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Deadly Over-Doses and Private Equity - the Case of Bain Capital's Methadone Clinics

Some reporting by Bloomberg provides more evidence about what happens when direct care of the most vulnerable patients is commercialized.  The vulnerable patients in this case were narcotic addicts. By way of introduction, one method of treating narcotic addiction is the use of methadone.  Methadone is a narcotic that may block the "high" produced by other narcotics and thus may lead to the abuse of these drugs.  Because methadone is long-acting and can be given orally in liquid form, methadone clinics traditionally provided patients one dose a day which they swallowed on the spot.  The methadone would presumably block their craving for other narcotics for that day, and the method of administration would prevent diversion of the drug.  Methadone clinics became more prevalent starting in the 1960s, and like most "health care provider organizations," as we now call them, were then largely non-profit. On a personal note, in the 1980s, I was the internal medicine physician for a non-profit hospital based methadone clinic designed for patients who had become addicted to prescription narcotics.  It was a challenging task, but the challenges seemed manageable.  That was then. Nowadays, methadone clinics are more likely to be for-profit.  In this brave new world of for-profit "health care delivery," there may be problems unlike those seen "back in the day."   For example, Bloomberg just <a href="http://www.businessweek.com/news/2013-03-07/dead-man-spurs-methadone-probe-at-bain-s-crc-clinic-in-baltimore">reported </a>on a case with a distinctly colorful title <blockquote>Dead Man Spurs Methadone Probe at Bain’s CRC Clinic in Baltimore  <div class="">Maryland state regulators are investigating an addiction-treatment clinic owned by Bain Capital Partners LLC after the methadone-related death of a Baltimore man. </div><div class=""> </div>The probe is focused on the Pine Heights Treatment Center in Baltimore, one of dozens of clinics operated by Bain’s CRC Health Corp., the largest methadone-treatment provider in the U.S. It was triggered by a complaint from the public, said Dori Henry, a spokeswoman for the state Alcohol and Drug Abuse Administration. She declined to comment on the investigation’s details. The complaint alleges that Warren Lumpkin, 34, a forklift operator, died on Jan. 4 after ingesting methadone that was given to him by a CRC patient, according to a copy obtained by Bloomberg News. An autopsy found that 'methadone intoxication' contributed to his death, records show. Lumpkin’s ex-wife, Sabrina M. Lumpkin, who filed the complaint, said in it that he wasn’t a patient at the CRC clinic. He had a friend who was, and that friend gave half a dose of methadone from the clinic to Lumpkin, according to the complaint. </blockquote> Note that "back in the day," such an event would have been nearly impossible.  As noted above, patients were given a cup of liquid containing their daily methadone dose, and drank it under observation.   Practically, they could not "cheek" or otherwise divert the drug.  Of course, that approach required personnel to observe each patient each day.  Paying those personnel made the operation more expensive.  "Back in the day," though, non-profit hospitals and clinics were willing to provide the service in the interest of making sure the patients, and only the patients got the prescribed treatment. Things may be different when methadone clinics are run for a profit.  A Bloomberg investigative<a href="http://www.bloomberg.com/news/2013-02-08/drug-users-turn-death-dealers-as-methadone-from-bain-hits-street.html"> report</a> published in February looked into the operations of the company that owned the clinic in Maryland.  That too had a provocative title and started with a similarly disconcerting case. <blockquote class="tr_bq">Drug Users Turn Death Dealers as Methadone From Bain Hits Street   After Jennifer Vanlieu turned to methadone treatment to beat an addiction to heroin and pain pills, she morphed from drug user to convicted drug dealer.   Vanlieu said she got a carryout methadone dose at a clinic operated by CRC Health Corp. in Richmond, Indiana, in March, 2010, and then gave about 15 milligrams to her friend Carissa Plemons. Plemons died hours later, after ingesting a lethal mix of methadone and other drugs, according to police reports. Take-home methadone -- doses patients carry out instead of taking at clinics -- enabled the abuse, said Vanlieu, 26, who was sentenced to six years in prison for dealing the drug to Plemons. While she didn’t sell it to her friend, she said in an interview that other clinic patients often resold their take- homes. CRC is owned by Boston-based Bain Capital Partners LLC and is the largest U.S. provider of methadone treatment. 'Some would sell it in the parking lot,' she said. </blockquote> As in the first case, unlike the process "back in the day," now patients, who are almost all presumably narcotic addicts, may be given multiple doses of liquid methadone to take home.  They are no longer required to take a daily dose of methadone under observation.  As the case above illustrates, it is all too easy to divert take home doses of methadone.  While methadone can be used to block the effects of other narcotics, it can also be abused.  Obviously, as in the cases above, abused methadone can cause a lethal overdose.  Wide Use of Take-Home Methadone The Bloomberg report found multiple instances in which CRC Health clinics handed out multiple take-home methadone doses apparently without proper consideration of the risk or supervision of the patients. <blockquote class="tr_bq"> In states where CRC has had its highest patient counts -- Indiana, West Virginia, California and Oregon -- available data and interviews show the company tries to provide take-home packages, which range from one dose to as many as 30, more often than other clinics. </blockquote> In addition,  <blockquote class="tr_bq">The Richmond, Indiana, clinic gave take-home methadone to a patient who flunked a drug test, a January 2012 audit found. The company’s Williamson, West Virginia, clinic didn’t immediately revoke take-homes from a patient who had two positive drug tests in 2010, records show. In 2011, inspectors found no evidence that a physician at CRC’s clinic in Renton, Washington, used 'good clinical, judgment' in giving patients carryout doses. A CRC center in Chattanooga, Tennessee, failed to supervise take-home doses properly in a case 'clearly indicative of drug diversion,' state authorities found in June 2011. The company’s clinics in Claymont, Delaware, and Coatesville, Pennsylvania, were faulted in May 2012 and October 2010, respectively, for giving carry-outs to patients who missed required counseling, records show. As for the spot-checks Herschman described -- they hardly ever happened at CRC’s clinic in Goldsboro, North Carolina, said Liaudaitis, the former counselor. </blockquote>Furthermore, <blockquote class="tr_bq">In Indiana, CRC’s five clinics served 69 percent of methadone patients in 2011, while distributing 96 percent of the take-homes tracked by state records. Patients of CRC’s dozen California clinics received carryout packages of as many as 30 doses at a rate twice that of all others. In Virginia, 74 percent of patients at CRC’s three clinics got at least one take-home dose a week in August 2012, while 47 percent of patients at all other clinics did, state records show.  </blockquote> The Business Model Behind Take-Home Methadone So why would a methadone clinic hand multiple doses of an abusable narcotic to narcotic abusers?  