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Hype, Spin and Health Care: the Case of an Apparently Failed Hospital Purchase by Steward Health Care

Health care is drowning in a sea of hype and spin.  We have frequently posted about <a href="http://hcrenewal.blogspot.com/search/label/deception">deceptive</a> <a href="http://hcrenewal.blogspot.com/search/label/marketing">marketing</a> used to sell drugs, devices, and health care services.  We have also posted about deceptive <a href="http://hcrenewal.blogspot.com/search/label/public%20relations">public relations</a> and<a href="http://hcrenewal.blogspot.com/search/label/stealth%20lobbying"> lobbying</a> used to sell policy positions and strategies favorable to health care organizations, and usually most favorable to their leaders. Nevertheless, there rarely is much public skepticism about or criticism of such marketing and public relations messages when they appear.  Rather, often the media and other public voices, including those of politicians with power over the relevant public policy issues, seem to accept the messages at face value. The Case of Steward Health Care and Landmark Medical Center The Buy-Out Falls Apart Therefore, it is instructive to look at examples of how such messages in retrospect appear to be fallacious, to use a polite term.  A local example that just popped into view was documented in two short news items by Felice Freyer in our own Providence Journal.  (Web access to a longer version story that appeared in the print version of the journal is <a href="http://digital.olivesoftware.com/Olive/ODE/ProJo/LandingPage/LandingPage.aspx?href=VFBKLzIwMTIvMDkvMjc.&pageno=MQ..&entity=QXIwMDEwMA..&view=ZW50aXR5">here</a>.)  The <a href="http://news.providencejournal.com/business/2012/09/deal-to-sell-woonsocket-hospital-to-steward-may-be-falling-apart.html">first item</a> included, <blockquote>The deal to sell Landmark Medical Center to Steward Health Care System may be falling apart. In a court filing this week, Jonathan N. Savage, the special master in charge of the hospital, made reference to the possibility that Steward would withdraw. The Boston hospital group faces a Sept. 30 deadline to complete the sale. </blockquote>The Message Promoted by Steward Health Care  We have <a href="http://hcrenewal.blogspot.com/search/label/Steward%20Health%20Care">blogged</a> about the rapid expansion of Steward Health Care, despite the name, a for-profit company owned by private equity/ leveraged buyout firm <a href="http://hcrenewal.blogspot.com/search/label/Cerberus">Cerberus Capital Management</a>. Steward has hyped its supposedly world class "new health care" model in its advertising (look <a href="http://hcrenewal.blogspot.com/2012/08/private-equity-obfuscatory-advertising.html">here</a>). In promoting its bid for Landmark, Steward's well-paid CEO (look <a href="http://hcrenewal.blogspot.com/2012/07/steward-health-care-vs-rhode-island.html">here</a>), displayed his vision for promoting the medical center through "economies of scale," "right-siting," and emphasizing ties with the community: "it's not a community hospital system. It's really a health care system," as reported by Felice Freyer in April, 2012 (Freyer F. Landmark Medical Center. A Leap into the unknown. Providence Journal, April 22, 2012.)  In a dispute over payment rates with Rhode Island Blue Cross Blue Shield, Steward ran full-page newspaper advertisements claiming that insurance companies leaders issued an order to "terminate Landmark Medical Center," because they did not care if "residents would lose their only hospital, ... employees ... would lose their jobs, or the elderly ... would have to travel for care." (Look <a href="http://hcrenewal.blogspot.com/2012/07/steward-health-care-vs-rhode-island.html">here</a>.) That implied, of course, that Steward, which did not mention that it is a for-profit corporation owned by a private equity firm in the ads, cared deeply about the health care of residents of Woonsocket. Some Skepticism, but More Acceptance The article by Felice Freyer above did feature journalistic skepticism and include interviews with some local physicians who questioned whether Steward could possibly fulfill all its promises to simultaneously increase the quality of care and reduce costs. However, the article showed that there was lots of positivity about Steward's track record in neighboring Massachusetts. Predictably, the President of Steward owned Quincy Medical Center boasted, "Not one person has been laid off. We have not reduced any service lines. Our focus is on enhancing." However, some people who were apparently independent of Steward also had favorable views.  