have served on boards of trustees of top medical schools and academic medical centers, and their parent universities.  The top leaders of medical schools, academic medical centers, and their parent universities have served on the boards of such financial firms.  There are also board interlocks among Wall Street firms and all sorts of health care corporations.  The corporate culture of Wall Street and health care have long overlapped.  We have further noted how the leadership of big health care organizations has deceptively influenced policy, particularly through <a href="http://hcrenewal.blogspot.com/search/label/stealth%20health%20policy%20advocacy">stealth health policy advocacy</a>.  Meanwhile, until the last few years, much of health care dysfunction has been <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic</a>.  Now the media is beginning to report some of the abuses.  Little about them appears, however, in the medical and health care literature that health care professionals are likely to trust more than news media.  Summary We have frequently suggested that true health care reform requires reform of health care leadership and governance.  We need leaders who understand the health care context, uphold health care professionals' values, and put patients first.  We do not need leaders who are ill-informed, incompetent, self-interested, conflicted, or corrupt.  We need governance that is accountable, honest, transparent, ethical, and again puts patients first.  Maybe to do that we will have to "occupy health care." In any case, it is time for health care's "99 percenters" to stand up for their patients and the integrity of their values.

Health Care's "99 Percenters"

As Occupy Wall Street has gone from an obscure protest covered only on blogs and social media to a national phenomenon, the apparent paralle...

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Still More Electronic Medical Data Chaos, Pandemonium, Bedlam, Tumult and Maelstrom: But Don't Worry, Your Data is Secure