The Bloomberg article went on to document some possible reasons which ultimately have to do with the business model of for-profit methadone clinics. First of all, providing multiple doses of methadone requires less time from clinic personnel, which is handy when the clinics may be under-staffed by over-worked poorly paid personnel.   <blockquote class="tr_bq">'That was the culture -- keep the census up,' said Mike Liaudaitis, who worked as a counselor at CRC’s clinic in Goldsboro, North Carolina, from mid-2009 until early 2011. He recalls being swamped with a 64-person caseload that exceeded the state’s limit of 50. </blockquote> Also, <blockquote class="tr_bq">'Clearly the company is saving money if they’re distributing multiple take-home doses at one time,' said West Virginia Delegate Don Perdue, a Democrat who has pursued stricter oversight of for-profit clinics. 'They don’t have to have as many staff handing out the merchandise.'</blockquote> In particular, <blockquote class="tr_bq">the Goldsboro clinic -- like others described by regulators and former CRC employees in Indiana and West Virginia -- was frequently understaffed, Liaudaitis said. Since Jan. 1, 2009, CRC’s clinics haven’t met staffing standards more than 50 times, regulatory records from 15 states show. Clinics were cited 80 times for failing to document that they gave patients enough counseling. In response, the company agreed to hire more, recruit more aggressively and increase supervision. Competition for qualified workers is intense, CRC said in its 2011 annual report. CRC didn’t pay well enough to attract or keep experienced counselors, said Malaysia Williams, who worked at its clinic in Huntington, West Virginia, from June 2009 through March 2010. 'Nobody stayed there,' she said. 'It paid poorly.' Williams got $13 an hour, she said -- about the same amount other former counselors reported. That’s roughly $27,000 a year. </blockquote> There is evidence that under-staffing, under-payment of personnel, and the wide use of take-home methadone lead to big increases in short-term revenue for CRC Health, the for-profit corporation running the clinics. <blockquote class="tr_bq"> Until recently, there was little difference between the operations of for-profit and non-profit methadone clinics, said Thomas D’Aunno, a professor of health policy and management at Columbia University who has tracked the treatment centers for years. That changed in 2011 survey data, which showed 'significant differences,' he said: For-profit clinics had fewer staffers than public clinics. As Williams struggled to catch up in Huntington, the clinic pushed its revenue up almost 8 percent to $5 million in 2010 -- while expenses increased less than 1 percent to $2.6 million, according to state regulatory documents. </blockquote>Private Equity's Take Over of Methadone Clinics The potential for big revenues has drawn private equity into the world of methadone maintenance for the treatment of narcotic addiction. <blockquote class="tr_bq"> Nurtured by government spending, methadone clinics spread nationwide in the 1960s and ’70s until strapped state and local governments began decreasing their outlays. By 2010, for-profit providers controlled 52.8 percent of the 1,200 U.S. clinics. Over the past seven years, private equity firms have invested more than $2.2 billion in substance-abuse treatment and behavioral health companies in 62 deals, according to PitchBook Data Inc., a Seattle-based research firm. Addiction-treatment companies are 'some of the most sought-after -- and valuable -- acquisition candidates in health care,' partly because of profit margins that can top 20 percent, according to the Braff Group, a Pittsburgh-based mergers and acquisitions advisory firm.</blockquote>  As it turns out, CRC Health was acquired by one of the more notable private equity firms. <blockquote class="tr_bq">Bain Capital, the private equity firm co-founded by former Republican presidential candidate Mitt Romney, paid $723 million for CRC in 2006, corporate filings show. Romney, who left Bain in 1999, had no input in its investments or management of companies after that, he has said. Still, Romney reported last year that he owned more than $1 million worth of a Bain fund that holds most of CRC’s shares. He reported receiving between $100,000 and $1 million in dividends, interest and capital gains from that holding, as well as income from two other Bain funds with interests in CRC, according to the financial disclosure he filed with the U.S. Office of Government Ethics in June. Bain executives declined to comment, said Alex Stanton, a spokesman. Representatives for Romney didn’t respond to requests for comment.  CRC has reported paying Bain about $15.4 million in management fees along with $7.2 million in fees related to the merger since 2006. The company’s revenue more than doubled to $446 million in 2011 from $209 million in 2005. Methadone clinics generated more than a quarter of the 2011 revenue, $123 million. </blockquote> Note that last year, when Mr Romney was running for the US Presidency, and hence his ties to Bain Capital were particularly newsworthy, several investigative reports about care at Bain owned health care provider organizations were published.  We <a href="http://hcrenewal.blogspot.com/2012/07/private-equity-vs-patient-care-bainful.html">posted</a> about issues at another CRC Health operation, Aspen, which operates in -patient treatment centers for psychiatric patients.  Investigative reporting about that part of CRC Health also suggested that the company was putting short-term revenue ahead of patient welfare.  We also <a href="http://hcrenewal.blogspot.com/2012/08/paging-doctor-ebdita-how-private-equity.html">posted</a> about issues at HCA, a for-profit hospital chain partially owned by Bain, which again suggested revenue came before patients.  In one sense, this should be no surprise, since the business model for private equity is all about extracting the most money in the shortest time for acquired corporations.  (Look <a href="http://hcrenewal.blogspot.com/search/label/private%20equity">here</a> for more details.) Summary We now have more evidence that patients "cared for" directly by for-profit corporations, especially those owned by private equity firms, do not do well.  Meanwhile, the top executives of these firms do exceedingly well. We have <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">noted</a> how health care organizations have increasingly been "financialized," lead by executives who put short-term revenue generation ahead of all other goals, including good patient care. Furthermore, hospitals are increasingly likely to be formally for-profit, and hence likely to be lead by such executives. Worse, hospitals are increasingly likely to be owned by <a href="http://hcrenewal.blogspot.com/search/label/private%20equity">private equity</a> firms, further increasing the emphasis on short-term money making. Even worse, physicians are now more frequently <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">employed by such organizations</a>, which may pressure them to do what it takes to increase revenue, no matter what the effect on patients' and the public's health. The probably effects on the quality of care, access, and costs are obvious. In my humble opinion, before the health care bubble bursts, 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 states 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.  True health care reform will require an end to market fundamentalism in health care.