A Massachusetts consumer advocate said "as far as we know, it's going fine." A Brandeis University Professor said, "it's impressive how successful they've been." The Politicians' Buy In Elsewhere, there were plenty of statements of support for Steward by local politicians.  The Mayor of Woonsocket supported Landmark (and implicitly Steward) it its dispute with RI BCBS, as <a href="http://news.providencejournal.com/breaking-news/2012/07/woonsocket-mayo-5.html">reported</a> by the Providence Journal, saying that the proposed buyout by Steward "is far too critical for our city, and I must take every step possible to ensure that the interests of the city and those who rely upon Landmark (Medical Center) for healthcare are being protected [by taking Steward's side in the dispute.]" Also, as <a href="http://www.woonsocketcall.com/node/5343">reported</a> by the Woonsocket Call, RI Congressman David Cicilline said, "I look forward to working with Landmark's new administration [that is, Steward] to ensure that it continues to deliver affordable, quality health care and well-paying jobs for hardworking Rhode Islanders." To fulfill Steward's wishes, The Rhode Island state legislature rushed to make its laws about for-profit conversion of non-profit hospitals more lenient (see the <a href="http://www.pbn.com/Legislation-to-speed-Stewards-Landmark-bid-introduced,64973">Providence Business News</a>). The Attorney General Later Says it was All About the "Bottom Line" However, now Steward has apparently pulled out of the deal with nary a public mention of the reason why, much less demonstration of its concern for the poor people of Woonsocket. As reported in a second small <a href="http://news.providencejournal.com/breaking-news/2012/09/ag-steward-leaves-landmark-in-a-worse-positionready.html">item</a> in the Providence Journal, <blockquote>Steward Health Care System, which is apparently backing out of its deal to buy Landmark Medical Center, 'has left the hospital, its patients and its employees in a worse position,' </blockquote><blockquote>Attorney General Peter F. Kilmartin said in a statement today. 'It has become very clear that Steward's only interest was the bottom line, not, as the Company claimed, the patients, the employees or the Woonsocket community,' Kilmartin said. </blockquote>Summary This is just one local kerfuffle about a small hospital system. However, looking at it in granular detail says a lot about how big health care organizations, like the one that here attempted to buy the local hospital system, push misleading messages to secure their private interests. These misleading messages often promote these organizations' commitments to the traditional health care mission, often in the modern argot of quality, access, and affordability), when their leaders may really care more about short term revenue. This case also shows how at least some local policy makers may be drawn in by such messages, and how the few skeptics get lost in the shuffle. An important feature of the modern, commercialized, laissez faire health care system in the US is the role of opinion manipulation through modern, sophisticated marketing and public relations in promoting the short-term financial interests of health care organizations and their leaders at the expense of patient's and the public's health. This role seems rarely to be discussed, particularly in health care research and policy circles. It may be that some members of the public, health care professionals, and health policy makers are naturally skeptical of marketing and public relations hype, spin, and deception. However, we have seen too many <a href="http://hcrenewal.blogspot.com/2012/05/ceo-as-false-messiah.html">examples</a> of health care leaders promoted as "visionaries" who are anything but. Health care professionals, patients, policy makers, and the public at large ought to be extremely skeptical of the self-serving messages packaged by marketing and public relations. Academics ought to be dissecting these messages more often. Skeptics need to make their voices heard. Meanwhile, look out for the next "visionary," or the next "new health care" promotion. They may not turn out to be what is advertised.

