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IT Specialist and the job he wouldn't take: hospital management's health IT "plan" is a checklist for failure

Received unsolicited on June 14, 2013 from a computer professional whose identity I am redacting.  Posted with his permission: <blockquote class="tr_bq"><div>Dr. Silverstein,</div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">Thank you very much for the many insights and helpful references provided on your "Contemporary Issues in Medical Informatics" (<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/</a>) web site! In performing my due diligence for a position as an IT Director at a small rural hospital, I have come across your writings. </div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">I originally applied for this position in the hopes of leveraging my IT, project management, compliance and security experience to gain new expertise in healthcare IT. After my initial phone interview with the "CIO" and HR Director, at which I discovered that I would have the responsibility to implement a poorly conceived new EMR project, without the authority or resources to make it successful, additional red flags were raised which required further research. This led me to you.  </div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">I cannot help but chuckle at the organizational, social and project management dysfunctions in medical IT, as described in your "Ten Critical Rules for Applied Informatics..."  (<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=tenrules">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=tenrules</a>).   I have encountered similar dysfunctions in the world of military and commercial IT.  With a little tweaking, your lessons learned are applicable across a wide range of IT disciplines and a good reminder of how to avoid IT project and career failures and achieve successes.</div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">Yet, I understand and have come to appreciate your thesis that medical IT is fundamentally different from business IT. Even though I am convinced that I could do better than most, I have concluded that it is probably wiser for a competent healthcare informaticist to lead HIT implementation projects. I wonder how many such competent informaticists there can be! Unfortunately, since I have no background in medicine, it is probably a little late for me to become one. </div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">I certainly will not engage in this particular opportunity. What I know of the hospital management's "plan" at this point is a checklist for failure. The reality of this rural hospital, and apparently thousands of similar situations, is unnecessarily and depressingly tragic for patients and clinical professionals. I appreciate your crusade to raise the bar for healthcare IT, and therefore IT in general. Thank you for saving me from jumping in to an untenable situation.</div></blockquote> Ironically, and sadly, this letter is similar to others I have received dating to 1999.  Little has changed in nearly 15 years, except that with the rush to implement this unregulated, experimental technology thanks to the HITECH Act, there's likely going to be a lot more patient harm, especially at smaller hospitals new to this endeavor. -- SS

IT Specialist and the job he wouldn't take: hospital management's health IT "plan" is a checklist for failure

Received unsolicited on June 14, 2013 from a computer professional whose identity I am redacting. Posted with his permission: Dr. Silverste...

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The Financialized Medical Center - Executives of Non-Profit Wake Forest Baptist Medical Center Make an "Investor Call," but Have no Investors