Deadly Over-Doses and Private Equity - the Case of Bain Capital's Methadone Clinics

Some reporting by Bloomberg provides more evidence about what happens when direct care of the most vulnerable patients is commercialized. T...

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Medscape re: Class Action suit: "Doctors Who Sued EHR Company Win First Round"

Interesting article about a Class-Action lawsuit against a health IT seller, Allscripts, see Medscape link below (the story is copyrighted so I cannot repost it here). Relevant excerpts: <blockquote class="tr_bq">On Monday, March 4, a group of doctors who are suing their electronic health record (EHR) manufacturer for selling them a "buggy" product and then discontinuing it learned that the defendant's motion to block the lawsuit and compel them to accept binding arbitration was overruled by a judge in Miami, the first step in getting a court date in what is believed to be a first-of-its-kind case. ... In December 2012, 4 physician practices -- 2 pain clinics in Florida, 1 in Missouri, and a family medicine practice in Alabama -- became plaintiffs in a class-action suit filed against Allscripts, "an action arising from an expensive, but defective electronic health records software product," according to the complaint. The bottom line: The EHR was "buggy." Says one of the doctors plaintiffs: Anesthesiologist Robert J. Joseph, MD, of the Pain Clinic of Northwest Florida in Panama City, a plaintiff in the suit, makes no bones about it. "Our EHR is a piece of crap," he states.</blockquote> ----- Link to full article: <a href="http://www.medscape.com/viewarticle/779721" target="_blank">http://www.medscape.com/viewarticle/779721</a> (It seems to come up fulltext without Medscape login, but I cannot guarantee this will persist.) -- SS

Medscape re: Class Action suit: "Doctors Who Sued EHR Company Win First Round"

Interesting article about a Class-Action lawsuit against a health IT seller, Allscripts, see Medscape link below (the story is copyrighted ...

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On EHR's: See No Evil, Hear No Evil, Speak No Evil: Part 1

This is the first of a series of posts I plan on the issue of "See No Evil, Hear No Evil, Speak No Evil" regarding EHR's.  Frequent reminders are needed by all stakeholders, I believe, to think critically about, and take with a big grain of salt, effusive praise by key opinion leaders, politicians, etc. about health IT, and accompanying attempts to deride those critical of the technology, to counterbalance ongoing HIT hyperenthusiasm (e.g., <a href="http://www.youtube.com/watch?v=ZQIzdBg5gXw" target="_blank">link</a>). In face of growing evidence of risk and adverse outcomes of bad health IT from multiple sources and organizations (such as <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html" target="_blank">this</a>, as just one example), growing advice on risk remediation from government (such as <a href="http://www.nist.gov/healthcare/usability/upload/NIST-IR-7865.pdf" target="_blank">here</a>), and mass privacy violations (see the multiple posts under <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy" target="_blank">this query link</a>), it might also be entitled a series on what health IT <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">hyper-enthusiasts</a> "knew, should have known, or should have made it their business to know." Let's start out with an extract from a post I wrote on June 29, 2003 entitled "<a href="http://hcrenewal.blogspot.com/2009/06/mark-leavitt-head-of-cchit-behind-times.html" target="_blank">Mark Leavitt, Head of CCHIT: Behind the Times and Uninformed on Health IT Realities?</a>". At the time Leavitt was head of <a href="http://www.cchit.org/" target="_blank">CCHIT</a>, a tester and MU compliance/safety certifier of electronic health records systems:  <blockquote class="tr_bq">... The head of CCHIT, Mark Leavitt, has penned the following at iHealthBeat:  <a href="http://www.ihealthbeat.org/perspectives/2009/health-it-under-arra-its-not-the-money-its-the-message.aspx">June 19, 2009 - Perspectives</a>  Health IT Under ARRA: It's Not the Money, It's the Message by Mark Leavit   ... Before ARRA, most surveys concluded that cost was the No. 1 barrier to EHR adoption. But as soon as it appeared that the cost barrier might finally be overcome, individuals with a deeper-seated "anti-EHR" bent emerged. Their numbers are small, but their shocking claims -- that EHRs kill people, that massive privacy violations are taking place, that shady conspiracies are operating -- make stimulating copy for the media. Those experienced with EHRs might laugh these stories off, but risk-averse newcomers to health IT, both health care providers and policymakers are easily affected by fear mongering. </blockquote> "Laugh these stories off?"  That was, and is, simply perverse. Ironically, this statement was written less than a year before my own mother was seriously and fatally harmed as a result of a health IT-related error.   <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMLAOY-zSe3l0ImSmaQsj6EX7UtY9yNRp6gka3ZuuCaH9i3Rdu3NYYL1b0ybojlliYFz96WUIKGEutgtICnhM9O1lk7TPB9a8hwgzlVaia499PLd_nvDohorpZqIeYoEp8M5eKdQZTrUnv/s1600/Cute-Chimpanzees.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMLAOY-zSe3l0ImSmaQsj6EX7UtY9yNRp6gka3ZuuCaH9i3Rdu3NYYL1b0ybojlliYFz96WUIKGEutgtICnhM9O1lk7TPB9a8hwgzlVaia499PLd_nvDohorpZqIeYoEp8M5eKdQZTrUnv/s200/Cute-Chimpanzees.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">On EHR's:  See No Evil, Hear No Evil, Speak No Evil</td></tr></tbody></table> While I don't proffer claims of "shady conspiracies" (international health IT expert Dr. Richard Cook explains that in a recent guest post "<a href="http://hcrenewal.blogspot.com/2013/03/dr-richard-cook-on-health-it-sectors.html" target="_blank">Dr. Richard Cook on the Health IT Sector's Ills</a>"), I do proffer alternate explanations including arrogance, <a href="http://hcrenewal.blogspot.com/2013/03/solutionism-are-all-healthcare-issues.html" target="_blank">Radical Solutionism</a>, and <a href="http://www.amazon.com/Assholes-A-Theory-Aaron-James/dp/0385535651" target="_blank">this</a>. More to come in this series. There are many more statements like this one already on this blog, and elsewhere. -- SS Note:  Part 2 is <a href="http://hcrenewal.blogspot.com/2013/03/on-ehrs-see-no-evil-hear-no-evil-speak_8.html" target="_blank">here</a>.