Hype, Spin and Health Care: the Case of an Apparently Failed Hospital Purchase by Steward Health Care

Health care is drowning in a sea of hype and spin. We have frequently posted about deceptive marketing used to sell drugs, devices, and h...

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HIMSS Senior Vice President on Medical Ethics: Ignore Health IT Downsides for the Greater Good

The Health Information Management Systems Society (<a href="http://www.himss.org/" target="_blank">HIMSS</a>) is the large health IT vendor trade group in the U.S.  At a Sept. 21, 2012 <a href="http://blog.himss.org/2012/09/21/will-health-it-increase-fraud-and-abuse/" target="_blank">HIMSS blog post</a>, <a href="http://blog.himss.org/author/jcasillas2/" target="_blank">John Casillas</a>, Senior Vice President of HIMSS Financial-Centered Systems and HIMSS Medical Banking Project dismisses concerns about health IT with the refrain: <blockquote class="tr_bq">... To argue that the existence of something good for healthcare in many other ways, such as having the right information at the point of care when it’s needed, is actually bad because outliers use it to misrepresent claims activity is deeply flawed. Through the best use of health IT and management systems, we have the opportunity to improve the quality of care, reduce medical errors and increase patient safety. Don’t let the arguments of some cast a cloud over the critical importance and achievement of digitizing patient health records. Surely, no one can argue paper records are the path forward. Name one other industry where this is the case. I can’t. Let’s not let the errors of a few become the enemy of good.</blockquote> The ethics of these statements from a non-clinician are particularly perverse. The statement "Don’t let the arguments of some cast a cloud over the critical importance and achievement of digitizing patient health records" is particularly troubling. When those "some" include organizations such as FDA (see FDA Internal 2010 memo on HIT risks, <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html" target="_blank">link</a>) and IOM's Committee on Patient Safety and Health Information Technology (see 2012 report on health IT safety, <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">link</a>) both stating that harms are definite but magnitude unknown due to systematic impediments to collecting the data, and the ECRI Institute having had health IT in its "top ten healthcare technology risks" for several years running, <a href="http://hcrenewal.blogspot.com/2012/03/ecri-institutes-top-health-technology.html" target="_blank">link</a>, the dismissal of "clouds" is unethical on its face. These reports indicate that nobody knows if today's EHRs improve or worsen outcomes over good paper record systems or not.  The evidence is certainly conflicting (see <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html" target="_blank">here</a>). It also means that the current hyper-enthusiasm to roll out this software nationwide in its present state could very likely be at the expense of the unfortunate patients who find themselves as roadkill on the way to the unregulated health IT utopia. That's not medicine, that's perverse human subjects experimentation without safeguards or consent. As a HC Renewal reader noted: <blockquote class="tr_bq">Astounding hubris, although it does seem to be effective.  Such is PC hubris.  Who could ever call for reducing the budget of the NIH that is intended to improve health.  Has health improved?  No. So why does a group with spotty successes if not outright failure never get cut?  It’s not the results, it’s the mission that deserves the funding.  So it’s not the reality of HIT, it’s the promise, the mission, that gets the support.  Never mind the outcome, it’s bound to improve with the continued support of the mission.</blockquote> Is this HIMSS VP aware of these reports?  Does he even care? Does he believe patients harmed or killed as a result of bad health IT (and I know of a number of cases personally through my advocacy work, including, horribly, infants and the elderly) are gladly sacrificing themselves for the greater good of IT progress? It's difficult to draw any other conclusion from health IT excuses such as proffered, other than he and HIMSS simply don't care about unintended consequences of health IT. Regarding "Surely, no one can argue paper records are the path forward" - well, yes, I can.  (Not the path 'forward', but the path for now, at least, until health IT is debugged and its adoption and effects better understood).  And I did so argue, at my recent posts "<a href="http://hcrenewal.blogspot.com/2012/09/good-health-it-v-bad-health-it-paper-is.html" target="_blank">Good Health IT v. Bad Health IT: Paper is Better Than The Latter</a>" and "<a href="http://hcrenewal.blogspot.com/2012/09/a-reason-to-refuse-use-of-ehrs-in-your.html" target="_blank">A Good Reason to Refuse Use of Today's EHR's in Your Health Care, and Demand Paper</a>".  I wrote: <blockquote class="tr_bq">I opine that the elephant in the living room of health IT discussions is that bad health IT is infrequently, if ever, made a major issue in healthcare policy discussions. I also opine that bad health IT is far worse, in terms of diluting and decreasing the quality and privacy of healthcare, than a very good or even average paper-based record-keeping and ordering system.   This is a simple concept, but I believe it needs to be stated explicitly.  </blockquote> A "path forward" that does not take into account these issues is the path forward of the <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">hyper-enthusiastic technophile</a> who either deliberately ignores or is blinded to technology's downsides, ethical issues, and repeated local and mass failures. If today's health IT is not ready for national rollout, e.g., causes harms of unknown magnitude (e.g., see <a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">this query link</a>), results in massive breaches of security as the "Good Reason" post above, and mayhem such as <a href="http://hcrenewal.blogspot.com/2012/09/in-addition-to-nurses-doctors-now-air.html" target="_blank">at this link</a>, then: The best - and most ethical - option is to slow down HIT implementation and allow paper-based organizations and clinicians to continue to resort to paper until these issues are resolved.  Resolution needs to occur in lab or experimental clinical settings without putting patients at risk - and with their informed consent. Anything else is akin to the medical experimentation abuses of the past that led to current research subjects protections such as the "<a href="http://grants.nih.gov/grants/policy/hs/ethical_guidelines.htm" target="_blank">Ethical Guidelines & Regulations</a>" used by NIH. -- SS

HIMSS Senior Vice President on Medical Ethics: Ignore Health IT Downsides for the Greater Good

The Health Information Management Systems Society ( HIMSS ) is the large health IT vendor trade group in the U.S. At a Sept. 21, 2012 HIMSS...