We recently discussed the uncomfortable situation of Wake Forest Baptist Medical Center, the non-profit health system/ academic medical center of Wake Forest School of Medicine.  The organization suffered acute monetary losses after a problem plagued roll out of its new electronic health record.  Presiding over this mess were some extremely well paid executives who had been hailed as "visionaries" by their own public relations people. (Look <a href="http://hcrenewal.blogspot.com/2013/05/executive-compensation-as-legal.html">here</a> and <a href="http://hcrenewal.blogspot.com/2013/05/clouded-visionary-leadership-wake.html">here</a>.) An Even Bigger Financial Loss The resourceful Richard Craver, <a href="http://www.journalnow.com/business/business_news/local/article_52778d60-d2f5-11e2-aeb0-001a4bcf6878.html">writing</a> in the Winston-Salem Journal, just documented that the financial losses due to this cybernetic chaos now seem even bigger, <blockquote class="tr_bq">The center said Monday in a report submitted to bond agencies that it had a $62.8 million operational loss and an overall loss of $3.2 million in the third quarter of fiscal year 2012-13, which ended March 31. Stock investment gains of $54.6 million helped offset much of the operational revenue loss. Still, the operational loss was $13.2 million higher than the $49.6 million it reported Dec. 31. At that time, the center reported $7.4 million in overall excess revenue because of investment gains.  </blockquote>A Call to Non-Existent Investors   That, however, was not the big news.  Mr Craver further noted, <blockquote class="tr_bq">Wake Forest Baptist chief executive Dr. John McConnell and chief financial officer Edward Chadwick held an<a href="http://emma.msrb.org/ER677717-ER525248-ER927930.pdf"> investors call</a> on Monday to discuss the financial performance. It is the third such presentation of the fiscal year, according to the Municipal Securities Rulemaking Board’s <a href="http://www.emma.msrb.org/">www.emma.msrb.org</a> website.</blockquote> Mr Craver noted that there was something distinctly odd about this.  <blockquote class="tr_bq">The investor call represents a potential blurring of the lines between how not-for-profit hospitals and corporations operate, which also includes executive compensation as a hot-button topic. Analysts said the call is comparable to an earnings warning that corporations provide when they try to soften the negative reaction from a poorer-than-projected financial performance. Wake Forest Baptist did not comment when asked how long has it made investor calls and who receives notifications of the presentations. According to <a href="http://emma.org/">emma.org</a>, the center did not have investor calls listed prior to the first quarter of the current fiscal year. A search of Wake Forest Baptist’s public website did not find any references to investor calls or quarterly and annual financial reports. Spokesman Chad Campbell said the quarterly financial calls are in the public domain.</blockquote> While US publicly traded for-profit companies usually do schedule quarterly conference calls with investors to inform them about recent developments, Wake Forest Baptist Medical Center is clearly not a publicly held for-profit company.  It is a non-profit organization.  Non-profit organizations do not have investors or shareholders, For-profit corporations also may do periodic calls with bondholders.  Wake Forest Baptist Medical Center does have bondholders.  But the <a href="http://emma.msrb.org/ER677717-ER525248-ER927930.pdf">posted notice</a> for the call discussed above clearly refers to an "investor call," not a bondholders call.  One can now listen to the call (+1 855 859 2056, conference ID 90279604), and when I did, I heard the call was introduced by the operator, and by the Wake Forest Baptist Medical Center CFO as an "investor call."   A Financialized Mindset? So what in the world is going on here?  So why would its CEO and CFO make a quarterly call to "investors?"  The idea is absurd on its face.  Mr Craver was able to find one person to comment, who seemed to assume that the calls were truly "investor calls," not mislabeled calls to bondholders: <blockquote class="tr_bq">Ken Berger, president and chief executive of Charity Navigator, said a not-for-profit hospital holding an investors call 'is the antithesis of why a nonprofit exists.' 'Nonprofits are not supposed to be trying to maximize shareholder value, but maximize their benefit to the communities they serve,' Berger said. 'Transparency is great, whether corporation or nonprofit, for shedding light on financial performance.' 'In this instance, the investor call doesn’t represent full transparency, but only represents more morphing of a not-for-profit into a for-profit organization where only a select few investors are chosen to have access to pertinent current information.' </blockquote>My guess is that Mr Berger got it right.  It may be that the top executives of Wake Forest Baptist Medical Center have the mindsets of executives of a big for-profit corporation in an era of <a href="http://hcrenewal.blogspot.com/search/label/financialization">financialization</a>.  <a href="http://economix.blogs.nytimes.com/2013/06/11/financialization-as-a-cause-of-economic-malaise/">In the New York Times Economix blog</a>, Bruce Bartlett, an economist who has served in the administration of two Republican Presidents, Ronald Reagan and George HW Bush, and has worked for two Republican legislators, Jack Kemp and Ron Paul, cited financialization as the big largely anechoic reason for the global economic malaise.  He wrote, <blockquote class="tr_bq"> According to <a href="http://web.williams.edu/Economics/wp/BakijaColeHeimJobsIncomeGrowthTopEarners.pdf">research</a> by the economists Jon Bakija, Adam Cole and Bradley T. Heim, financialization is a principal driver of the rising share of income going to the ultrawealthy – the top 0.1 percent of the income distribution. Research by the University of Michigan sociologist <a href="http://cas.umkc.edu/econ/economics/faculty/wray/631Wray/Week%207/Krippner.pdf">Greta R. Krippner</a> supports this position. She notes that financialization exacerbates the well-known problem of corporate ownership and control: while corporate assets are owned by shareholders, they are controlled by managers who often extract an excessive share of corporate profits for themselves.</blockquote>  As we have <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">discussed</a>, for a generation business schools have taught managers that there primary goal is to maximize shareholder value, which has been interpreted to mean short-term financial performance.  Large corporations now give top managers tremendous incentives to maximize such performance, such that top managers have become rich, often the richest members of society.  Many top managers of health care organizations now come from a business background, and health care managers, even of non-profit organizations, also get large incentives.  Note also that the two executives on the "investor call" both had outsize compensation in 2011, the latest year for which the non-profit Wake Forest Baptist Medical Center has released the disclosure form (990 form) required by the US government.  The CEO, Dr McConnell, received over $2 million, while the CFO, Mr Chadwick, received just short of $1 million. (Look <a href="http://hcrenewal.blogspot.com/2013/05/executive-compensation-as-legal.html">here</a>.)  So it looks like they have a good reason to continue to operate a financialized organization so they can keep extracting sufficient revenue to make themselves rich. Clearly, though, if we want our health care organizations to preserve and protect patients' and the public health, we need them to be lead by leaders who care much more about health care than about short-term revenue and making themselves rich. As we have said endlessly,  true health care reform would put in place leadership that understands the health care context, upholds health care professionals' values, and puts patients' and the public's health ahead of extraneous, particularly short-term financial concerns. We need health care governance that holds health care leaders accountable, and ensures their transparency, integrity and honesty.

The Financialized Medical Center - Executives of Non-Profit Wake Forest Baptist Medical Center Make an "Investor Call," but Have no Investors

We recently discussed the uncomfortable situation of Wake Forest Baptist Medical Center, the non-profit health system/ academic medical cent...

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A Legal Settlement of One Aspect of the Fall of AHERF, Only 15 Years Later