Case 1. Tumult <blockquote>October 5, 2011 New York Times <a href="http://www.nytimes.com/2011/10/06/us/stanford-hospital-patient-data-breach-is-detailed.html?_r=1">Patient Data Landed Online After a Series of Missteps</a> By KEVIN SACK Private medical data for nearly 20,000 emergency room patients at California’s prestigious Stanford Hospital were exposed to public view for nearly a year because a billing contractor’s marketing agent sent the electronic spreadsheet to a job prospect as part of a skills test, the hospital and contractors confirmed this week. The applicant then sought help by unwittingly posting the confidential data on a tutoring Web site. [Got all that? - ed.] In an e-mail sent to a victim of the breach, the billing contractor, Joe Anthony Reyna, president of Multi-Specialty Collection Services in Los Angeles, explained that his marketing vendor, Frank Corcino, had received the data directly from Stanford Hospital, converted it to a new spreadsheet and then forwarded it to a woman he was considering for a short-term job. The position was with Mr. Corcino’s one-man shop, Corcino & Associates, Mr. Reyna wrote in the e-mail, which was authenticated by his lawyer, Ellyn L. Sternfield. The job applicant apparently was challenged to convert the spreadsheet — which included names, admission dates, diagnosis codes and billing charges — into a bar graph and charts, Stanford Hospital officials said. Not knowing that she had been given real patient data, the applicant posted it as an attachment to a request for help on <a href="http://studentoffortune.com/">studentoffortune.com</a> [I wrote about that earlier <a href="http://hcrenewal.blogspot.com/2011/09/new-way-to-get-kids-interested-in.html">here</a> - ed.], which allows students to solicit paid assistance with their work. First posted on Sept. 9, 2010, the spreadsheet remained on the site until a patient discovered it on Aug. 22 and notified Stanford. </blockquote> My, how electronic data can travel when mishandled. Try that trick with 20,000 paper charts ... <blockquote> The hospital, located on the campus of Stanford University in Palo Alto, demanded that the spreadsheet be removed, and the Web site quickly complied. Pressed for time, the job prospect wound up completing the assignment herself and, in the end, did not get hired, Ms. Sternfield said. </blockquote> Ironically, this was all for naught. <blockquote>Mr. Corcino, in his first public statement, attributed the breach to “a chain of mistakes which are far too easy to make when handling electronic data.” </blockquote> Far too easy to make - especially by the dyscompetent. <blockquote>... Breaches of private medical data have become distressingly commonplace, with two substantial ones disclosed in the last week alone. [We don't know the details of those yet; that's for next week - ed.] </blockquote> Case 2: Pandemonium (from same NYT article) <blockquote>In Orlando, officials with Florida Hospital reported that three employees had improperly combed through emergency department records of 2,252 patients, apparently to forward information about accident victims to lawyers. The employees were fired, and law enforcement officials are investigating. </blockquote> Trolling for Torts - is this a new EMR TV game contestant show? Perhaps it could be followed by "<a href="http://hcrenewal.blogspot.com/2011/02/what-was-this-medical-resident-looking.html">Trolling for Tarts?</a>" Case 3: Bedlam (from the same NYT article) <blockquote>Meanwhile, Science Applications International Corporation disclosed that computer backup tapes containing medical data for 4.9 million military patients [that number also amounts to almost 2% of the total U.S. population - ed.] had been stolen from an employee’s car in San Antonio. The data included Social Security numbers, clinical notes, laboratory test results and prescriptions. The company said the risk of harm was low because retrieving data from the tapes would require specialized knowledge, software and hardware. [Who's to say the theft was not by someone with that specialization, or someone paid by same to steal the tapes? - ed.] The Texas breach is by far the largest since September 2009, when a new federal law began requiring disclosures of medical privacy violations involving at least 500 people. Some 330 such episodes have been tallied, including four others that affected more than one million people each. </blockquote> We'd all be buried in stray clinical paper by now if it weren't for computers. Thank god for them! <blockquote>Officials at the Department of Health and Human Services said the new reporting requirements had exposed deep vulnerabilities and encouraged renewed vigilance. </blockquote> Exposed to whom? The blind, deaf and dumb? <blockquote>“We’re moving in the right direction in terms of a culture of compliance,” said Leon Rodriguez, director of the department’s Office for Civil Rights, which investigates medical privacy cases. “Are there still a lot of problems out there? Yeah, my sense is there are still a lot of problems.” </blockquote> The Titanic was moving in the right direction - towards New York Harbor, in fact, when it met a little unexpected obstacle. Perhaps a culture of brains would be better than a culture of compliance... <blockquote>The Stanford breach was notable for the duration of public exposure, and for spotlighting the vulnerability created by a medical provider’s business relationships with outside parties. Last week, lawyers filed suit in state court in Los Angeles, seeking certification as a class action and $20 million in damages from Stanford Hospital & Clinics and Multi-Specialty Collection Services, which is known as MSCS. </blockquote> $20 million might hurt a bit, and might help motivate the organization to hire better and/or more appropriate clinical information management expertise - in house where it belongs (see below). <blockquote>The threat of liability set off a predictable round of finger-pointing. In written responses to questions, Lisa Lapin, Stanford University’s assistant vice president for university communications, said, “MSCS bears the complete and sole responsibility for the breach.” </blockquote> It's their fault, not ours. <blockquote>Ms. Lapin said the hospital had sent the data in encrypted form to Mr. Corcino, who requested it on behalf of MSCS to analyze a strategy for improving billing collections. She said Mr. Corcino had regularly represented himself as MSCS’s executive vice president and had been Stanford’s “primary contact” during a seven-year relationship. MSCS, a five-person firm that audits hospital accounts to maximize reimbursement, possessed the passwords to unencrypt the data, she said. </blockquote> It was all about money and outsourcing. <blockquote>“This mishandling of private patient information was in complete contravention of the law and of the requirements of MSCS’s contract and is shockingly irresponsible,” the hospital said in a statement. </blockquote> It is foolish to believe that someone else can run critical aspects of your business, and it is even more foolish to believe that it is OK for someone else to run critical aspects of your business. <blockquote>Ms. Sternfield, Mr. Reyna’s lawyer, said Mr. Corcino had never been an MSCS employee, but rather was paid a monthly fee to drum up business, typically in face-to-face meetings with health care executives. Mr. Reyna, she said, had no knowledge that the Stanford data had been sent to Mr. Corcino, or that he had passed it on. Mr. Corcino was not authorized to use an MSCS title, Ms. Sternfield said, but she declined to say whether Mr. Reyna was aware of the practice. She acknowledged that Mr. Corcino sometimes used an MSCS e-mail account. In his e-mail to the breach victim, who shared it with The Times, Mr. Reyna wrote that Stanford had sent the file to Mr. Corcino “for a potential MSCS project that would audit paid accounts to verify that the reimbursement was correct.” For his part, Mr. Corcino said in a statement that he was an independent contractor but was “the marketing face of the company,” and that MSCS “allowed me to use the title of executive vice president.” He wrote: “Stanford sent the file to me at MSCS, and I imported the data into a spreadsheet that was forwarded to the job applicant as part of a skills test. I did not intend to provide any personal health information in the file. This was a marketing project.” Without explaining how or why he sent the data to the applicant, Mr. Corcino said MSCS had not trained him properly and faulted Stanford for sending him private information that he did not need. That, he said, was the “first link in a chain of mistakes.” “I regret that Stanford released a file containing unnecessary information,” Mr. Corcino said, “that MSCS did not have an appropriate training and audit system for the handling of electronic data and that I was not more careful with the file. While Stanford and MSCS left the information in the file I received, it was my mistake to not catch its inclusion and remove the data.” ... The hospital has terminated its relationship with MSCS, and Mr. Reyna has done the same with Mr. Corcino. </blockquote> Even I can't follow all that. This will be one convoluted court case... <blockquote>Stanford Hospital has reassured affected patients that the posted spreadsheet did not contain Social Security numbers, birthdates or credit card numbers, and has offered free identity theft protection services. The hospital said it had not uncovered any misuse of the exposed data. </blockquote> Yet, that is. (Is it no