On EHR's: See No Evil, Hear No Evil, Speak No Evil: Part 1

This is the first of a series of posts I plan on the issue of "See No Evil, Hear No Evil, Speak No Evil" regarding EHR's. Fr...

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More Cause for Hope - After Novartis Chairman's Rescinded Golden Parachute, Swiss Voters Give Control of Hired Executives' Salaries Back to Owners

Recently, we <a href="http://hcrenewal.blogspot.com/2013/02/reason-for-hope-novartis-rescinds.html">discussed</a> the latest stupefyingly big <a href="http://hcrenewal.blogspot.com/search/label/golden%20parachutes">golden parachute</a> given to a departing pharmaceutical executive.  Former Novartis CEO and outgoing chairman Daniel Vasella was to be given more than $75 million, after making multiple millions previously, ostensibly so he would not go to work for a competitor.  After a public outcry, the company cancelled the plan, and Vasella admitted a "mistake."  This was the only instance in recent memory in which a big health care organization pulled back some huge executive pay package due to public protest. Swiss Voters Give Control of Pay of Hired Executives Back to Company Owners Now Swiss voters have approved a referendum which would actually let the owners of public companies, the stockholders, decide how much to pay hired executives.  As <a href="http://www.nytimes.com/2013/03/04/business/global/swiss-voters-tighten-countrys-limits-on-executive-pay.html">summarized</a> by the New York Times, <blockquote class="tr_bq"> Swiss citizens voted Sunday to impose some of the world’s most severe restrictions on executive compensation<a class="meta-classifier" href="http://topics.nytimes.com/top/reference/timestopics/subjects/e/executive_pay/index.html?inline=nyt-classifier" title="More articles about executive pay."></a>, ignoring a warning from the business lobby that such curbs would undermine the country’s investor-friendly image. <div itemprop="articleBody"> The vote gives shareholders of companies listed in Switzerland<a class="meta-loc" href="http://topics.nytimes.com/top/news/international/countriesandterritories/switzerland/index.html?inline=nyt-geo" title="More news and information about Switzerland."></a> a binding say on the overall pay packages for executives and directors. Pension funds holding shares in a company would be obligated to take part in votes on compensation packages. </div><div itemprop="articleBody"> </div><div itemprop="articleBody">In addition, companies would no longer be allowed to give bonuses to executives joining or leaving the business, or to executives when their company was taken over. Violations could result in fines equal to up to six years of salary and a prison sentence of up to three years. </div></blockquote><div itemprop="articleBody"> </div><div itemprop="articleBody">The new rules in Switzerland would be unprecedented in the current era.  </div><div itemprop="articleBody"> </div><div itemprop="articleBody">Those who are Ostensibly Pro-Business Defend Hired Executives, not Owners </div><div itemprop="articleBody"> </div><div itemprop="articleBody">Despite the fact that the new rules would give control over one type of hired employees, hired executives, back to the shareholders, the owners of companies, spokespeople for big companies, but presumably really for their top executives, claimed that the rule would be bad for shareholders.</div><div itemprop="articleBody"> </div><div itemprop="articleBody"> </div><blockquote class="tr_bq"><div itemprop="articleBody">Ahead of the vote, [the Swiss business federation] EconomieSuisse and Mr. Minder’s other opponents warned of dire consequences if the referendum passed, notably in terms of keeping Switzerland attractive to foreign companies and investors. </div><div itemprop="articleBody"> </div>But [chief proponent of the new rules] Mr. Minder argued that Switzerland would benefit if it gave shareholders control over the companies in which they invested.</blockquote> Furthermore, the Guardian <a href="http://www.guardian.co.uk/world/2013/mar/03/swiss-referendum-executive-pay">reported</a>,  <blockquote class="tr_bq">Minder says the massive sums demonstrate that company boards have lost control of pay and prefer to fork out 'astronomical' salaries rather than pay dividends to shareholders. Minder told the Swiss daily Le Temps that the only solution was to give shareholders the power to set pay.</blockquote>  A Bloomberg <a href="http://www.bloomberg.com/news/2013-03-04/angry-swiss-aren-t-done-slimming-the-fat-cats.html">article</a> suggested that driving the vote were how the Swiss are <blockquote class="tr_bq"> worried about how long they can fend off the crisis that has engulfed the rest of Europe, and dissatisfied with a feeling of being ripped off by their elites. 'It is scandalous. No one deserves to be paid such monstrously high salaries, especially when their employees get paid not much in comparison,' Marianne Lecoultre, a pensioner who lives in a modest flat on the outskirts of Geneva, told me.  </blockquote> The Germans are Thinking of Making Hired Executives More Accountable The German media outlet Deutsche Welle <a href="http://www.dw.de/swiss-referendum-fans-executive-pay-debate-in-germany/a-16643835">reported</a> that there is now more interest in returning control of hired executive pay to company owners there as well. <blockquote class="tr_bq"> After Swiss citizens voted Sunday to impose controls on executive pay, a similar debate has started in Germany. </blockquote> Furthermore, <blockquote class="tr_bq">Joachim Poß, the parliamentary leader of the opposition Social Democratic Party, told the daily Neue Osnabrücker Zeitung that the outcome of the referendum was an important step towards restricting the money-grabbing prevalent in corporate management, He noted that the referendum was encouragement for an initiative at the EU level, and added that 'people do no longer accept perverted bonus systems, neither in banks nor in the real economy.'</blockquote> Summary: Ripped Off by Health Care Elites I can start to imagine how supposedly pro-business people in the US will dismiss actions taken by European countries as anti-business and probably "job killing," even though these actions actually gave more control of publicly held business to their owners, not to government, which would seem to be fully in support of capitalism.  Again, maybe some people making the loudest pro-business noises are really sympathetic to, if not paid by, the hired managers of businesses who have put their enrichment ahead of the interests of other employees, customers, clients or patients, the business owners (stockholders, that is), and the public at large.  Enormous compensation of hired health care executives, out of all proportion, if related at all to whether their work had any positive effect on patients' or the public's health, has long been a <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">concern</a> on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>.  For example, back in 2006, we posted repeatedly (look <a href="http://hcrenewal.blogspot.com/2006/10/another-really-big-one-bites-dust-ceo.html">here</a> for links) about the billion dollar plus fortune amassed by the then CEO of UnitedHealthcare which vividly contrasted with the company's avowal to "make health care more affordable."  That seemed to be an example back then of a rip off by a member of the health care elite.  Now the notion that our top elites have been generally ripping us off is becoming more widespread. In my humble opinion, the perverse incentives generated by a system that allows top executives to make almost unlimited amounts, regardless of all other considerations, has been a major reason for US and global health care dysfunction.  Making executive compensation less perverse, and ultimately making health care leaders accountable for the effects of what they do on patients' and the public's health may be an absolutely necessary step to make our health care system more functional.  Now at least there is some precedent, admittedly from Europe, for making top hired managers more accountable.  As Pierre Briancon<a href="http://blogs.reuters.com/breakingviews/2013/03/04/swiss-may-show-the-way-on-pay/"> wrote</a> in Reuters, <blockquote class="tr_bq"> Corporate boards had better take notice: public outrage at what looks like persistent and unapologetic greed in the most severe economic slump in decades is forcing governments to step in. Throughout Europe, indignation at private excess has become a policy problem for administrations trying to explain the need to cut public spending.</blockquote> In addition, <blockquote class="tr_bq">Self-moderation doesn’t work and self-interest continues to prevail. Throughout the Western world, corporate boards have paid lip service to the need to take into account public opinion, and nothing much has changed either in the banking industry – the symbol of immoderation – or in the wider corporate world. In desperation, governments are taking more forceful action – sometimes reluctantly: the Swiss referendum followed a failure by the country’s parliament to heed to public indignation. Government intervention can often be clumsy, and it is fraught with the risk of unintended consequences. But it is the right of governments to legislate on social ills – and excessive and provocative private-sector pay has become one. Meanwhile the lobbies promising economic apocalypse have failed to make their case – and to scare anyone with warnings that 'talent' – as they call it – may relocate to friendlier countries. It would be in the interest of all if they stopped turning a deaf ear to calls for decency emanating even from countries like Switzerland, which is hardly a hotbed of Soviet-style command economics.</blockquote> Even though the final impetus for the overwhelming majority vote on the Swiss referendum came from a ridiculous golden parachute from a pharmaceutical company, the discussion so far has not centered on health care.  So I get to close with something I have repeated on and on, now with a little hope that it may not be considered so extreme....  Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior. If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

More Cause for Hope - After Novartis Chairman's Rescinded Golden Parachute, Swiss Voters Give Control of Hired Executives' Salaries Back to Owners

Recently, we discussed the latest stupefyingly big golden parachute given to a departing pharmaceutical executive. Former Novartis CEO an...

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Solutionism: are all healthcare issues transparent and self-evident processes that can be easily optimized, if only the right algorithms are in place?