It only took 15 years, but litigation related to one of the most important, but obscure cases of bad health care leadership and governance from the 1990s was finally settled.    Background The Allegheny Health Education and Research Foundation (AHERF) was a large integrated health care system formed out of multiple mergers.  AHERF went bankrupt in 1998, leading to massive layoffs, hospital closures, and the near dissolution of a medical school (which ended up taken over by Drexel University).  We last discussed the case in 2012 <a href="http://hcrenewal.blogspot.com/2012/04/pittsburgh-experiment-ii-another-echo.html">here</a>.. A summary of other important points about it is appended below.  As we <a href="http://hcrenewal.blogspot.com/2008/07/10-years-later-eerie-echo-of-fall-of.html">noted</a> in 2008, although the AHERF bankruptcy appears to be the largest failure of a not-for-profit health care corporation in US history, its story has produced remarkably few echoes for doctors, other health care professionals, health care researchers, and health policy makers. I often use the fall of AHERF as an example in talks, at least the few talks I am allowed to give on such unpleasant subjects. Rarely have more than a few people in the audience heard of AHERF prior to my discussion of it. I only could locate <a href="http://content.healthaffairs.org/cgi/reprint/19/1/7.pdf">one article </a>in a medical or health care journal that discussed the case in detail, but was written too early to address it very completely [Burns LR, Cacciamani J, Clement J, Aquino W. The fall of the house of AHERF: the Allegheny bankruptcy. Health Aff (Millwood) 2000; 19: 7-41.]  I doubt the case is used for teaching in most medical or public health schools, although it.was a formative influence on my <a href="http://www.ncbi.nlm.nih.gov/pubmed/12719032">2003 article</a> on health care dysfunction [Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130] and on this <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a> blog.  (A book about the case, Merger Games, by Judith Swazey, was published in 2012, and is available <a href="http://muse.jhu.edu/books/9781439907191">here</a> as  a set of PDF files from Project Muse for those with the proper password, but it has not yet had much of an impact, and I confess I have not yet read it.)  The lack of discussion of such a significant case is a prime example of the <a href="http://hcrenewal.blogspot.com/2007/08/bling-bling-poltical-correctness-and.html">anechoic effect</a>.  One Legal Settlement, 15 Years Later, for a Secret Amount But a brief echo of the case did appear in a brief <a href="http://triblive.com/news/allegheny/3875012-74/aherf-settlement-creditors">article</a> in the Pittsburgh Tribune Review published in April, 2013: <blockquote class="tr_bq"><div class="News-body-text"> Lawyers would not say Tuesday how much money an accounting firm will pay to settle a 13-year-old lawsuit claiming it helped destroy one of the state's largest health care systems. </div><div class="News-body-text"> </div><div class="News-body-text"> 'It will result in a very significant recovery,' James Jones, one of the lawyers representing the unsecured creditor of the Allegheny Health Education and Research Foundation, said during a settlement hearing in Pittsburgh federal court. </div><div class="News-body-text"> </div><div class="News-body-text">The creditors in 2000 sued Coopers & Lybrand LLP, the predecessor of PricewaterhouseCoopers LLP, claiming that if auditors in 1996 and 1997 had informed AHERF's board about the foundation's true financial condition, it would have acted to avoid a bankruptcy that resulted in huge losses. The foundation's assets included the Allegheny General Hospital system. </div></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> It seems only fitting, given how anechoic this case has been, that much about this settlement remains obscure,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq"><div class="News-body-text"> U.S. District Judge David Cercone, in a joint session with U.S. Bankruptcy Judge Judith Fitzgerald, approved the settlement with PricewaterhouseCoopers. </div><div class="News-body-text"> </div><div class="News-body-text"> The company disputes the method the committee used to calculate losses and denies liability in the settlement. </div><div class="News-body-text"> </div><div class="News-body-text">Joseph McDonough, a lawyer for PricewaterhouseCoopers, agreed the settlement amount is significant. He and Jones declined comment. </div><div class="News-body-text"> </div><div class="News-body-text">Jones said during the hearing that a trial could have lasted 40 days. Preparation for the case generated more than 200 depositions, 19 expert opinions and more than a million documents, he said. </div><div class="News-body-text"> </div><div class="News-body-text">The committee sent more than 3,500 notices to creditors about the proposed settlement, and none objected, he said. </div><div class="News-body-text"> </div><div class="News-body-text">Both sides agreed to keep the amount secret, and they discussed with Fitzgerald how to avoid releasing the amount in filings for related bankruptcy action. </div></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Maybe if the case had somehow generated more echoes, health care professionals and policy makers, and patients and the public at large might have learned some of its lessons.  The story of AHERF is not merely that of an unlucky bankruptcy. It shows what can go wrong when health care is taken over by <a href="http://hcrenewal.blogspot.com/search/label/generic%20managers">generic managers</a> who adapt the latest management fads, and health care decision making is ruled by <a href="http://hcrenewal.blogspot.com/search/label/marketing">marketing</a>, <a href="http://hcrenewal.blogspot.com/search/label/public%20relations">public relations</a> and <a href="http://hcrenewal.blogspot.com/search/label/propaganda">propaganda</a> instead of evidence and logic, and allows power to be <a href="http://hcrenewal.blogspot.com/search/label/concentration%20of%20power">concentrated</a> in organizations run by<a href="http://hcrenewal.blogspot.com/search/label/imperial%20CEO"> imperial CEOs</a>.  .</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">We did not get a chance to learn this history, so we seem bound to repeat it.   </div></div> Appendix Some important points about AHERF not found above (see also <a href="http://www.acponline.org/chapters/ri/nl-fall04.pdf">this narrative</a>, starting on page 5): <ul><li>AHERF, one of the largest health care systems of its day, was built by the poster-boy for health care imperial CEOs, Sherif Abdelhak.</li><li>Abdelhak, who <a href="http://www.post-gazette.com/aherf/part2.asp">started as food services purchasing manager </a>at Allegeheny General Hospital, was repeatedly hailed as a "visionary" (<a href="http://www.acponline.org/journals/news/mar97/phillymc.htm">in the March, 1997, ACP Observer</a>) a "genius," and the like. His plans to create a huge integrated health care system were part of the wave of the future. Abdelhak was even invited to give the prestigious John D Cooper lecture at the annual meeting of the American Association of Medical Colleges (AAMC), which was published in Academic Medicine [Abdelhak SS. How one academic health center is successfully facing the future. Acad Med 1996; 71: 329-336.] He proclaimed that "we will need to create new forms of organization that are more flexible, more adaptive, and more agile than ever before." And he announced that "my aim as chief executive has been to unleash the creativity and productive potential of every individual and to provide an environment that encourages teamwork" </li><li>While Abdelhak was making these grandiose promises, he paid himself and his associates very well. For example, he received $1.2 million in the mid-1990s, more than three times the average then for a hospital system CEO. He lived in a hospital supplied mansion worth almost $900,000 in 1989. Five of AHERF's top executives were in the top 10 best paid hospital executives in Philadelphia.</li><li>Although Abdelhak talked of teamwork, he warned the combined faculty of the new Allegheny University of the Health Sciences (AUHS): <a href="http://www.post-gazette.com/aherf/part6.asp">"Don’t cross me or you will live to regret it."</a></li><li>As AHERF was hemorrhaging money, Abdelhak continued to pay himself and his cronies lavishly.</li><li>After the AHERF bankruptcy, which was at the time the second largest bankruptcy recorded in the US, Abdelhak was charged with numerous felonies involving receiving charitable assets. In a plea bargain, <a href="http://www.post-gazette.com/localnews/20020830abdelhak0830p4.asp">he pleaded no contest </a>to misusing charitable funds, a misdemeanor, and was sentenced to more than 11 months in county prison.</li></ul>Posted by Roy M. Poses MD to the Health Care Renewal blog

A Legal Settlement of One Aspect of the Fall of AHERF, Only 15 Years Later

It only took 15 years, but litigation related to one of the most important, but obscure cases of bad health care leadership and governance f...

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Is the Cystic Fibrosis Foundation a Charity or a Venture Capital Firm?