wonder that sedatives are among the most highly-prescribed medications?) Moving from the NYT article: Case 4: Tumult (I'm running out of descriptors) <a href="http://newsandinsight.thomsonreuters.com/California/News/2011/06_-_June/Health_Net%E2%80%99s,_IBM%E2%80%99s_negligence_compromised_medical_data,_suit_says/"></a><blockquote><a href="http://newsandinsight.thomsonreuters.com/California/News/2011/06_-_June/Health_Net%E2%80%99s,_IBM%E2%80%99s_negligence_compromised_medical_data,_suit_says/">A large class action lawsuit again Health Net and IBM</a>: California Legal Westlaw Journal Insurance Coverage Health Net’s, IBM’s negligence compromised medical data, suit says June 7 (Westlaw Journals) - Health Net Inc. and IBM face a class-action lawsuit seeking $5 million in damages over the loss of computer storage devices that held the medical histories, financial data and Social Security numbers of 2 million people. Health Net Policyholder Alana Bournas’ class-action complaint in the U.S. District Court for the Eastern District of California alleges that the insurer and IBM breached their duty of confidentiality and negligently allowed the release of highly personal and confidential information of millions of Health Net employees and policyholders. The complaint alleges violation of California’s Confidentiality of Medical Information Act, Cal. Civ. Code § 56; Cal. Civ. Code § 1798.2, which concerns the unauthorized disclosure of customer records; Cal. Bus. & Prof. Code § 17200, the state’s unfair-competition law; and public disclosure of private facts. </blockquote> Companies will either pay the going price for competent employees, or pay for the mistakes of incompetent ones. It would probably be better for society, however, to do the former habitually. <blockquote>The suit says IBM agreed to manage Health Net’s information technology database for five years beginning in 2008. IBM informed Health Net Jan. 21 that it had lost nine disk drives containing the confidential information of 2 million people, including Health Net policyholders and employees. Health Net failed to alert the victims of the breach until March 14, the complaint says. IBM allegedly also failed to encrypt the data, thereby enabling anyone who possesses the hard drives to easily access the confidential information. This puts the victims at an increased risk of identity theft and “other unauthorized uses of plaintiff and class members’ personal information” the suit says. </blockquote> Encryption, a feature now built into mainstream OS's by Microsoft and Apple? (Oh wait...IBM...) <blockquote> Health Net’s attempt to compensate the victims by providing two years of free credit monitoring services through TransUnion is an inadequate remedy for the defendant’s conduct, Bournas says. This “remedy” fails to address unauthorized disclosures of medical information, and the monitoring services only protect against new account fraud but do not address fraudulent activity with existing accounts, the suit says.</blockquote> These executives apparently can't even get the fix straight. <blockquote>Moreover, the complaint says, Health Net has previously been accused of a similar breach of confidential information. In 2009 it lost the same types of records of nearly 1.5 million people and waited six months before notifying the victims. In settling the state of Connecticut’s lawsuit stemming from that security breach, the company promised “to enhance security procedures and training,” the suit says. </blockquote> What can I say? <blockquote>The current breach could have been avoided had Health Net and IBM taken proper precautions and implemented security policies to maintain consumers’ confidential data, according to Bournas. Therefore, the protections granted under California law require that Health Net be penalized for its negligence, she says. The plaintiff notes that millions of people entrusted Health Net with their private data. “At best, defendants’ actions allowed this private information to go astray. At worst, the private information is being viewed, sold, resold, and used for illegitimate and illegal purposes,” the complaint says. The suit is seeking injunctive relief, compensatory damages, declaratory relief, and attorney fees and costs. Bournas v. Health Net Inc., No. 2_11-CV-01262, complaint filed (E.D. Cal. May 11, 2011).</blockquote> I would revise that to say "The current breach could have been avoided had Health Net and IBM hired personnel in adequate numbers with the qualifications and true gravitas (and not laid them off, of course) to maintain consumers’ confidential data." Case 5: Maelstrom (I am reaching to the bottom of the barrel for such descriptors). <a href="http://www.ama-assn.org/amednews/2011/08/01/bisc0801.htm"></a><blockquote><a href="http://www.ama-assn.org/amednews/2011/08/01/bisc0801.htm">Wellpoint recently settled class-action suit in CA</a>. AMA news By Pamela Lewis Dolan, amednews staff. Posted Aug. 1, 2011. WellPoint reaches tentative accord in data breach suit It is the second settlement to come from lawsuits claiming that the company failed to protect the privacy of individual insurance applicants online. WellPoint has reached a preliminary settlement that will, if approved, bring an end to a class-action lawsuit filed more than a year ago. The lawsuit, filed in the Superior Court of the State of California, involves the potential exposure of data belonging to more than 600,000 individual health insurance applicants on a company-run website that allowed insurance applicants to track their applications. The situation came to light when an applicant to WellPoint-owned Anthem Blue Cross of California sued the company in March 2010. The applicant was able to manipulate the web address within the site to gain access to other applicants' information, including names, addresses, dates of birth, Social Security numbers and health and financial information. </blockquote> In other words, probably changing a simple number in the URL brought up someone else's records. Good going there, Wellpoint. What were the programmers thinking? (Were they thinking?) <blockquote>When the suit was filed, the company said an upgrade to the system caused the information to become exposed. The company said a third-party vendor validated that all security measures were in place when, in fact, they were not. Changes were made to the system soon after the situation was discovered.</blockquote> Blame someone else, yet again. <blockquote>In addition to the class-action suit, the company was sued by Indiana Attorney General Greg Zoeller in July 2010. The suit, filed in Marion County Civil Superior Court, alleged that the company violated the Indiana Disclosure of Security Breach Act by failing to notify Zoeller, and the 32,051 Indiana residents affected by the incident, in a timely manner. That suit was settled in early July, when WellPoint agreed to pay a $100,000 fine. As part of the settlement, WellPoint admitted it had a security breach and failed to properly notify the attorney general's office as required by law.</blockquote> <a href="http://www.urbandictionary.com/define.php?term=oy%20gevalt">Gevalt</a>. <blockquote> Under the preliminary settlement in the California class-action matter, WellPoint agreed to offer credit monitoring for two years to all affected individuals. Class members are eligible to receive reimbursement for identity theft losses of up to $50,000 per incident, as well as additional time to file identity theft claims until May 31, 2016. Those making identity theft claims are eligible for an additional five years of credit monitoring. The company also will donate a total of $250,000 to two nonprofit organizations whose efforts are directed at protecting consumers' privacy on the Internet.</blockquote> It might have been cheaper and better for goodwill not to outsource a vital function...those third-party vendors can really hurt you. (I'd really like to know - was this "third party vendor" domestic, or overseas?) <blockquote>WellPoint did not admit wrongdoing in the case, nor was it found guilty. A fairness hearing is scheduled for November, and the courts then will decide whether to approve the settlement.</blockquote> Large corporations are immune from such formalities as admitting wrongdoing or being found guilty. ----------------------- But don't worry. <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy">Your medical data's safe.</a> Sort of. See also: <ul><li>"<a href="http://hcrenewal.blogspot.com/2010/02/networked-emrs-and-healthcare.html">Networked EMR's and Healthcare Information Security: Practical When Massive IT Security Breaches Continue</a>?",</li></ul><ul><li>"<a href="http://hcrenewal.blogspot.com/2010/02/networked-interoperable-secure-national.html">Networked, Interoperable, Secure National Medical Records a Castle in the Sky?</a>",</li></ul><ul><li>"<a href="http://hcrenewal.blogspot.com/2010/01/it-flaws-and-coverups-of-same-why-i.html">Operation Aurora And a Widespread Reluctance to Discuss IT Flaws: Is Universal Healthcare IT Really a Good Idea in 2010?</a>",</li></ul><ul><li>"<a href="http://hcrenewal.blogspot.com/2010/10/medical-data-breach-of-week-but-your.html">Medical data breach of the week - but your EMR data is secure, trust us, we're IT experts</a>", </li></ul><ul><li>"<a href="http://hcrenewal.blogspot.com/2010/11/insurers-test-data-profiles-to-identify.html">Insurers Test Data Profiles to Identify Risky Clients</a>",</li></ul><ul><li>and <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20confidentiality">others</a></li></ul> -- SS