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Good Health IT (GHIT) v. Bad Health IT (BHIT): Paper is Better Than The Latter

An unspoken running assumption of the health IT enthusiast crowd seems to be that any health IT is better than no health IT, because using paper results in mistakes. I offer a different view. At the introduction to <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">my Medical Informatics teaching site</a> I've defined good health IT and bad health IT as follows: <blockquote class="tr_bq">Good Health IT ("GHIT") is defined as IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes.  Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.  .     </blockquote> There are also good paper systems and bad paper systems. I opine that the elephant in the living room of health IT discussions is that BHIT is infrequently, if ever, made a major issue in healthcare policy discussions. I also opine that BHIT is far worse, in terms of diluting and decreasing the quality and privacy of healthcare, than a very good or even average paper-based record-keeping and ordering system.   This is a simple concept, but I believe it needs to be stated explicitly.  In today's healthcare world, where health IT is dominated by <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">hyper-enthusiasts</a> of one motive or another, such an axiomatic statement will probably be viewed as controversial if not heretical.  This blog has numerous postings about health IT debacles, e.g., query links <a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">here</a> and <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy" target="_blank">here</a>, that could not occur with paper systems.  The defects of just one company's products, the only one that publicly reports them to FDA (<a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">link</a>) are frightening in terms of potential consequences. GHIT needs to be promoted and BHIT needs to be eliminated.  That implies a major transformation of the health IT industry and its oversight. -- SS

Good Health IT (GHIT) v. Bad Health IT (BHIT): Paper is Better Than The Latter

An unspoken running assumption of the health IT enthusiast crowd seems to be that any health IT is better than no health IT, because using p...

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No Skin in the Game - A Private Health System for the Very Rich