We have often discussed how health care organizations now seem prone to diversion from their stated missions, often when money is the object.  While the organizations in question are frequently academic, teaching hospitals, academic medical centers, or medical schools in particular, in May, the Milwaukee Journal Sentinel <a href="http://www.jsonline.com/watchdog/watchdogreports/charitys-investment-a-prescription-for-profits-for-drug-maker-p79tfc9-208027961.html">presented</a> an example of a disease specific charity.  This article deserves considerably more attention than it apparently initially received. Background The background was, <blockquote class="tr_bq">What happens when a disease-fighting charity dives into venture capitalism? In the first case of its kind, the results include one of the planet's most expensive pills, huge sales projections for a drug company and windfalls for executives who sold stock in the glow of enthusiastic news releases about the drug. Kalydeco is a breakthrough drug designed from knowledge of the genetic roots of cystic fibrosis, a lung disease that kills most victims before they reach middle age. Developed by Vertex Pharmaceuticals with a $75 million investment from the Cystic Fibrosis Foundation, it is an early example of 'venture philanthropy,' where a nonprofit helps finance development of a treatment in return for a cut of sales.</blockquote> Remember that while disease specific charities often sponsor basic and clinical research, in this case, the CFF sponsored drug development.  In fact, much of the research on which this development was based was sponsored by charities and the US National Institutes of Health: <blockquote class="tr_bq">In the 1980s, Francis Collins, now director of the National Institutes of Health, was a researcher at the University of Michigan and on his way to becoming a renowned gene hunter. Collins and a team headed up by Lap-Chee Tsui at the Hospital for Sick Children in Toronto collaborated to identify the gene responsible for cystic fibrosis. That breakthrough involved funding from the NIH, the Cystic Fibrosis Foundation and the Howard Hughes Medical Institute, said Collins. Another decade of intense basic science followed, much of it funded by NIH.</blockquote> The Price to Patients  Despite, or perhaps because of the funding provided by CFF, Vertex chose a stratospheric price for its new drug. <blockquote class="tr_bq"> Yet it costs each patient $307,000 a year to take two Kalydeco pills a day - a price borne by taxpayers through Medicaid and other government programs and by the workers and companies who finance employee health insurance plans. In 2012, with less than a full-year on the market, Vertex sold $172 million worth of Kalydeco....</blockquote> To put that in perspective, the yearly cost of Kalydeco is approximately six times the median family income in the US. Minimizing the Harms To put it further into perspective, keep in mind that for the moment, the data from the single best published clinical trial on Kalydeco suggests that while the drug seems to help the average patient, it is not without risks, and it is certainly not a cure. The largest published trial that followed patients for a reasonable amount of time appeared in 2011 in the New England Journal of Medicine.  [Ramsey BW, Davies J, McElvaney G et al.  A CFTR potentiator in patients with cystic fibrosis and the G551D mutation. N Engl J Med 2011; 365: 1663-1672.  Link <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1105185">here</a>.]  The study followed 161 patients for 48 weeks.  The patients treated with Kalydeco on average showed improved lung function (increase of FEV1 [forced expiratory volume in one second] of 10% compared to essentially no change (-0.2 percent) in the placebo group.  Treated patients were less likely to have an exacerbation of their pulmonary disease requiring hospitalization (31% vs 49%).  So the drug certainly seems to have benefits at least in the short term.  The number needed to treat to prevent one exacerbation requiring hospitalization in one year is five, which seems quite respectable. On the other hand, the drug may have significant harms, even thought the report of the study seems to have attempted to minimize them.  The article stated <blockquote class="tr_bq">there was a lower rate of serious adverse events in the ivacaftor [Kalydeco] group than in the placebo group (24% vs 42%).   </blockquote> However, this statement depended on a rather peculiar definition of severe adverse events.  In particular, pulmonary exacerbations of cystic fibrosis were included among severe adverse events.  Yet these are, as the term suggests, manifestations of the disease that is being treated.  Reduction of pulmonary adverse events should be and was considered a measure of efficacy.  So placing exacerbations within the definition of adverse events essentially double counts these incidents.  Furthermore, the presence of these within the category of adverse events swamps out other events which may in fact be adverse results of the study drug.  If one subtracts pulmonary exacerbations and hemoptysis from the counts of serious adverse events, what remains is that patients on Kalydeco were more likely to have a serious adverse event (10%) than those on placebo (4%).  Thus the apparent number needed to harm was 17.  Thus, using this peculiar definition of adverse events appears to be a way to <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulate the analysis</a> to minimize the apparent harmfulness of the drug. While the study did appear to show that more patient received the benefit of avoiding a hospitalization due to a pulmonary exacerbation of cystic fibrosis than had a serious adverse event, the study did not show that the drug had overwhelming efficacy, or tremendous safety.   The study did not last long enough to show long term advantages, or to rule out rare but severe side effects. This is the only drug available of this type, and it may well provide benefits that outweigh harms, at least over the short-term, but it is not a wonder drug, and the rationale to charge so much money for it, other than that is what the market will bear, is not obvious.   A Windfall for Corporate Executives, and a Question of Insider Trading The drug's approval has lead to a lot of financial success for stock holders, particularly Vertex executives: <blockquote class="tr_bq"> Last month, news about success of the drug sent Vertex stock soaring more than $6 billion in a single day. That surge and a similar one last May allowed top executives and directors of the company to sell stock and options worth more than $100 million.</blockquote> The executives' lavish windfall occurred in somewhat questionable circumstances: <blockquote class="tr_bq">Vertex and its executives have benefited greatly from Kalydeco and foundation funding. Last May, when <a href="http://investors.vrtx.com/releasedetail.cfm?ReleaseID=670755" target="_blank">Vertex</a> and the <a href="http://www.cff.org/aboutCFFoundation/NewsEvents/2012NewsArchive/5-7-Phase-2-Kalydeco-VX-809-Interim-Data-Results.cfm" target="_blank">foundation</a> reported positive results from a clinical trial involving Kalydeco and whether it could be combined with another drug to treat more patients, the company's stock jumped more than 70%, from $37.41 to $64.85 a share. Five executives and two directors sold off more than $35 million in shares, mainly at prices from about $55 to $64 a share. Many of the options were priced between $16 and $40 a share. Three weeks later, the <a href="http://investors.vrtx.com/releasedetail.cfm?ReleaseID=677520" target="_blank">company said it overstated</a> the effectiveness of the drug in that trial and the stock dropped about $7 a share, ultimately falling back under $40 by December. Vertex spokeswoman Nikki Levy said in an email the company does not comment on individual stock sales.  She said the executive stock sales either were part of pre-existing 10b5-1 plans or followed the company's internal stock trading policy. A 10b5-1 plan is an automatic trading tool in which executives specify timing or pricing of sales to avoid questions about inside information the seller had at the time. U.S. Sen. Chuck Grassley (R-Iowa) <a href="http://www.grassley.senate.gov/about/upload/2012-06-07-CEG-to-SEC-Vertex.pdf" target="_blank">wrote a letter</a> to the U.S. Securities and Exchange Commission, saying it could appear that Vertex executives took advantage of the situation, knowing the overstated clinical trial results would eventually be made public and cause the stock price to drop. The letter said the stock sales were troubling for industry investors and the federal government, which pays billions of dollars a year for drugs through Medicaid and Medicare. Judith Burns, a spokeswoman for the SEC, declined to comment on the Grassley letter. Last month, the company's stock shot up more than 60% again, from $52.87 to $85.60, after <a href="http://investors.vrtx.com/releasedetail.cfm?ReleaseID=757597" target="_blank">positive early data</a> from a clinical trial of Kalydeco and another drug it is developing with funding from the foundation. On April 19, the day after the news was released, the company's market value jumped by more than $6 billion. That same day, two company executives sold huge chunks of stock options. Executive Vice President and Chief Financial Officer Ian Smith alone sold 745,685 shares worth more than $60 million. Most shares were sold at $81.50, with options purchased from $29 to $39.