Still More Electronic Medical Data Chaos, Pandemonium, Bedlam, Tumult and Maelstrom: But Don't Worry, Your Data is Secure

Case 1. Tumult October 5, 2011 New York Times Patient Data Landed Online After a Series of Missteps By KEVIN SACK Private medical data for ...

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Enabled by the Revolving Door, Corporatistic US Trade Policy Seems to Put US Drug Companies Ahead of Global Public Health

We just <a href="http://hcrenewal.blogspot.com/2011/10/exporting-us-health-ecosystem-and-its.html">discussed</a> how leaders of big health care corporations with histories of ethical and legal missteps want to export our supposedly "wonderful technology, wonderful approaches" to the rest of the world.  A <a href="http://www.huffingtonpost.com/2011/09/28/bill-daley-big-pharma-trans-pacific-partnership_n_981973.html">story</a> on the Huffington Post showed how big health care corporations, partnering with the US government, have already been doing that with not very pretty results.  The article discussed two cases, connected by a single person who transited the revolving door from government to the pharmaceutical industry and then back to government. The US Dispute with Brazil, on Behalf of Merck and Pfizer, About HIV Drugs <blockquote>When [William] Daley was commerce secretary in the later years of the Clinton administration, Brazil rankled U.S. drug companies by opting to provide its citizens with a generic version of another HIV drug. Like Thailand, Brazil declared a public health emergency in an effort to lower the cost of treating roughly a half-million HIV infections. The U.S. government responded by sending Daley to Brazil with executives from U.S. pharmaceutical giants Merck & Co. and Pfizer to try to pressure the Brazilian government into reversing its decision.</blockquote>Thus the US government appeared to be putting the revenues of US corporations ahead of the public health, at least in Brazil. Daley soon made the transition to the private sector: <blockquote>In a speech at Johns Hopkins University before leaving for Brazil, Daley encouraged students to enter the revolving door between big business and public policy-making. 'Let me say this: As one of the only members of the president's Cabinet to come from business, it's good when you mix both government and business in your careers,' he said. 'It makes better public servants, and it makes better businesspeople.' It has certainly been good for Daley's career. His effort to twist arms in Brazil failed, but drug companies apparently took note. It was after leaving the Clinton administration that Daley was hired by Abbott, where he raked in more than $1.3 million as a board member from 2004 to 2010, according to Securities and Exchange Commission filings. Over the same period, he served on Boeing's board and was a top lobbyist for JPMorgan Chase.</blockquote>Abbot's Dispute, Supported by the US Government, with Thailand About Kaletra Soon Abbot was involved in a similar dispute. The background is: <blockquote>[HIV drug] Kaletra costs more than $10,000 a year for a patient living in the United States, a price that is reflective of the highly protective American patent system. The U.S. is the only country that grants long-term monopolies on life-saving medicine without regulating the price of monopolized drugs. </blockquote> In addition <blockquote>In countries that negotiate with companies on drug prices, the cost of medicine is often far lower. But though American pharmaceutical companies do supply drugs to developing nations at rates below those charged in the U.S., those discounted prices are still too high for many poor or hard-hit nations to afford. 'In many developing countries, it's a death sentence,'said Nobel Prize-winning economist Joseph Stiglitz, referring to high drug prices.</blockquote> The core of the dispute: <blockquote>In 2007 negotiations with the Thai government, Abbott Labs wouldn't budge below a price of $2,200 per person, per year for Kaletra. At the time, Thailand was classified as a 'lower-middle income' country by the World Bank -- the second lowest of four categories. With more than a half-million citizens living with HIV, Thailand considered that price beyond its budgetary capacity. So it declared a public health emergency and began importing a vastly cheaper generic version of Kaletra from India. And then, by international trade standards, all hell broke loose. 'When countries declare the health emergency, they face a huge backlash, particularly from the USTR [US Trade Representative] and the drug companies,'said Tim Boyd, policy research coordinator with the AIDS Healthcare Foundation, a U.S. nonprofit dedicated to eradicating HIV. Abbott responded by withdrawing pending applications to register drugs in Thailand, cutting its citizens off from other medications. The move was unprecedented: Never before had an American drug company attempted to punish a country during drug price negotiations by cutting off the supply of other medicines. At the time, Brook Baker, a law professor at Northeastern University and a member of the board at the Health Global Access Project, called the move a 'ruly appalling example of corporate hubris'that 'irectly violates any conceivable norm of corporate responsibility.'</blockquote> At that time, the US government went along with Abbott: <blockquote>As for the USTR, it seemed to support the company, placing Thailand on its 'Priority Watch List 'of nations that do not respect U.S. intellectual property rights. 'In late 2006 and early 2007, there were further indications of a weakening of respect for patents, as the Thai Government announced decisions to issue compulsory licenses for several patented pharmaceutical products,' wrote the agency in its report announcing that Thailand had been added to the priority list. Although the USTR blacklist is little known domestically, it is a major economic indicator abroad and can affect a country's ability to import everything from software to DVDs to automobiles. Thailand's new status as an international rogue sparked concern among the country's economic policy officials and corporate leaders. And 35 members of Congress wrote to the USTR to protest Thailand's blacklisting, noting, 'The move is being interpreted in the public health community as a warning and a threat to other countries.'</blockquote> Note that: <blockquote>Abbott Labs declined to detail Daley's involvement in the Thailand episode, but as a member of the board, he should have been well informed about the strategy.</blockquote> US Government Pressure to Protect Drug Companies' Patents William Daley has transitioned the revolving door again in the other direction: <blockquote>As commerce secretary under Bill Clinton, William Daley worked with U.S. pharmaceutical giants to curb the use of cheaper generic drugs abroad. As a board member for Abbott Laboratories, he had a front-row seat on a brutal clash between a major drug company and a developing nation over access to life-saving medication. And as White House chief of staff today, Daley has President Barack Obama’s ear.</blockquote> In his new government job, <blockquote>Add up Daley’s power and experience, and experts who follow public health policy suspect his influence in the U.S. stance in negotiations over a major international trade deal -- a stance with hugely profitable implications for giant American drugmakers. The United States is in talks with eight other Pacific nations to establish the Trans-Pacific Partnership, which the administration hopes will serve as a template for other trade pacts. According to leaked documents from the negotiations, the Obama administration is using the deal to push hard-line intellectual property standards that could drive up medicine prices overseas, boosting the bottom line for U.S. drugmakers like Abbott Labs at the expense of public health. Public health advocates are worried. 'If the point of the trade policy is not just to protect the interests of our companies, but the public health benefit and burden of research, then [the United States] is doing this all wrong,' said James Love, director of Knowledge Ecology International, a nonprofit that focuses on how patent laws affect the poor. A White House spokesman said only that the negotiations -- which are being conducted behind closed doors with input from corporate lobbyists -- are being 'ably led' by the United States Trade Representative (USTR) and that Daley is 'not directing or participating in those negotiations.'</blockquote> Note that the USTR leadership includes other travelers through the revolving door: <blockquote>Daley's personal history with drug access is not unique among top-tier government officials with trade responsibilities. McCoy lobbied on intellectual property issues at the influential D.C. law firm Covington & Burling before moving to the USTR in 2006. His top deputy, Kira Alvarez, was a lobbyist for drugmaker Eli Lilly before joining the agency.</blockquote> Summary Per Zach Carter, the author of the Huffington Post article: <blockquote>Daley, who previously lobbied for JPMorgan Chase, is a prominent examplar of a bipartisan phenomenon in American government in which corporate insiders, and the profit-driven perspective of the boardroom, have come to dominate formal and informal debate over public policy.</blockquote> Another way to describe this is corporatism. The corporatism in this case is partly enabled by the continuation of the revolving door, the free transit of individuals from leadership positions in top corporations and in government. The government and big corporations have teamed up to produce solutions that may seem beneficial to the people making the decisions, and may benefit their long term career strategies, but may not be good for the US public, for patients' and the public's health in this case, and for the ability of the country to conduct foreign policy based on some ethical and moral principles. By the way, note that combined with other cases we have discussed, this shows that the revolving door pheonomenon, and other aspects corporatism affecting health care are not linked with any one political party. So, <blockquote>There is no evidence that any of these players, including Daley, have done anything illegal or explicitly corrupt during the Trans-Pacific trade negotiations. But public health doesn’t seem to be their first priority. 'The real concern is that the U.S. is using its international power and prestige to force poor countries to enforce our intellectual property standards, and the result of that is that access to medicine is denied and people are dying,' said Joseph Stiglitz.</blockquote>Until we dispel the fog of corporatism that has spread over the government that was once supposed to be of the people, by the people, and for the people, expect no real health care reform, and expect continuing rising costs, declining access, and worsening patient care. Obviously, true health care reform would start with the government and its officials putting patients' and the public's health first, way ahead of the financial comfort of corporate leaders. xx

Enabled by the Revolving Door, Corporatistic US Trade Policy Seems to Put US Drug Companies Ahead of Global Public Health

We just discussed how leaders of big health care corporations with histories of ethical and legal missteps want to export our supposedly ...

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Spend Billions More on HIT When Public-Health Services Get Crunched by Budget Woes?