We have <a href="http://hcrenewal.blogspot.com/search/label/executive%20health%20plans">noted</a> occasional hints that the very rich may have a separate health care system which may shield them from the vicissitudes of our dysfunctional health care system. A broader hint came in an <a href="http://online.wsj.com/article/SB10000872396390444620104578008182459803120.html">interview</a> in the Wall Street Journal. The Company  The subject of the interview was Leslie Michelson, the CEO of Private Health Management.  The activities of the company were defined somewhat vaguely, <blockquote class="tr_bq">an ultra high-end company that borrows from concierge medicine, managed care, applied-sciences research and information technology while fitting into no neat category. The best analogue might be the investment and tax specialists that the affluent employ to run their finances; Mr. Michelson does the same for their health care. 'Like private wealth management, just far more important,' he quips in his modern Beverly Hills offices, all green glass and steel, white walls, white floors.</blockquote> The Clientele The company manages health care for a select clientele: <blockquote>Private Health caters to 'high net worth individuals' and to businesses that retain its services for their executives as a benefit. Mr. Michelson says he serves between 12,000 and 15,000 clients, 'principally in private equity, hedge funds, professional and financial services firms.' </blockquote>Note that the clientele seem to come mainly from the ranks of top executives of financial firms, probably some of the richest of the rich in the US. Rapid Response Team for Acute Illness Private Health Management's most distinctive service is the rapid response team it can "parachute in" to provide care for an acute illness, <blockquote>whenever one of its patients has a medical emergency or complex condition, say, a traumatic brain injury or newly diagnosed cancer. A personal-care team parachutes in, led by a clinician employed by the company, and compiles a brief on the patient. They centralize and digitize the patient's medical records, usually dog-eared paper piles that can run to thousands of pages. Research scientists immerse themselves in the latest findings and treatment regimens for the particular condition involved. </blockquote><blockquote>Tests are double-checked—biopsy tissues are sent to an outside pathologist, MRIs to another radiologist. For an era of targeted therapies, Private Health runs a full battery of molecular diagnostics 'to sequence the entire three billion base pairs of somebody's DNA in a couple of hours,' Mr. Michelson marvels. </blockquote><blockquote>The goal is to ensure an accurate diagnosis and lay out all the treatment options. Private Health functions as a kind of running, independent second opinion. </blockquote>Physician Network In addition, Private Health Management provides access to a network of ostensibly the very best physicians, <blockquote>Mr. Michelson built a series of proprietary algorithms to distinguish 'the few who are the very best' from 'the many who are very good,' based on 'the factors that predict excellence.' For example, the premier caregivers for metastatic cancer are usually academic researchers on the cutting edge, not general oncologists. The best orthopedic surgeons perform many procedures as they master the clinical learning curve, ideally for a single injury. </blockquote><blockquote>His referral database includes 2,200 specialists across 160 medical fields, 'reified into far finer groupings of disease than is standard practice.' He says that 'the world becomes so much clearer when you are able to identify the physician with the deepest and narrowest expertise in exactly what you need.' </blockquote><blockquote>Mr. Michelson says doctors like to belong to his informal network because they're 'interested in excellence and what we stand for.' </blockquote>However, next, <blockquote class="tr_bq"> He adds, with more than a little euphemism, 'In a world in which 98% of the conversations are about cost containment, it's a joy for them to have somebody who's focused on enhancing quality only.' No doubt true, though it probably doesn't hurt that providers also like to have a relationship with his client base, the sort of people who become university patrons or donate a hospital wing.</blockquote>This raises the question of whether doctors in his network may exhibit some greed along with their putative excellence. Questions Begged About How it Works The article actually devoted more space to Mr Michelson rationalizing his business as part of his overall interest in reforming health care than to discussion of how it works and what its implications are.  The short description of the processes above actually raised more questions about how the Private Health System works than it answered.  Some examples are: how could an optimal rapid response team be quickly mobilized given that the nature of acute illnesses may not be immediately apparent?  How would such a team interact within a hospital setting, or does the company have its own parallel hospital system?  What about the rest of medicine and health care outside of acute and intensive care, particularly primary care and management of chronic disease?  How does the referral data base function, and how would a classification that seems focused on the "narrowest expertise" cope with patients with multiple common illnesses or patients with undefined or undiagnosed problems?  These begged questions suggest there may actually be much more to the Private Health Management system than was discussed in the article. Perhaps instead the care provided by Private Health Management might not actually result in better outcomes for its patients.  Consider some other questions: given how hard it is to assess physician performance and measure quality of care, how can Private Health Management be assured that its physicians are really the best of the best?  Given the apparent financial incentives for participating in the system, would the doctors who most appreciate these incentives be likely to provide the best care?  Would the apparent bias of the system toward high technology and super specialized care, would the system over-treat most of its patients?  Summary and Implications Nonetheless, the article provides more evidence that the US has a secretive parallel health care system for the very rich.  The most important implication is that such a system could protect the very rich from the access problems and bureaucratic annoyances that plague ordinary patients in larger dysfunctional health care system.  By thus having "no skin in the game," those among the very rich who are not themselves directly involved with health care would have little reason to care or want to do anything about the problems besetting the larger health care system.  Since the very rich have become increasingly politically powerful, the absence of such interest or motivation for change among them would make true health care reform much more difficult.  If there is a parallel health care system for the very rich, its real effects on health and health care are unknown.  As best as I can tell, the very concept is almost entirely anechoic except for our very limited <a href="http://hcrenewal.blogspot.com/search/label/executive%20health%20plans">discussions </a>on Health Care Renewal.  The subject cries out for investigative reporting, and consideration by health care policy, research, and ethics experts.

No Skin in the Game - A Private Health System for the Very Rich

We have noted occasional hints that the very rich may have a separate health care system which may shield them from the vicissitudes of our...

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Just the Latest Legal Settlement for HCA