</blockquote> So at least Senator Grassley raised the question of whether Vertex executives may have taken advantage of their insider knowledge to personally profit even more from this useful but not miraculous drug meant to be used on vulnerable patients. Keep in mind that those huge trading gains were layered on top of already lavish compensation.  The 2013 Vertex <a href="http://investors.vrtx.com/secfiling.cfm?filingID=875320-13-13&CIK=875320">proxy statement</a>, the total compensation and stock holdings of its top executives in 2012 was: Jeffrey M Leiden, CEO                                $5,656,684      441,160 shares Ian F Smith, CFO                                           $3,109,193      795,434 Stuart A Arbuckle, Chief Commercial Officer   $4,808,697         66,477 Kenneth L Horton, Chief Legal Officer             $2,802,735         41,161 Peter Mueller, Chief Scientific Officer              $3,614,890        997,651 Matthew W Emmens, Former CEO                  $6,896,029    1,486,748 David T Howton Jr, Fomer Chief Legal Officer $3,447,898           3,105 So the top executives of Vertex, while their company got $75 million from an ostensible charity to develop what became an extremely expensive drug, got very rich in the process, although how they got rich may yet attract attention from the SEC. A Windfall for the Cystic Fibrosis Foundation and its Executives Furthermore, it appears that the supposedly charitable Cystic Fibrosis Foundation also made quite a bit of money, and its executives, while not getting quite as rich as their associates in Vertex, did not do at all badly. As the Journal Sentinel noted, <blockquote class="tr_bq">the foundation cashed in by selling future royalties from the drug to an undisclosed firm for $150 million.</blockquote>Keep in mind that since the CFF was to receive royalties, the money it gave for drug development was not a grant, but an investment. Furthermore, according to the Foundation's 2011 form 990 (the latest available), its executives received the following total compensation from the foundation and its affiliated organizations: Robert J Beall, CEO                                                      $1,073,725 C Richard Mattingly, COO                                              $759,799 Preston W Campbell MD, Exec VP of Medical Affairs     $736,031 Vera H Twigg, CFO                                                         $445,183 Ann Palmer, Senior VP                                                     $276,029  Daniel Klein, Senior VP                                                    $277,300 Gregory August, CIO                                                       $262,698 David McLoughlin, Senior VP                                          $316,122 Glen Goldmark, VP                                                          $253,215 Amy DeMaria, Senior VP                                                 $241,672 Mary Dwight, Senior VP                                                   $246,232 These compensation amounts may be much lower than the gargantuan pay dealt out to for-profit health care corporate executives, but they are very high for those who are managing a supposed charity meant to help vulnerable patients. A More Complex Web While profiting from its underwriting of the development of Kalydeco, the CFF also sponsored guidelines about the treatment of cystic fibrosis, with not unexpected results. <blockquote class="tr_bq">Last month, new treatment guidelines for doctors who handle cystic fibrosis patients strongly recommended use of Kalydeco. The guidelines were funded by the Cystic Fibrosis Foundation. Three of the 10 authors of the guidelines were employees of the foundation and four others worked for institutions that received grants from the foundation. The chairman, Peter Mogayzel, is a professor of pediatrics at Johns Hopkins University, which foundation tax records show received more than $2 million in grants from 2009 through 2011.</blockquote>These guidelines hardly look like they would be deemed trustworthy according to the Institute of Medicine's standards (look <a href="http://hcrenewal.blogspot.com/2012/11/what-if-institute-of-medicine-wrote.html">here</a>).  However, they certainly look like they might help sell ivacaftor, and hence help justify higher pay for the executives listed above. Criticism of Venture Philanthropy Merriam-Webster online <a href="http://www.merriam-webster.com/dictionary/charity">suggests</a> one definition of a charity is an institution funded by a gift for public benevolent purposes. The Cystic Fibrosis Foundation appears to be such a charity, but now one that functions more as a venture capitalist.  In this case, it did provide venture capital to develop a new drug for its disease of interest.  However, the foundation appeared to have done so not to provide public benevolence, but to generate a  return on its investment.  It is using that return not for public benevolence, but to provide more venture capital to other drug companies, presumably with the goal of getting further returns.  Meanwhile, its executives make generous compensation for people who are supposed to be running a charity.  Finally, the drug has an astronomical price, and its pricing has helped make investors in and executives of the company supported by the CFF very rich. This has not been lost on some dissidents, per the Journal Sentinel, <blockquote class="tr_bq">'The concept of a charitable, not-for-profit taking on the role of a venture capitalist is new and difficult to digest at the moment,' said Paul Quinton, a cystic fibrosis researcher at the University of California, Riverside and the University California, San Diego. Quinton, who has cystic fibrosis, is one of 28 doctors and scientists who sent a <a href="http://media.jsonline.com/documents/CFletteruse.pdf">letter</a> to Vertex calling the price of Kalydeco 'unconscionable.' A copy of the letter was provided to the Journal Sentinel and MedPage Today. Kalydeco, the doctors wrote, costs 10 times more than what a typical cystic fibrosis patient pays in total drug costs. 'This action could appear to be leveraging pain and suffering into huge financial gain for speculators, some of whom were your top executives who reportedly made millions of dollars in a single day,' the doctors wrote.</blockquote> Vertex responded with seeming contempt, <blockquote class="tr_bq"> Since receiving the letter last July, Vertex has raised the annual price of Kalydeco another $13,000.</blockquote> The funding by the supposedly charitable CFF of guidelines that promote the drug it financed has also drawn criticism, <blockquote class="tr_bq"> 'It is definitely a conflict of interest,' said Eric Campbell, an associate professor at Harvard Medical School who has researched conflicts of interest in patient treatment guidelines. In the past, drug companies have been criticized for funding treatment guidelines that recommend their drugs. It is no different if the guidelines are funded by a foundation that gets royalties from drug sales, Campbell said.</blockquote> Also, <blockquote class="tr_bq">'It is concerning that the organization now stands to profit when patients choose to use the drug,' ... [Prof Lisa Schwartz of Dartmouth Medical School] said. 'Financial entanglement with industry, even with the best of intentions, creates a conflict of interest.' </blockquote> However, the very well paid CEO of the CFF pooh poohed concerns about conflicts of interest, <blockquote class="tr_bq">Robert Beall, president of the Cystic Fibrosis Foundation, said that without its financial support, drugs such as Kalydeco would never get to patients. Neither insurance companies nor patients have voiced any concern to him about conflicts of interest, he said. 'They applaud the decision and our business model to the utmost,' Beall said. 'The patients are excited.' He rejected the idea of using the royalty money to help patients pay for the medical care, noting that the foundation needed the money to entice drug companies to get involved in risky cystic fibrosis drug research.</blockquote> One wonders when patients would ever have the opportunity to voice any "concerns" to Mr Beall, who also disdained any restraints on the price of the drug, <blockquote class="tr_bq">.Beall said the foundation did not ask Vertex to price the drug more affordably. 'That would have been a deal-breaker,' he said.</blockquote>That seems to put making money ahead of patients' needs.  Was this venture philanthropy, or vulture philanthropy?   Summary We have discussed numerous cases in which non-profit health care organizations seem to put short term revenue ahead of their missions to further patients' and the public's health.  In this case, a disease specific charity seems to have foregone its mission to directly support patient care, teaching, or research to provide venture capital, an action which lead to a profit for the organization, huge profits for a drug company, large rewards for the charity's executives, and even greater wealth for the drug company's executives.  It did also lead to the marketing of a beneficial drug, but at a breathtaking price that no middle-class patient without exceedingly good insurance could afford.   Where is the public benevolence here?  Where is the charity?  How much is about patients and how much is about  making insider executives wealthy?  As we have said until blue in the face, true health care reform would ensure health care organizational leadership that upholds the health care mission, not their personal finances.