I have the answer to these cutbacks of pubic health services. In the midst of economic chaos, let's spend tens of billions or even better, hundreds of billions of dollars more on experimental healthcare IT. (It <a href="http://hcrenewal.blogspot.com/2011/09/npfit-programme-going-pffft.html">worked out so well for the UK's NPfIT</a>, we should follow the NHS's example of how to wisely spend our crucial healthcare billions.) I will comment no further: <blockquote>Wall Street Journal Health Blog October 5, 2011, 10:00 AM ET <a href="http://blogs.wsj.com/health/2011/10/05/public-health-services-get-crunched-by-budget-woes/" style="font-weight: bold;">Public-Health Services Get Crunched by Budget Woes</a> By Betsy McKay Immunizations, emergency preparations for hurricanes, and restaurant inspections are among local public-health services being cut back or eliminated amid budget constraints. Some 55% of the nation’s county and city health departments reduced or eliminated at least one program between July 2010 and June 2011, and the public-health workforce continued to shrink, according to a new survey by the National Association of County and City Health Officials. The cuts hit maternal and child health services (at 21% of the departments reporting cuts), personal health services (20%), emergency preparedness (20%), chronic disease screenings (17%), and food safety (11%), among other programs. Health departments lost 5,400 jobs in the first half of this year, after losing 6,000 in all of 2010. There are currently about 120,600 local health department employees across the country after those cutbacks. While the workforce has been shrinking since 2008, the downsizing “is now eating into program capacity,” says Robert Pestronk, NACCHO’s executive director. Particularly worrying are the cutbacks in emergency-preparedness programs, he says. “It’s troublesome given what we’re seeing in terms of weather conditions and threats in communities,” he tells the Health Blog. Health-department employees help plan for emergencies such as hurricanes, make sure supplies are in place and work as responders. Meantime, cutbacks in immunization programs are making it harder for some children to get needed polio, tetanus and other preventive vaccinations, while reductions in food-safety programs mean fewer restaurant inspections or staff to interview people sickened in a food-borne illness outbreak, Pestronk says. These woes aren’t limited to local health departments. The Centers for Disease Control and Prevention has seen its budget for preparedness and response fall by more than $350 million since 2005, to about $832 million in fiscal 2011. That challenges the CDC’s ability to respond to a pandemic like the type featured in the recent bio-thriller “Contagion,” Rear Admiral Ali Khan, the CDC’s chief of public health preparedness and response, <a href="http://blogs.wsj.com/health/2011/09/09/contagion-screening-a-busmans-holiday-for-cdc-staffers/" target="_blank">told the Health Blog at a screening of the film</a>.</blockquote> Also see my March 2010 post "<a href="http://hcrenewal.blogspot.com/2010/03/hospitals-under-knife-sacrificing.html">Hospitals Under the Knife: Sacrificing Hospital Jobs for the Extravagance of Healthcare IT?</a>" where I observed: <blockquote>... In effect, NY hospital physicians, nurses and support staff will lose their job due to budget shortfalls, at the same time the NY hospitals have been spending hundreds of millions of dollars on the extravagance of experimental clinical IT systems whose benefit is still an unknown. Perhaps some of those millions could have been better spent on human beings, such as employees or better yet, patient care.</blockquote> -- SS

Spend Billions More on HIT When Public-Health Services Get Crunched by Budget Woes?

I have the answer to these cutbacks of pubic health services. In the midst of economic chaos, let's spend tens of billions or even bette...

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Exporting the US "Health Ecosystem" and its "Wonderful Technology, Wonderful Approaches," or Exporting "A Parasite Eating Its Host?"