I've ordered this book:  "<a href="http://www.amazon.com/Save-Everything-Click-Here-Technological/dp/1610391381" target="_blank">To Save Everything, Click Here: The Folly of Technological Solutionism</a>" by <a href="http://www.amazon.com/s/ref=ntt_athr_dp_sr_1?_encoding=UTF8&field-author=Evgeny%20Morozov&search-alias=books&sort=relevancerank">Evgeny Morozov</a>. I've read some excerpts prior to its delivery and find them fascinating.  Emphases mine: <blockquote>... Alas, all too often, this never-ending quest to ameliorate—or what the Canadian anthropologist Tania Murray Li, writing in a very different context, has called “the will to improve”—is shortsighted and only perfunctorily interested in the activity for which improvement is sought. Recasting all complex social situations either as neatly defined problems with definite, computable solutions or as transparent and self-evident processes that can be easily optimized—if only the right algorithms are in place!—this quest is likely to have unexpected consequences that could eventually cause more damage than the problems they seek to address. I call the ideology that legitimizes and sanctions such aspirations “solutionism.” I borrow this unabashedly pejorative term from the world of architecture and urban planning, where it has come to refer to an unhealthy preoccupation with sexy, monumental, and narrow-minded solutions—the kind of stuff that wows audiences at <a href="http://www.ted.com/pages/registration" target="_blank">TED Conferences</a>—to problems that are extremely complex, fluid, and contentious. These are the kinds of problems that, on careful examination, do not have to be defined in the singular and all-encompassing ways that “solutionists” have defined them; what’s contentious, then, is not their proposed solution but their very definition of the problem itself. Design theorist Michael Dobbins has it right: solutionism presumes rather than investigates the problems that it is trying to solve, reaching “for the answer before the questions have been fully asked.” [Such as, how risk-prone are paper records, exactly, and how might the risks be ameloriated without spending hundreds of billions of dollars on healthcare IT? - ed.] How problems are composed matters every bit as much as how problems are resolved. Solutionism, thus, is not just a fancy way of saying that for someone with a hammer, everything looks like a nail; it’s not just another riff on the inapplicability of “technological fixes” to “wicked problems” (a subject I address at length in The Net Delusion). It’s not only that many problems are not suited to the quick-and-easy solutionist tool kit. It’s also that what many solutionists presume to be “problems” in need of solving are not problems at all; a deeper investigation into the very nature of these “problems” would reveal that the inefficiency, ambiguity, and opacity—whether in politics or everyday life—that the newly empowered geeks and solutionists are rallying against are not in any sense problematic. Quite the opposite: these vices are often virtues in disguise. [Such as - paper charts that are rapid to produce and browse, redundancies in healthcare processes that can help prevent errors of omission, ambiguities in decision making that take into account that not everyone fits a guideline, etc.? - ed.] That, thanks to innovative technologies, the modern-day solutionist has an easy way to eliminate them does not make them any less virtuous.</blockquote> It occurs to me that what I've been calling "<a href="http://www.jpands.org/vol14no2/silverstein.pdf" target="_blank">the syndrome of inappropriate overconfidence in computing</a>" or <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">"healthcare IT hyper-enthusiasm that ignores the downsides</a>" -- or that which authors such as Nemeth/Cook might call a blindness to complexity that is "<a href="http://www.ctlab.org/documents/Hiding%20in%20plain%20sight.pdf" target="_blank">hiding in plain sight</a>" and "<a href="http://hcrenewal.blogspot.com/2013/03/dr-richard-cook-on-health-it-sectors.html" target="_blank">HIT techno-fantasies</a>" -- and similar ideas, may all be the same thing. "Solutionism" may be a good umbrella label for these ideas.   Thus, those who challenge these ideas in healthcare and call for caution and restraint are not anti-health IT, not anti-technology, but anti-Solutionism, or maybe 'temperate solutionists' as opposed to 'extremist solutionists' or 'radical solutionists.' And the reason the pushback is so vicious at times may be that we are attacking not just an industry but a broad philosophy or ideology - "a systematic body of concepts especially about human life or culture." The current culture promotes solutionism - the belief that there's a technocratic (technological & bureaucratic, i.e., management of society by technical 'experts') solution to every problem as "solutionism" is defined elsewhere.  I think a vast majority of people, including the 'intellectuals', have bought into it.   It doesn't help that "radical solutionism" is exceptionally profitable for its proponents.... Solutionism may be applicable to, say, domains where numbers or logistical matters predominate (e.g., banking and FedEx), but not to "messy" domains such as medicine.  Or at least not to all of medicine's component parts, such as the parts that clinicians perform using hard-earned expertise, judgement and ethics. Finally, I ask: Why can't be cure mental illness, or ensure perfect outcomes in cardiac surgery, or prevent wars, with the appropriate computer apps? After all, with the appropriate tools, why can't we easily perform nuclear fission on our kitchen tables? More after I read the book. -- SS

Solutionism: are all healthcare issues transparent and self-evident processes that can be easily optimized, if only the right algorithms are in place?

I've ordered this book: " To Save Everything, Click Here: The Folly of Technological Solutionism " by Evgeny Morozov . I'...

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Comments by Dr. Reed Gelzer on RAND Health IT Report and Op-Ed in Pittsburgh Post Gazette