Is the Cystic Fibrosis Foundation a Charity or a Venture Capital Firm?

We have often discussed how health care organizations now seem prone to diversion from their stated missions, often when money is the object...

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Long After the Start of the "War on Terror," a Conflict of Interest about an Anthrax Scare Comes to Light

In May, David Willman writing for the Los Angeles Times broke a <a href="http://www.latimes.com/news/nationworld/nation/la-na-anthrax-resistant-20130519-dto,0,3192936.htmlstory">story</a> of a somewhat new variant on the conflict of interest theme, one that has not gotten a lot of attention, but should. The issue was medical, with a twist, - how to best treat a bioterror attack with anthrax engineered to be resistant to multiple drugs, an event that luckily is not known to ever have occurred.  The story came from the bad old days of the "war on terror," but only has now come to light years later. The Alarm Raiser The story opened thus, <blockquote class="tr_bq">Over the last decade, former Navy Secretary Richard J. Danzig, a prominent lawyer, presidential advisor and biowarfare consultant to the Pentagon and the Department of Homeland Security, has urged the government to counter what he called a major threat to national security. Terrorists, he warned, could easily engineer a devastating killer germ: a form of anthrax resistant to common antibiotics.</blockquote> In particular, <blockquote class="tr_bq">Danzig began warning about antibiotic-resistant anthrax after the terrorist attacks of Sept. 11, 2001, and the mailings of anthrax-laced letters that fall. The powdered anthrax in the letters killed five people but was not resistant to common antibiotics. Asked what gave rise to his concern about resistant strains, Danzig cited conversations with 'people whose technical skills exceed mine.' One of them, Dr. Robert P. Kadlec, a bioterrorism advisor in the Bush White House, said he and others were concerned that terrorists could develop such a weapon. Danzig has sounded the alarm in published papers and in private briefings and seminars for biodefense and intelligence officials. In a 2003 report funded by the Pentagon, "<a href="http://documents.latimes.com/catastrophic-bioterrorism-what-be-done/" target="_blank">Catastrophic Bioterrorism — What Is To Be Done?</a>" he wrote that it would be 'quite easy' for terrorists to produce antibiotic-resistant anthrax. He has expanded on that theme over the years, including in a 2009 paper for the Pentagon. In the 2003 report, published while raxi [raxibacumab, an anthrax anti-toxin] was in development at Human Genome, Danzig said a drug to combat resistant strains of anthrax should be produced 'as soon as possible' and that stockpiling such a treatment, 'even if expensive and in limited supply' would deter an attack. John Vitko Jr., a top Homeland Security official during the Bush and Obama administrations, said he turned frequently to Danzig for advice on biodefense matters — and read and 'paid attention to' his 'Catastrophic Bioterrorism' report.</blockquote> Note that while Danzig is a lawyer, and certainly not a physician or biomedical researcher, he had major credibility in the defense field, particularly in anti-terrorism, so his recommendations had great influence. <blockquote class="tr_bq">He served as a Pentagon appointee during the Carter administration and as undersecretary and then secretary of the Navy under President Clinton. He has a long-standing interest in biowarfare. During the 2008 presidential campaign, Danzig advised then-Sen. Barack Obama on national security and bioterrorism. After Obama's election, Danzig was named to the Pentagon's Defense Policy Board and the President's Intelligence Advisory Board, in addition to his consulting positions with the Defense Department and Homeland Security.</blockquote> So apparently at least partly due to Mr Danzig's persistent warnings, the government took action, <blockquote class="tr_bq"> In 2004, President Bush signed into law Project BioShield, which provided billions of dollars for biodefense drugs. The contracts are administered by the Department of Health and Human Services, based on advice from federal agencies and consultants. Homeland Security must certify the need for a drug before the government can buy it.  Danzig, through his seminars, writings and consulting duties, has helped frame the discussion over whether a given biological threat is 'material' and whether the government should stockpile medicines to defend against it.</blockquote> Also, <blockquote class="tr_bq">Speaking of Danzig's broader role as a government advisor, Vitko said: 'Richard's got incredible insights into this and I think has made major contributions' He called Danzig one of 'the major bio player' and said his views had informed a range of policy considerations, including 'how many countermeasures do you need, of what kind.' It was in response to advice from Vitko and his staff that Homeland Security Secretary Tom Ridge in 2004 declared anthrax a 'material threat,' the certification required for the government to buy drugs to fight it. The drug the government bought was raxibacumab, or raxi, an anthrax anti-toxin made by Human Genome Sciences Inc.   In 2006, the Department of Health and Human Services finalized its first order of raxi — 20,000 doses at a cost of $174 million. That year, Ridge's successor, Michael Chertoff, signed a second, more specific declaration, adding 'multi-drug-resistant' anthrax to the government's list of material threats. Asked the basis for the second declaration, Vitko said: 'I think the concern was more forward-looking, and saying, 'How could the threat evolve, and are we prepared for that?'' Since 2009, the Obama administration has ordered an additional 45,000 doses of raxi for $160 million.</blockquote> There was just one catch. The Undisclosed Conflict Mr Danzig had a largely undisclosed conflict of interest.  He was on the board of directors of Human Genome Sciences Inc, the company whose drug his constant warnings and exhortations lead the government to buy. <blockquote class="tr_bq">When Human Genome named Danzig to its board on May 24, 2001, the company's chief executive said his high-level federal experience would 'serve us well.'</blockquote> He thus was on the board on September 11, 2001, and later when the events on that day and soon after apparently induced him to start sounding the alarm about resistant anthrax, and he stayed on the board as he continued sounding alarms, and after the government started buying his company's drug. <blockquote class="tr_bq">During his 11-year tenure on the board, which ended in August, Danzig collected at least $1,054,255 in director's fees and by cashing in grants of Human Genome stock and stock options, according to Fred Whittlesey of Compensation Venture Group, who reviewed the company's Securities and Exchange Commission filings for The Times. Nearly half of Danzig's compensation came from the stock options, of which he had been granted 184,000 by the end of 2011, Whittlesey said.