Last month, we<a href="http://hcrenewal.blogspot.com/2012/08/paging-doctor-ebdita-how-private-equity.html"> posted</a> about investigative reports that suggesting that for-profit hospital chain HCAwas pushed by its private equity owners to put short-term revenue ahead of good patient care.  A legal settlement announced this week corroborates these concerns.  As <a href="http://www.wrcbtv.com/story/19584753/hca-to-pay-165-million-to-resolve-health-care-fraud-charges">reported</a> by television station WRCB in Chattanooga, TN, <blockquote>HCA Inc., one of the nation's largest private hospital chains, has agreed to pay $16.5 million to settle alleged violations of the Ethics in Patient Referrals Act (also known as the Stark law), the False Claims Act, and other federal and state laws and regulations in connection with the operation of its subsidiary, Parkridge Medical Center, Inc., in Chattanooga. In addition, Parkridge Medical Center has entered into a comprehensive five-year Corporate Integrity Agreement with the Office of Inspector General of the U.S. Department of Health and Human Services (HHS-OIG) to ensure its continued compliance with federal health care benefit program requirements. As alleged in the settlement agreement, during 2007, HCA, through its subsidiaries Parkridge and HCA Physician Services (HCAPS), entered into a series of financial transactions with a physician group, Diagnostic Associates of Chattanooga, through which it provided financial benefits intended to induce the physician members of Diagnostic to refer patients to HCA facilities. The financial benefits included lease of office space from Diagnostic at a rental rate well in excess of fair market value to meet the mortgage obligations of the Diagnostic members and release of Diagnostic members from a separate lease obligation. These financial arrangements violated the Ethics in Patient Referrals Act and the Anti-Kickback Statute – laws designed to protect patients as well as the integrity of government-funded health care benefit programs such as Medicare, Medicaid, TRICARE, and TennCare. </blockquote>The issue here were allegations that HCA and its subsidiaries were paying physicians extra so that they would refer patients to an HCA hospital. Obviously, physicians are supposed to put each patient's interests ahead of extraneous considerations, and hence should make referral decisions based on the patients needs, and the likely benefits and harms of the referral, not the amounts the physicians might make from such payments. Referrals for particular services can be very lucrative for hospitals.  So this settlement seems to provide more evidence that to get profitable referrals, HCA was willing to subvert physicians' values by paying physicians to induce to make what might have been the wrong decisions for individual patients.  Of course, in this situation some physicians were hardly blameless, since they were also willing to set aside their values to receive the payments that generated those referrals. This fits with the thesis we advanced last month.  While hospitals are supposed to have a mission to put care of the sick ahead of all else, it appears that for-profit hospitals, and especially those owned by private equity are more likely to put short-term revenue ahead of patient care. As an aside, while this settlement provides useful information, do not think of it as a solution to the immediate problem.  As we have frequently asserted, it is doubtful that the relatively small payment and the relatively unlikely to be enforced corporate integrity agreement imposed in this settlement will change the company's behavior, in the absence of any negative consequences for the people who authorized, directed or implemented the bad behavior.  HCA once made a $1.7 billion fraud settlement, at the time the biggest such settlement ever made (see <a href="http://hcrenewal.blogspot.com/2010/05/how-did-ceo-who-presided-over-company.html">this post</a>).  However, the company's CEO at the time, Rick Scott, left the firm with a golden parachute and no negative consequences, and is now Governor of Florida.  If that previous huge settlement did not deter the more recent bad behavior in the absence of any penalties for company executives, why should we expect that the current comparatively tiny settlement also in the absence of such penalties will have any effect? As we have now said many, many times, we will not deter unethical behavior by health care organizations until the people who authorize, direct or implement bad behavior fear some meaningfully negative consequences. Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich. Furthermore, as I <a href="http://hcrenewal.blogspot.com/2012/08/paging-doctor-ebdita-how-private-equity.html">wrote</a> last month, we need to challenge the notion that direct health care should ever be provided, or that medicine ought to be practiced by for-profit corporations. Before market fundamentalism became so prominent, many stated prohibited the corporate practice of medicine, and the American Medical Association <a href="http://hcrenewal.blogspot.com/2007/12/relman-in-jama-on-threats-to-physicians.html">forbade the commercialization of medicine.</a> It is time to heed that wisdom. I submit that we will not be able to have good quality, accessible health care at an affordable price until we restore physicians as independent, ethical health care professionals, and until we restore small, independent, community responsible, non-profit hospitals as the locus for inpatient care.

Just the Latest Legal Settlement for HCA

Last month, we posted about investigative reports that suggesting that for-profit hospital chain HCAwas pushed by its private equity owner...

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Another unsolicited email from a physician describing EHR-caused chaos in the clinic

Another unsolicited email from a physician describing EHR-caused chaos in the clinic

I periodically receive unsolicited stories of EHR difficulties (mayhem, really) as a result of clinicians or others locating my materials on...