Last week, an <a href="http://www.startribune.com/business/130604608.html">article </a>in the Minneapolis Star-Tribune suggested that our US corporate health care giants think they are doing such a good job they want to export the "world's best health care system" overseas: <blockquote>A coalition of U.S. health care businesses, including Minnesota-based UnitedHealth Group and Medtronic, proposes to rebuild America's battered economy by selling the country's 'health ecosystem' internationally. The Alliance for Healthcare Competitiveness (AHC) wants the U.S. government to build its foreign free-trade policy around the health care industry, noting that the sector has been a significant jobs creator since the recession began in 2008. Breaking down tariffs and other forms of international discrimination against America's 'health ecosystem' will allow developing countries such as China, India and Brazil to improve medical care while allowing U.S. companies to rescue the American economy by hiring more people, AHC leaders said Monday. The worldwide need for health care in aging populations will lead to a demand for goods and services that can drive sales of American insurance, medical devices and record-keeping technology, said Simon Stevens, UnitedHealth's president of global health and an AHC member.</blockquote> AHC members seem really convinced of the value of what they have to sell: <blockquote>'We've got a lot of wonderful technologies, wonderful approaches,' said Alex Gorsky, Johnson & Johnson's vice chairman. </blockquote> The Star-Tribune did note that our "health ecosystem" is <blockquote>beset with skyrocketing costs and inefficiencies. Americans currently pay more for health care and rank lower in life expectancy and infant mortality than much of the developed world.</blockquote> The article also managed to find one slightly dissenting expert, <blockquote>'It seems ironic, at best,' said Jean Abraham, a professor of health policy and management at the University of Minnesota</blockquote> Let me add a little more irony. The AHC advocates are top leaders at UnitedHealth and Johnson and Johnson. UnitedHealth Group's Sorry Record UnitedHealth would be the company whose CEO once was worth over a billion dollars due to back dated stock options, some of which he had to give back, but despite all the resulting legal actions, was still the ninth best paid CEO in the US for the first decade of the 21st century (look <a href="http://hcrenewal.blogspot.com/2010/08/despite-scandal-former-unitedhealth-ceo.html">here</a>). UnitedHealth would be the company whose current CEO made a cool $106 million in 2009 (look <a href="http://hcrenewal.blogspot.com/2010/08/can-1-billion-group-of-babies-provide.html">here</a>). Howver, UnitedHealth would also be the company known for a string of ethical lapses: - as <a href="http://www.courant.com/business/hc-natbizdigbrf0530.art2may30,0,109447.story">reported</a> by the Hartford Courant, "UnitedHealth Group Inc., the largest U.S. health insurer, will refund $50 million to small businesses that New York state officials said were overcharged in 2006." - UnitedHalth promised its investors it would continue to raise premiums, even if that priced increasing numbers of people out of its policies (see post <a href="http://hcrenewal.blogspot.com/2008/05/commercial-managed-care-organizations.html">here</a>); - UnitedHealth's acquisition of Pacificare in California allegedly lead to a "meltdown" of its claims paying mechanisms (see post <a href="http://hcrenewal.blogspot.com/2008/01/bungled-not-brilliant-results-of.html">here</a>); - UnitedHealth's acquisition of Sierra Health Services allegedly gave it a monopoly in Utah, while the company allegedly was transferring much of its revenue out of the state of Rhode Island, rather than using it to pay claims (see post <a href="http://hcrenewal.blogspot.com/2007/03/unitedhealth-declares-health-care.html">here</a>) - UnitedHealth frequently violated Nebraska insurance laws (see post <a href="http://hcrenewal.blogspot.com/2007/01/on-performance-on-one-supposedly.html">here</a>); - UnitedHealth settled charges that its Ingenix subsidiaries manipulation of data lead to underpaying patients who received out-of-network care (see post <a href="http://hcrenewal.blogspot.com/2009/01/unitedhealth-and-ingenix-settles.html">here</a>). - UnitedHealth was accused of hiding the fact that the physicians it is now employing through its Optum subsidiary in fact work for a for-profit company, not directly for their patients (see post <a href="http://hcrenewal.blogspot.com/2011/07/here-comes-your-new-doctor-brought-to.html">here</a>). Johnson and Johnson's Sorry Record Johnson and Johnson also would be the company known for recalling heroic numbers of products, 26 different recalls since 2009, the latest, of Eprex, two weeks ago (see the WSJ Health blog recall watch <a href="http://blogs.wsj.com/health/2011/09/23/jj-recall-watch-eprex-anemia-drug-pulled-on-potency-worries/">here</a>.). Johnson and Johnson also has an amazing recent record of ethical lapses and guilty pleas, including: -  Convictions in two different states in 2010 for misleading marketing of Risperdal -  A guilty plea for misbranding Topamax in 2010 -  Guilty pleas to bribery in Europe in 2011 by J+J's DePuy subsidiary -  A guilty plea for marketing Risperdal for unapproved uses in 2011 (see <a href="http://hcrenewal.blogspot.com/2011/08/why-cultivate-weldons-confidence-ceo.html">this link</a> for all of the above) -  Accusations that the company, which makes smoking cessation products,  participated along with tobacco companies in efforts to lobby state legislators (see post <a href="http://hcrenewal.blogspot.com/2011/09/smart-alecs-strange-bedfellows.html">here</a>) -  A guilty plea to misbranding Natrecor by J+J subsidiary Scios (see post <a href="http://hcrenewal.blogspot.com/2011/09/johnson-and-johnson-pleads-guilty.html">here</a>) With the justification that "he met expctations," so despite, or maybe because of all this, Johnson and Johnson paid its CEO $29 million in 2010 (see post <a href="http://hcrenewal.blogspot.com/2011/03/despite-recalls-legal-settlements.html">here</a>). Summary   So maybe UnitedHealth Group and Johnson and Johnson want to quickly export their brilliance before someone else realizes how bad their corporate records are, and takes action in response.  Note that the "international discrimination" against such companies noted above could simply be another description of better regulatory systems in other countries which are more able to defend against the sorts of sleazy behavior that has plagued US health care.  If US "free-trade" policy succeeds in challenging such regulation, other developed countries, which provide generally better health care at lower costs, could become more susceptible to catching the US health care dysfunction syndrome.   For more pithy comments, Minneapolis Public Radio published a <a href="http://minnesota.publicradio.org/display/web/2011/09/30/durenberger/">commentary</a> by David Durenberger in which he noted: <blockquote>A physician I know read a story in Tuesday's newspaper at about the same time I did, 6 a.m. By 8 we'd found that we were having identical reactions to this absurdity. But he had a better way of expressing it: 'It's like a parasite eating its host.' 'They have bankrupted our culture, so now they want to try and bankrupt China and India,' he said. </blockquote> Of course, if maybe we could export all of Johnson and Johnson, UnitedHealth Group, and other corporations with similarly bad records of crimes, legal settlements, ethical missteps, and bad leadership to India and China, maybe our health care system would start recovering from its dysfunction (but then pity the poor Chinese and Indians). Maybe the corporate leaders quoted above suffer from the same apparently complete lack of insight that another health care CEO (actually former CEO) exhibited recently (look <a href="http://hcrenewal.blogspot.com/2011/09/do-health-care-leaders-realize-they-do.html">here</a>). However, such glaring inability to perceive one's own problems surely will lead them to grief in the near future. Our corporate health care giants have already lead our dysfunctional health care system to enough grief. True health care reform would favor leaders of health care organizations who understand the health care context, and uphold health care professionals' values, and have enough insight to realize when they are falling short of these standards. Meanwhile, rest assured that US health care is the system where nothing can go wrong, go wrong, go wrong.

Exporting the US "Health Ecosystem" and its "Wonderful Technology, Wonderful Approaches," or Exporting "A Parasite Eating Its Host?"

Last week, an article in the Minneapolis Star-Tribune suggested that our US corporate health care giants think they are doing such a good j...

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How the Rich and Influential Get Health Care Different from You and Me: Data About How Very Influential Persons Get Expedited Care