<div class="ajy">A 2005 RAND Corporation report predicted that health IT could save the U.S. healthcare system $81 billion a year. Since then, however, annual health spending has increased by almost a trillion dollars, and quality and efficiency have not budged much, even with an increase in health IT adoption, according to researchers Arthur L. Kellerman and Spencer S. Jones in a Jan. 2013 <a href="http://content.healthaffairs.org/content/32/1/63.abstract?sid=1667406b-f4db-408e-8226-b472f25c225c">RAND study</a> published in Health Affairs.  Kellermann is chair in policy analysis, and Spencer Jones is an information scientist..</div> A new Op-Ed by Kellerman and Jones entitled "<a href="http://www.post-gazette.com/stories/opinion/perspectives/it-in-health-care-is-mia-677680/" target="_blank">IT in health care is MIA</a>" appeared on Mar. 3, 2013 in the Pittsburgh Post-Gazette. They wrote: <blockquote class="tr_bq">Because information technology has so quickly transformed people's daily lives, we tend to forget how much things have changed from the not-so-distant past. Today, millions of people around the world regularly shop online; download entire movies, books and other media onto wireless devices; bank at ATMs wherever they choose; and self-book travel while checking themselves in at airports electronically. But there is one sector of our lives where adoption of information technology has lagged conspicuously: health care. Some parts of the world are doing better than others in this respect. Researchers from the Commonwealth Fund recently reported that some high-income countries, including the United Kingdom, Australia and New Zealand, have made great strides in the use of electronic medical records among primary-care physicians. Indeed, in those countries, the practice is now nearly universal. Yet some other high-income countries, such as the United States and Canada, are not keeping up.</blockquote> Of course, the U.K. recently suffered a rather severe blow, <a href="http://hcrenewal.blogspot.com/2011/09/npfit-programme-going-pffft.html" target="_blank">on the order of 13 billion Pounds' worth</a>, to its National Programme for Health IT in the NHS (NPfIT).  Australia is not exactly an "Emerald City" in terms of health IT, either, as can be seen from numerous links at the blog of Sydneysider Dr. David More, <a href="http://aushealthit.blogspot.com/" target="_blank">Australian Health Information Technology</a>. The RAND authors throw in some boilerplate grandiose predictions of certainty about health IT, which seems to have become a common phenomenon in newspapers and even scientific publications of late: <blockquote class="tr_bq"> ... The U.S. government is trying to help. In 2009, Congress passed the Health Information Technology for Economic and Clinical Health Act. HITECH has undeniably accelerated IT adoption, yet the problems of usability and interoperability persist. ... The sky is the limit when it comes to potential gains from health IT ... The payoff will be worth it. Indeed, as with the adoption of IT elsewhere, we may soon wonder how health care could have been delivered any other way.</blockquote> Read the whole Op-Ed at the Gazette. (My mother, an unwitting expert with significant experience on health IT adverse effects, is unavailable for comment, as she is dead due to a HIT-related accident.) However, another expert is available: Reed D. Gelzer, MD, MPH is an EHR/HIT systems and policy analyst for private and Federal agency clients, primarily in program integrity and clinical quality support.  In clinical practice for 11 years before transitioning into health IT, he also co-chairs the HL7 Records Management and Evidentiary Support (RMES) Workgroup.  He served US Navy Medicine’s Data Quality Office, various private insurers, as well as three years on CCHIT workgroups.  He was the Prevention Workgroup Chair for the 2007 ONC study on mitigation of EHR mediated waste fraud and abuse. I find his opinions posted at the Gazette comment board of interest.  Some of the themes are very familiar. His comments are reproduced here with just a few comments of mine interjected: <blockquote class="tr_bq">Good afternoon Mr. Kellerman and Mr. Jones, Thank you for the recitation of the arguments for HIT. I am particularly pleased that you note that a principle block to advancing HIT in the US is the fact that systems are not standardized. One of the reasons many of our Industrialized Nation peers are far ahead of us is that they, in effect, standardized their systems by having one customer, a government entity operating health care. I assume you are not proposing that. If not then what, in the absence of regulation, will achieve your proper objective of standardizing HIT? Well, we could simply let the market decide among the current non-standardized, non-regulated systems by accepting the accompanying burdens of cost, patient harms, and highly variable to unreliable data, and so on, in a nationwide experiment using the citizens of the U.S. as the test subjects [without informed consent or opt-out provisions, I might add - ed.] . A free market though would necessitate an absence of market-corrupting subsidies and transparency on comparing products, so that we can all equally hear when systems don't work as expected or cause problems for users, clinics, hospitals, and patients. No subsidies, no advantage to legacy vendors, and publicly available information about system problems, defects, and harms for a free market in HIT seems as unlikely as a single payer, government run system in the U.S., so what other options do we have? We could say, we as a country want to improve this faulty and expensive industry, and so that is what we will hold providers responsible for. Doctors, hospitals, nurses, clinics, everybody -You have a duty to achieve better.  IT is a means, not the end. Purchase and apply the tools you decide you need to fix the problems you see. If you find you cannot do it, then close your doors and go to work for someone who can. In support of this, as we do with drugs, we do not expect doctors, hospitals, nurses, clinics to independently research what is safe, what is usable in medications, in lab and imaging equipment and medical devices. We make sure that the tools available are safe, reliable, and do what they are intended to do. We do not de-regulate pharmaceuticals to speed innovation [due to the common claim by HIT hyper-enthusiasts that regulation would harm IT innovation, one might surmise they presumably would support pharma deregulation as well - ed.], we regulate minimum requirements of safety and efficacy so that such tools of medicine can be delivered to the bedside without the clinicians having to spend hours worrying about whether they're even fit for use. Improving the safety, value, and effectiveness of patient care is not dependent on HIT.  Fit HIT is an indispensable enabler of KNOWING that we are doing our best and KNOWING where we are falling short and where improvements can best be directed. Meanwhile, there can be no doubt that we will increasingly regulate HIT simply because it is the only way we can ever have non-anecdotal and systematic reporting on what HIT actually does (or doesn't do) for benefiting patients. Otherwise we will continue to be stuck where we are now: between a defective government policy that has bought the vision and promise (and there's a "no return" policy) without evidence, and the accumulating evidence of the difficulty, complexity, costs, and harms rendered by the current national experiment. [This evidence is often ignored or denied by the hyper-enthusiasts - ed.] Again, thank you for reiterating the necessity of standardization. This should progressively elevate the attention to the vast library of HIT standards existent (and still evolving) that remain unused by vendors. Not just vendors, though. Standards also remain unused by doctors, nurses, hospitals, and clinics (and their organizational advocates) who still, amazingly do little, if any due diligence on the fitness of HIT to their use as patient care tools and records thereof.  [This is known as "negligence" and perhaps "gross negligence" - ed.]  Given that Meaningful Use has lowered the Certification bar so much lower than it was in 2009 and since subsidies have made it a Sellers market (and a race to avoid penalties) it is hard to imagine how the geometric progression of risk of non-standardized [systems] untested for safety, usability, or fitness will not assure pain and suffering of many kinds for years to come. I look to you RAND to project your dynamic model for how Standardization will be achieved. In the meantime, of course this means that, among other things, they are not standardized for fitness in use for patient care. RDGelzer, MD, MPH.</blockquote> These are good thoughts. I repeat my warnings that until sanity and caution is restored to the health IT sector (or started, as it may never have  existed) it is not likely that "we may soon wonder how health care could have been delivered any other way." -- SS

Comments by Dr. Reed Gelzer on RAND Health IT Report and Op-Ed in Pittsburgh Post Gazette

A 2005 RAND Corporation report predicted that health IT could save the U.S. healthcare system $81 billion a year. Since then, however, ann...