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At Risk in the Computerized Hospital: The HITECH Act as Social Policy Malpractice, and Passivity of Medical Professionals

I am revisiting the issue of HITECH in light of recent reports on health IT drawbacks and/or failure to achieve long-claimed advantages. The <a href="http://waysandmeans.house.gov/media/pdf/111/hitech.pdf" target="_blank">HITECH Act</a>, a multi-billion dollar EHR incentive/penalty measure inserted into the 2009 American Recovery and Reinvestment Act legislation (<a href="http://en.wikipedia.org/wiki/American_Recovery_and_Reinvestment_Act_of_2009" target="_blank">ARRA</a> or 'economic recovery' act), is proving to be an example of what should be called "Social Policy Malpractice." The HITECH Act was largely a consequence of intense industry lobbying on behalf of the IT industry (as in the Washington Post at "<a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?hpid=topnews">The Machinery Behind Health-Care Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records</a>", May 16, 2009). It is in fact not based on science or reliable evidence, and has led to increased patient endangerment and a worsening national debt picture. The recent revelations of reports from diverse sources including but not by any means limited to the following indicate that HITECH and its expenditures of billions of dollars on experimental, unregulated, unproven technology represents social policy malpractice:   <div></div><div><ul><li>ABC News (<a href="http://abcnews.go.com/Health/medical-records-private-abc-news-investigation/story?id=17228986" target="_blank">Your Medical Records May Not Be Private: ABC News Investigation</a>" - privacy of electronic health data is very poor, in ways that paper would and could never have permitted); </li></ul></div><div><ul><li>The Center for Public Integrity "<a href="http://www.publicintegrity.org/2012/09/19/10812/growth-electronic-medical-records-eases-path-inflated-bills" target="_blank">Growth of electronic medical records eases path to inflated bills</a>", on how EHRs lead to increased, not decreased healthcare costs; </li></ul></div><div><ul><li>Experts at Penn and Harvard -"<a href="http://online.wsj.com/article/SB10000872396390443847404577627041964831020.html?mod=googlenews_wsj" target="_blank">A Major Glitch for Digitized Health-Care Records</a>" - savings from EHRs are illusory;</li></ul><ul><li>Budget reports - in view of the deficit spending reported by OMB and others that is causing national debt to spiral out of control, jeopardizing the economic well being of the United States, and with upcoding as a side-effect and no cost savings, HITECH is an unaffordable extravagance.  </li></ul><ul><li>Recent revelations of outright EHR-induced mass chaos largely due to outspoken clinicians who've had enough - "<a href="http://hcrenewal.blogspot.com/2012/09/in-addition-to-nurses-doctors-now-air.html" target="_blank">Contra Costa County health doctors air complaints about county's new $45 million computer system</a>", "<a href="http://hcrenewal.blogspot.com/2012/09/the-extremes-to-which-faith-based.html" target="_blank">Lake County (IL) Health Department - Depression era soup lines at the clinic</a>";</li></ul><ul><li>Abuses of NPRM Public Comment periods on followup health IT incentive regulations via industry ghostwriting (stealth lobbying), reducing EHR effectiveness while further enriching the industry - "<a href="http://hcrenewal.blogspot.com/2012/08/health-it-vendor-epic-uses-clients-as.html">Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists - Did ONC Ignore This?"</a>;</li></ul> Of course, I'd already cited these reports in past posts but they bear repeating: <ul></ul><ul></ul></div><div><ul><li>The IOM report on HIT safety ("There's risk, but we don't even know the magnitude because there are major systemic impediments to diffusion of that information"), <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html</a>;</li></ul></div><div><ul><li>FDA (known injuries and deaths are likely the "tip of the iceberg" because of the impediments, and EHRs are medical devices that should fall under the FD&C Act, but FDA has largely refrained from enforcing our regulatory requirements with respect to HIT devices because they're a political hot potato - Jeff Shuren MD JD, CDRH), <a href="http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html" target="_blank">http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html</a>;</li></ul></div><div><ul><li>NIST (health IT usability is poor, major remediation is needed) - <a href="http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html" target="_blank">http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html</a></li></ul></div><div></div><div> I'd called for a moratorium on ambitious EHR plans for similar reasons as far back as 2008, at posts <a href="http://hcrenewal.blogspot.com/2008/11/should-us-call-moratorium-on-ambitious.html" target="_blank">here</a> and <a href="http://hcrenewal.blogspot.com/2009/01/i-ask-again-should-us-call-moratorium.html" target="_blank">here</a>.</div><div>  </div><div></div><div>The path that ethical medical centers and clinicians should take is to delay computerization in 2012 and push for slowdown or retraction of HITECH and its penalties for non-adopters.  