An MSNBC <a href="http://www.msnbc.msn.com/id/44723391/ns/health-health_care/#.Ton_TnK5LDU">story</a> summarized some new data about how at least a particular subset of the rich can get different health care from you and me: Expedited Care for the Influential <blockquote>In a letter published in this week’s Annals of Emergency Medicine, Dr. A.J. Smally of Hartford Hospital and the University of Connecticut reports that more than half of the 33 emergency department medical directors in his state said they routinely provide so-called 'expedited' care to influential people.</blockquote> The influential people here include "corporate donors, hospital administrators, or, say, the brother-in-law of the president of the board of directors." This was corroborated by "a survey of 100 emergency doctors nationwide" which showed that "84 of them had given or would given extra attention to an influential person, such as a famous person or a hospital donor." Dr Smally asserted, "emergency triage protocols mandate treating the sickest patients first, no matter their social status." However, he also acknowledged that influential people will get treated more quickly, <blockquote>'Somebody calls and says so-and-so is coming in, can you make sure they get good care,' Smally said. 'We bump them up a notch. If everyone is waiting four hours, they might just wait one hour.'</blockquote>Better "Hotel Services" The article also noted that influential people are likely to get better "hotel services" from hospitals, presumably at no extra cost to them: <blockquote>to the head of the Association for Healthcare Philanthropy, a 5,000-memeber organization dedicated to boosting donations, tending to contributors when they’re sick or injured is just part of doing business. 'It is true, we pay attention to our donors,' said Bill McGinly, president and CEO of AHP, who says most development departments are alerted when VIPs enter their hospitals. 'They’ve gone above and beyond. We recognize that their contributions can make a difference to the community.' In some cases, that care can border on coddling. At Norwalk Hospital in Norwalk, Conn., donors who contribute $100,000 or more are known as 'Navigators' who receive not only a place at the front of the line, but top-tier attention as well. 'We help the family in any which way that we can,' said Carol Brennan-Smith, communications manager for the Norwalk Hospital Foundation. 'If their cell phone has no juice or they need a battery charger. It can be ‘I want lemonade, I want a Ben and Jerry’s Cherry Garcia ice cream.’ If we can do it, we will.' </blockquote> Grumbling and a Little Dissent The ER docs involved also seemed unwilling to question the practic, although they did not seem perfectly comfortable with it: <blockquote>grumbling is common, but to Smally and other ED docs, there’s little moral dilemma. Dr. Michael Carius, chair of the emergency department at Norwalk Hospital, home of the 'Navigators,' said he’s confident that no one is harmed by the practice — and that it actually may wind up doing greater good. 'This is a way of building good will so that when there is a need the hospital has, there’s this favor bank,' he said.</blockquote> The article only noted briefly that not all would agree with him: <blockquote>ethicists and patient advocates worry that improved access for VIPs undermines the public mission of community emergency rooms and raises sharp questions about health care equality. 'It’s not fair at the micro-level and I’m not sure it’s fair at the macro-level,' noted Laura Weil, former director of the Health Advocacy Program at Sarah Lawrence College in Bronxville, N.Y. </blockquote> In my humble opinion, the data and anecdotes summarized in the article raise a host of issues that deserve further thought. Can the Self-Interested Be Donors, and Should They Receive Favored Treatment from the Government? First, let us address the issue of donors receiving better "hotel services." I am not sure there are problems with offering better hotel services, as long as they have no direct effect on medical care, for a price to anyone who is willing to pay. However, the article suggests that the donors receive special services that might not be available to anyone else, even for a price. If so, that challenges their claim to be donors. Donation implies a lack of self interest, and is honored socially, and financially by the US Internal Revenue Service in the form of a tax deduction. If donors are receiving special consideration in return for their donation, their donations may actually be self-interested means to get services they could not buy on the open market, and do not deserve honor. Even if the donation was given expecting a partial quid pro quo in the form of a service that could otherwise be obtained by others for a price, to the extent that the donations included money paid for services, they may not deserve tax deductions. If the hospitals did not report the donation less the price of the services received in exchange for it, or if the donors did not subtract this amount from their donation before deducting it from their taxes, it might be worth an IRS investigation, perhaps both of the hospitals' non-profit status and the donors' personal tax returns. I hope the IRS is paying attention to this issue. Is It Ethical to Give Patients Who Are Not Donors Slower Care for Acute Illnesses? A much bigger problem is the data suggesting donors, hospital executives, and their relatives may get not only cushier hotel services, but more rapid emergency department care.  Since emergency departments are often operating near capacity, this rapid care for some may mean slower care for others.  In many cases, slower care means more pain, more suffering, more morbidity, and in certain cases, a higher likelihood of dying. Physicians have an ethical obligation to put each patient's interests ahead of other concerns (like attracting more donations to the hospital). It seems unethical to me to put a less sick patient ahead of a more sick patient because the former is an influential person. Knowing that sick patients sometimes get delayed care to make way for a VIP may open a whole new area of legal discovery for plaintiffs' lawyers seeking to litigate against hospitals when patients suffer from slow care in the Emergency Department. I hope plaintiffs' attorneys are paying attention to this issue. There may also be legal issues for hospitals if the law requires them to make emergency care available to all acutely ill patients. If some hospitals delay emergency care for some acutely ill patients to provide expedited care for some less acutely ill patients because they are influential, there may be legal ramifications. I hope the US Department of Justice, state attorneys general, and state departments of health are paying attention to this issue. Does Insulating the Rich and Powerful from the Dysfunctional Health Care System Make for Bad Health Care Policy? Finally, there is a larger health policy issue. At least a few of my fellow health care dissenters has been known to grimly opine that no real health care reform will take place until some big-wig, or his or her child, spouse, lover, sibling, or parent gets really bad care at the hands of our dysfunctional health care system. However, it appears that the rich and powerful have found ways to make this improbable. In a number of ways, the rich and powerful have found ways to engineer a deluxe health care system for themselves. We have <a href="http://hcrenewal.blogspot.com/search/label/executive%20health%20plans">posted</a> how big corporate executives have access to "executive health insurance" which provides benefits beyond what any normal person can obtain, even from seemingly the best employer paid policy. In 2007, we <a href="http://hcrenewal.blogspot.com/2007/11/academic-medical-center-with-a-list.html">posted</a> about how one academic medical center had an "A-list" of influential people who got special amenities and more rapid care. Now there is data to suggest this may be common practice. If the rick and powerful can insulate themselves from the dysfunction of the current health care system, do not expect their sympathy or support in reforming this system. It appears that to truly reform health care, we will have do something about the context, call it a new gilded age, new age of the robber barons, oligarchy, plutocracy, or age of crony capitalism, in which it exists.

How the Rich and Influential Get Health Care Different from You and Me: Data About How Very Influential Persons Get Expedited Care

An MSNBC story summarized some new data about how at least a particular subset of the rich can get different health care from you and me: E...

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All The News That's Fit to Print: New York Times Notices UK National Health IT Project Goes "PfffT"