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Wisdom from the Medical Journal of Oz: "Good HIT and bad HIT"

The recognition and partitioning of "good health IT" from "bad health IT" is now a mainstream meme.  I have few comments about this new article; it reflects views frequently expressed here at Healthcare Renewal (indeed, one of its references is to this blog and this author): <blockquote class="tr_bq"><a href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit" target="_blank">Good HIT and bad HIT</a> Jon D Patrick and Susan Ieraci Medical Journal of Australia 2013; 198 (4): 205.</blockquote><div class="ui-tabs-panel ui-widget-content ui-corner-bottom" id="article"><blockquote></blockquote><div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><blockquote><div class="Intro">First and foremost, do no harm. Second, do some good</div><div class="Intro"> </div></blockquote><div class="field field-name-field-provenance field-type-text field-label-above"><blockquote><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_elementId-1140662" name="0_elementId-1140662"></a> <div class="P">O<a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1140078" name="0_pgfId-1140078"></a>ne of the key issues for high-volume, high-risk workplaces like hospital emergency departments (EDs) is the struggle of conflicting aims. While hospital managers need information systems for data collection and storage, clinicians need efficient clinical documentation, data retrieval and order-entry systems that save time rather than steal it from the patient. The work of clinicians is aided by reliable data but impaired by the delays of real-time input, difficult system navigation, suboptimal presentation of information, and other problems in the user experience of health information technology (HIT).<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#1">1</a></div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139847" name="0_pgfId-1139847"></a>Mohan and colleagues’ study of the impact of an electronic medical record information system on ED performance had some limitations.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#2">2</a> It was retrospective and unable to control for all confounders, and therefore could only show a correlation with ED delays, not causation. However, the premise for the study delivers an important message — the work required to use the information system was perceived by the ED staff to directly conflict with time spent with patients.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139851" name="0_pgfId-1139851"></a>Another study has shown that the same electronic medical record information system is perceived to have had a negative impact on the care of patients, as well as the productivity and morale of staff, in six EDs in New South Wales.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#3">3</a> The need to be hypervigilant about the accuracy of the information supplied by the electronic health record compounds an already stressful clinical environment, which in turn leads to resentment towards the technology and the people who have imposed it. This makes it “bad” HIT. Unless this is corrected, HIT efforts will overuse precious health care resources, will be unlikely to achieve claimed benefits for many years to come, and may actually cause harm.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#4">4</a>,<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#5">5</a></div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139861" name="0_pgfId-1139861"></a>The large HIT corporations produce a type of technology that is best categorised as enterprise resource planning (ERP), which has its roots in the manufacturing industry. It is based on the idea that all processes within an organisation can be standardised, and that all processes of the same type should have their information modelled and processed in the same manner. If this high degree of standardisation were considered the best way to process and model information derived from clinical activity, then ERP would be a favoured technology to adopt, as has happened in many places.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139862" name="0_pgfId-1139862"></a>However, there is an alternative, almost contradictory, perspective on the nature of clinical work: that it is non-deterministic and performed by a group of diverse staff working in an ecologically stable network of people that has to respond to diverse medical needs and diseases. The ecology model accommodates staff joining and leaving the process, with differing needs emerging at different times, so that the other individuals in the network have to adapt and modify their behaviour and improvise in an unpredictable manner. Amid all this variability is the ever-demanding imperative to improve the processes of care and attention to the patient, while also increasing staff productivity.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#6">6</a></div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139866" name="0_pgfId-1139866"></a>Where the ERP model has been imposed in the clinical setting, staff may be coerced into an approach to their work that is at odds with established best practices. This could only be considered “good” HIT if it brought greater staff productivity with at least no loss (and, preferably, improvement) of patient safety and services and staff morale.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139867" name="0_pgfId-1139867"></a>It is not enough just to identify problems: effort must be invested in transforming bad HIT into good HIT. This process must identify and optimise all the operative factors: human behaviour, system design, equipment performance, skills of the IT participants, and the operational policy framework.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#7">7</a> Good HIT should include clinician control of the interface design for content, dataflow and workflow. It includes the ability to change the system in real time, and it incorporates inbuilt data analytical capability, natural language processing, and native interoperability and clinical coding.<a class="SupXRef" href="https://www.mja.com.au/journal/2013/198/4/good-hit-and-bad-hit#8">8</a> Finally, there must be an appropriate opportunity to test systems for useability, effectiveness and suitability before their release.</div><div class="P"> </div><div class="P"><a href="http://www.blogger.com/blogger.g?blogID=9551150" id="0_pgfId-1139874" name="0_pgfId-1139874"></a>There must be a move away from standardised processing models and towards improving the user experience in the clinical setting. Clinicians should not have to shoehorn their activity into predefined, externally imposed work processes that do not reflect actual activity and will not improve efficiency. A true patient-focused system aligns all its components towards the same aim. Like a good clinician, good HIT does no harm — to patients or staff.</div></blockquote></div><div class="field field-name-field-provenance field-type-text field-label-above"> American medical / HIT journals are perhaps a bit too beholden to industry to directly commit such health IT heresy.  Thank the stars those Down Under are a bit more bold.</div></div></div></div><div class="field field-name-field-provenance field-type-text field-label-above"> </div><div class="field field-name-field-provenance field-type-text field-label-above">-- SS</div></div>

Wisdom from the Medical Journal of Oz: "Good HIT and bad HIT"

The recognition and partitioning of "good health IT" from "bad health IT" is now a mainstream meme. I have few commen...

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