Yet instead, what is usually seen is excuses and cheerleading by healthcare organization leaders, and passive physician and nurse acceptance of deficient information technology.  </div><div></div><div> This stunning passivity and acceptance by physicians and nurses of a deeply flawed technology of unknown risk seems largely due to physician learned helplessness and the Stockholm Syndrome.  See the posts on "physician learned helplessness" at <a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html" target="_blank">http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html</a> (commenting on observations in MedScape written by a lawyer), as well as on the "Stckholm Syndrome"  at <a href="http://en.wikipedia.org/wiki/Stockholm_syndrome" target="_blank">http://en.wikipedia.org/wiki/Stockholm_syndrome</a>.  Per a psychiatrist/informatics specialist Dr. Scott Monteith who has <a href="http://hcrenewal.blogspot.com/search/label/Dr.%20Scott%20Monteith" target="_blank">commented on this blog</a>, the compliance of clinicians may also be a manifestation of the inherent human psychopathology reflected in the <a href="http://en.wikipedia.org/wiki/Milgram_experiment" target="_blank">Milgram Experiment</a> (and elsewhere):</div><div></div> <blockquote class="tr_bq"><div>The Milgram experiment on obedience to authority figures was a series of notable social psychology experiments conducted by Yale University psychologist Stanley Milgram, which measured the willingness of study participants to obey an authority figure who instructed them to perform acts that conflicted with their personal conscience. Milgram first described his research in 1963 in an article published in the Journal of Abnormal and Social Psychology, and later discussed his findings in greater depth in his 1974 book, Obedience to Authority: An Experimental View. </div></blockquote><div> As to the consequences of physician "acceptance" of this technology in 2012 in its present condition, physicians are: <div><ul><li>Acting, in effect, 'in loco parentis' for their patients, not in the latter's best interests, who are not even afforded opportunity for informed consent.  This is in violation of long-accepted norms of human subjects experimentation and research such as the <a href="http://www.hhs.gov/ohrp/archive/index2.html" target="_blank">Belmont Report, Nuremberg Code</a> and <a href="http://www.hhs.gov/ohrp/humansubjects/index.html" target="_blank">HHS human subject protection</a> regulations at <a href="http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html">45 CFR part 46</a> themselves;</li></ul></div><div><ul><li>Giving free provision of their expertise and labor at improvisation and workarounds, in effect providing free alpha and beta testing to an entirely unregulated IT sector;</li></ul></div><div><ul><li>Engaging in passive acceptance of the entire liability and their hospital executives' breach of fiduciary responsibility to protect them from same due to Hold Harmless clauses, and breach of Joint Commission safety standards through signing "gag" clauses on defects and harms (see <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda" target="_blank">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda</a>). </li></ul></div> </div><div>National health IT leaders have proven to be hyperenthusiasts about health IT benefits as well:</div><div></div><div> <blockquote class="tr_bq">... This from Robert Kolodner, former head of the Office of the National Coordinator for Health IT (ONC) at HHS: <blockquote class="tr_bq">Dr. Robert Kolodner, a physician who headed the federal push for electronic medical records in 2007, acknowledged that billing abuse took a backseat to steps likely to entice the medical community to embrace the new technology. Kolodner said officials were certain the savings achieved by computerizing medicine would be so great that billing abuse, “while needing to be monitored, was not something that should be put as the primary issue at that time.”</blockquote> In other words, sideline (ignore) health IT-based billing abuse (and safety risks to the live patients subjected to this experimental technology without informed consent) because "we believe" the savings will be greater based on "our faith in the technology."</blockquote>  </div><div>Such individuals contributed materially to the social policy malpractice represented by the HITECH ACT.</div><div> </div><div>Considering all of the above, I call once again for a moratorium on further economic incentives for EHR adoption, and investment in the very measures recommended by the National Research Council in its Jan. 2009 report "<a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572" target="_blank">Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions</a>" that:</div><div> <blockquote class="tr_bq">In the long term, success will depend upon accelerating interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering. </blockquote></div><div></div><div></div><div> This research must be conducted, of course, with full human subjects protections in place.</div><div> </div><div>-- SS</div>

At Risk in the Computerized Hospital: The HITECH Act as Social Policy Malpractice, and Passivity of Medical Professionals

I am revisiting the issue of HITECH in light of recent reports on health IT drawbacks and/or failure to achieve long-claimed advantages. The...

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