At my Sept. 22, 2011 post "<a href="http://hcrenewal.blogspot.com/2011/09/npfit-programme-going-pffft.html">NPfIT Programme goes PfffT</a>" I wrote about the £12.7bn National Programme for IT in the NHS (National Health Service) in the UK being ended after years of delays, technical difficulties, contractual disputes and rising costs. I had predicted this for years. Now the New York Times has felt this to be News Fit to Print. The NYT may be alone in terms of US coverage of this situation by national newspapers: <blockquote> September 27, 2011, 7:40 am <a href="http://bits.blogs.nytimes.com/2011/09/27/lessons-from-britains-health-information-technology-fiasco/#preview">Lessons From Britain’s Health Information Technology Fiasco</a> New York Times By STEVE LOHR Government press releases tend to be bland, earnest blather. But not one posted on the British Department of Health’s Web site last Thursday. Its headline: “Dismantling the NHS National Programme for IT.” To translate the acronyms a bit, the NHS is Britain’s state-run National Health Service and the program in question was the ambitious drive to computerize England’s health records and let doctors, clinics and hospitals share patient information electronically. The project, begun in 2002, was budgeted at £12 billion (about $19 billion) and the government hailed it as “the world’s biggest civil information technology program.”</blockquote> Now, regrettably, it likely holds the honor as the "world's biggest civil IT failure." <blockquote> The British digital health project has been a slow-motion train wreck for some time with last week’s announcement mainly confirmation — and a pledge to change course. (The announcement was also a political gesture, as the Conservative government of David Cameron tries to get as much distance as it can from an unpopular initiative, begun by Tony Blair’s Labor government.) </blockquote> I addressed train wrecks at my Jan. 20, 2011 post "<a href="http://hcrenewal.blogspot.com/2011/01/healthcare-it-delirium.html">Healthcare IT Delirium</a>" and showed this picture and caption, only with respect to our own 'National Program for IT in the HHS': <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjurXqPDZbtzCsG-_L8uwSwAUR90Yw_1SpoUtX9Z8b_iS7Afci5-DzUztihtDx1qGNL68ZZmBr1Pg6HEORmpCQ5yg0jZzwky8VaUUQUP1RNqZ9w_oo5bFCGx-EGpFk-5EYXXMOeOLAGOPS/s1600/trainwreck.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5658274380489189922" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjurXqPDZbtzCsG-_L8uwSwAUR90Yw_1SpoUtX9Z8b_iS7Afci5-DzUztihtDx1qGNL68ZZmBr1Pg6HEORmpCQ5yg0jZzwky8VaUUQUP1RNqZ9w_oo5bFCGx-EGpFk-5EYXXMOeOLAGOPS/s320/trainwreck.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 196px; height: 236px;" /></a>Running off the rails. We seem to be going out of our way looking for this with HIT, sending it out full speed ahead on far too short a track ... </div> Back to the NYT: <blockquote>Yet the United States is about to begin its own government-funded drive to accelerate the adoption of electronic health records, with Washington set to hand out more than $20 billion in incentive payments over the next five years. So what are the lessons to be learned from the English experience?</blockquote> The lessons are mostly covered in this article: <blockquote>Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand). Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT. <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Goldfinch_pessimism_PAR.pdf">link</a> to pdf</blockquote> In that article's abstract is nearly all a citizen needs to know: <blockquote>The majority of information systems developments are unsuccessful. The larger the development, the more likely it will be unsuccessful. Despite the persistence of this problem for decades and the expenditure of vast sums of money, computer failure has received surprisingly little attention in the public administration literature. This article outlines the problems of enthusiasm and the problems of control, as well as the overwhelming complexity, that make the failure of large developments almost inevitable. Rather than the positive view found in much of the public administration literature, the author suggests a pessimism when it comes to information systems development. Aims for information technology should be modest ones, and in many cases, the risks, uncertainties, and probability of failure mean that new investments in technology are not justified. The author argues for a public official as a recalcitrant, suspicious, and skeptical adopter of IT. [Irrational exuberance is forbidden! - ed.] </blockquote>Back to the NYT article again: <blockquote>I asked three of the best-informed experts on this subject, with firsthand experience in government and health policy: Dr. David J. Brailer, the national coordinator for health information technology in the Bush administration; Dr. David Blumenthal, who held that position in the Obama administration for two years, before recently returning to Harvard; and Richard C. Alvarez, chief executive of the Canada Health Infoway, the nonprofit corporation established to push the adoption of electronic health records in Canada. Here are some of their comments. Dr. Brailer on the problem: “What we’re seeing in Britain is the final result of a number of fundamentally bad decisions. … It was classic top-down re-engineering that was forced upon physicians and nurses. The British government treated it as a big procurement program, putting out bids, selecting contractors, picking winners and concentrating their bets. They crushed what had been a pretty vigorous health information technology marketplace in Britain.”</blockquote> In 2006 or so at a national informatics meeting, I asked David Brailer, then Director of ONCHIT (now ONC) and who I knew from his role prior to that, the question "The UK's NPfIT is having severe difficulties. What are we in the US to do regarding our own program?" His response: we will learn from their mistakes. Have we done that? I don't really think so. <blockquote> ... Mr. Alvarez on how Canada and the United States are doing things differently than Britain: “As governments, we’re setting strategy, standards and outcomes in terms of what qualifies as the meaningful use of electronic health records. But we’re not doing the implementation. [Or product selection - ed.] That has to be done at the local level.”</blockquote> Considering the sorry state of the healthcare IT ecosystem (<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=ecosystem">link</a>), and considering that significant problems in the NPfIT were created through their use of <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=granger_speaks_out">American IT vendors and consultants</a>, that may actually be a mistake, as opposed to picking a product or products and producer that have been vetted by true, unconflicted experts instead of bureaucrats. We may have learned the wrong lessons from the UK's experience. Another example where we may have learned the wrong lessons: <blockquote> Dr. Blumenthal on the perils of trying to mandate changes in the work habits of doctors: “In a complex health system, you have an enormous number of independent actors, especially in a system like ours, but in England more than they thought. Physicians and health care professionals have to be part of the process every step of the way. You need to make this a collaborative effort, not a top-down procurement project.”</blockquote> I believe there has to be a balance of the two: one cannot have pure bottom-up or top-down. It does not work in the setting of a national health IT program. Local politics can be (are?) as bad as, or worse than, national politics. <blockquote>Dr. Brailer agreed and elaborated: “The experience in Britain is a warning to us. The thing that brought them to their knees was the confrontation with doctors.”</blockquote> There, I have no arguments, with the additional comment that what also brought them down was this <a href="http://www.packetslut.co.uk/weblog/archives/00000053.htm">Scott Adams adage</a>: <blockquote>IGNORING THE ADVICE OF EXPERTS WITHOUT A GOOD REASON Example: Sure, the experts think you shouldn't ride a bicycle into the eye of a hurricane, but I have my own theory.</blockquote> -- SS Oct. 6, 2011 addendum: Roy Poses opines: <blockquote>InformaticsMD found that the NY Times has now reported on the "slow motion train wreck" that has been the UK NHS electronic health record project. This brings into the mainstream the notions that electronic health records, and other ballyhooed health care information technology is not a panacea, and that rushing what amounts to medical devices into use before they have been fully developed and adequately tested was not a good idea. Note that this is not an effort to bash the British. In the US we have not had any obviously better ideas about using health care IT, and much of the technology is shared across countries and marketed by multinational companies. But IMHO, health care IT has been pushed in many countries because it has benefits for big health care organizations: 1) Government agencies (bureaucrats love having numbers to crunch, and health care IT facilitates the use of the guidelines they love to push to show they care about health care quality); 2) Health care insurance companies, non-profit or for-profit (because it facilitates their transactions, and facilitates guidelines as above); but also 3) Drug and device companies (because it allows incorporation of the clinical guidelines they have worked to hard to manipulate to market their products); 4) Hospitals and hospital systems (because it gives their managers more numbers to crunch, and more oversight and power over health care professionals); 5) Not to mention, of course, health care technology corporations. [I added the numbering - ed.] In some ways, health care IT benefited from a perfect storm of concordant interests of big health care organizations, but not necessarily from the interests of health care professionals or, most importantly patients. The lesson, again, is that patients' and the public' health, and health care professionals' core values need to take precedence over vested interests of for-profit companies or government agencies.</blockquote> This taxonomy of why health IT has been pushed is rather predictive of the ills seen with this experimental technology. -- SS

All The News That's Fit to Print: New York Times Notices UK National Health IT Project Goes "PfffT"

At my Sept. 22, 2011 post " NPfIT Programme goes PfffT " I wrote about the £12.7bn National Programme for IT in the NHS (Nationa...

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