</blockquote> Danzig did not seem to think that serving on the board of the company which made the primary drug directed at the perhaps hypothetical disease about which Danzig was sounding the warning constituted any sort of conflict of interest. <blockquote class="tr_bq">Danzig said in an interview that he believed his position at Human Genome posed no conflict. He said he had tried to improve policymakers' understanding of biodefense issues, including the threat of antibiotic-resistant anthrax, but never lobbied the government to purchase raxi. 'My view was I'm not going to get involved in selling that,' Danzig said. 'But at the same time now, should I not say what I think is right in the government circles with regard to this? And my answer was, 'If I have occasion to comment on this, it ought to be in general, as a policy matter, not as a particular procurement.' 'I feel that I've acted very properly with regard to this'' he said.</blockquote> He also apparently did not feel he needed to disclose his board membership to most of the people he was trying to persuade to be alarmed about resistant anthrax, and to pursue a treatment, such as that made by the company on whose board he sat. <blockquote class="tr_bq"> A number of senior federal officials whom Danzig advised on the threat of bioterrorism and what to do about it said they were unaware of his role at Human Genome. Dr. Philip K. Russell, a biodefense official in the George W. Bush administration who attended invitation-only seminars on bioterrorism led by Danzig, said he did not know about Danzig's tie to the biotech company until The Times asked him about it.</blockquote> Also, <blockquote class="tr_bq"> Vitko said he knew nothing of Danzig's involvement with Human Genome until a Times reporter asked him about it. 'I'm surprised I didn't,' Vitko said. 'I'm not aware of it.' Five other present or former biodefense officials who conferred with Danzig said they, too, had been unaware of his position with the company. Danzig, they said, made no mention of it in their presence during group discussions he led or in smaller meetings.</blockquote> Furthermore, <blockquote class="tr_bq">A Times search found seven papers Danzig had written on bioterrorism since 2001. In only one of those did he disclose his tie to Human Genome. As an advisor to the federal government, Danzig is required to file confidential forms annually, revealing any outside affiliations but not his related compensation. Danzig said he had noted his position with the biotech firm on the forms. Asked whether he mentioned his corporate role during contacts with government officials, Danzig replied: 'If I thought any of it posed a potential conflict that might cause somebody who knew about it to discount my views, I would tell them.'</blockquote> Some people disagreed with Danzig's failure to perceive a conflict of interest <blockquote class="tr_bq"> 'Holy smoke—that was a horrible conflict of interest,' said Russell, a physician and retired Army major general who helped lead the government's efforts to prepare for biological attacks.</blockquote> The Take-Over by a Familiar Corporation By the way, Human Genome Science was eventually bought out by a bigger company which has had its own sets of issues regarding conflicts of interest, GlaxoSmithKline, <blockquote class="tr_bq"> Human Genome was acquired by GlaxoSmithKline in August [presumably 2012] for $3.6 billion.</blockquote> It may yet stand to make even more money from raxi, <blockquote class="tr_bq"> Because raxi loses its potency after three years in storage, the government's supply will expire as of 2015, according to federal documents and people familiar with the matter. </blockquote> Summary This appears to be a variant on the "key opinion leader" (KOL) theme writ large.  Mr Danzig clearly functioned as a very major key opinion leader about bioterrorism.  Like many KOLs we have previously discussed, he had financial interests that favored the company whose drugs his key opinion leadership seemed to be favoring.  His influence seems to have lead to huge purchases of these drugs. Like many KOLs who are physicians or health care academics, Mr Danzig seems utterly blind to the possibility that his multiple efforts to emphasize the importance of the supposed disease for which his company made a drug could somehow be viewed as a conflict of interest, or to why failure to tell his audiences about his major relationship to this company might have appeared just a small bit dishonest.  We have seen many medical/ health care KOLs who deny that somehow their opinions could have been influenced by their financial relationships, or that their audiences deserved at least to be aware of these relationships.  Yet, of course, Mr Danzig is not a doctor, and he was trying to influence government purchasers of drugs, not physician prescribers of it. It does seem that the leadership of health care organizations, particularly but certainly not limited to pharmaceutical and biotechnology companies, have no lack of imagination about how to construct financial relationships with influential people who could help sell their products, whether or not they acknowledge what amounts to their marketing roles. Given that this story involved influencing the government, it will be interesting to see at this late date whether it results in any legal action.  After all, as David Willman pointed out, <blockquote class="tr_bq"> Federal law bars U.S. officials, including consultants, from giving advice on matters in which they or a company on whose board they serve have 'a financial interest.'</blockquote>It will also be interesting to see if it gets any more attention.  Only a few blogs have noted it, but at least they included <a href="http://www.the-scientist.com/?articles.view/articleNo/35639/title/Selling-an-Anthrax-Scare-/">The Scientist</a>. Yet our country has an unfortunately very long history of corporate leaders getting close to political leaders who then may overlook the legal niceties when their friends' interests are at stake.  Nonetheless, true health care reform would require all those who have decision making power over patients, health policy, or the public health to be completely transparent about their conflicts of interest, and would ban the more serious variants of conflicts of interest, even if that might cost some already rich people a bit of money.  I am not holding my breath, however, about when this might happen.

Long After the Start of the "War on Terror," a Conflict of Interest about an Anthrax Scare Comes to Light

In May, David Willman writing for the Los Angeles Times broke a story of a somewhat new variant on the conflict of interest theme, one that...

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Want to help a hospital go bankrupt? Get a bad EHR - Westchester hospitals' sale price over $54 million, Hospitals' debt about $200M

<div style="text-align: center;">- Posted at the Healthcare Renewal Blog on June 3, 2013 -  </div> <a href="http://www.ssmc.org/homepagess.cfm">Sound Shore Medical Center</a> (New Rochelle, NY) is filing for bankruptcy protection: <blockquote class="tr_bq">Montefiore Medical Center is offering to buy Sound Shore Health System for $54 million plus furniture and equipment, according to the latter’s bankruptcy filing — which also reveals just how far the troubled Westchester health network had fallen into the red. Sound Shore Medical Center in New Rochelle, Mount Vernon Hospital and five related entities have about $200 million in debts owed to more than 3,000 creditors, while possessing only $159.6 million in assets, the U.S. Bankruptcy Court documents show. Sound Shore filed for Chapter 11 bankruptcy protection Wednesday as the first step in discharging its debts and selling itself to the Montefiore system.</blockquote> Why were they in the red? You can read the full article "Westchester hospitals' sale price over $54 million; Hospitals' debt about $200M" in The Journal News for yourself at this link: <a href="http://www.lohud.com/article/20130530/NEWS/305300081/Westchester-hospitals-sale-price-over-54-million?odyssey=tab|topnews|text|News&gcheck=1">http://www.lohud.com/article/20130530/NEWS/305300081/Westchester-hospitals-sale-price-over-54-million?odyssey=tab|topnews|text|News&gcheck=1</a>, but there's this interesting passage: <blockquote class="tr_bq">... Beginning in 2006, the hospitals saw falling patient volume and a change in their case mix. That led to “significant” losses in recent years, negative cash book balances and bills paid more than 225 days late. A 2011 electronic medical record and billing system conversion caused major delays in billing and cash collection that still haven’t been fully solved. </blockquote> (This passage has a familiar ring to it; e.g., see SEC Count 9 at "Florida Hospital gets an 'F' on Informatics" at  <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=miami">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=miami</a>.) A 2011 EHR and billing conversion?  It's now 2013. How many hospital IT personnel does it take to <strike>screw in</strike> implement a <strike>light bulb</strike> new EHR? -- SS

Want to help a hospital go bankrupt? Get a bad EHR - Westchester hospitals' sale price over $54 million, Hospitals' debt about $200M

- Posted at the Healthcare Renewal Blog on June 3, 2013 - Sound Shore Medical Center (New Rochelle, NY) is filing for bankruptcy protectio...

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Is the Patient Centered Outcomes Research Institute Really More Industry-Centered?

One of the biggest reasons our health care system seems so dysfunctional is that clinicians and patients have great difficulty determining what might be the appropriate management of particular clinical problems.  Due to endless and sometimes <a href="http://hcrenewal.blogspot.com/search/label/deception">deceptive</a> marketing,<a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest"> conflicts of interest</a> affecting health care professionals and academics, and <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulation</a> and <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression </a>of clinical research, making truly evidence based decisions that put individual patients interests first has become very difficult.  Instead, we may end up using excessively expensive, relatively ineffective, and more dangerous than anticipated drugs, devices, and diagnostic and therapeutic strategies, thus leading to poor patient outcomes and high costs. Background - the Patient-Centered Outcomes Research Institute (PCORI) One lingering hope has been that better clinical research, particularly focusing on the outcomes that are most important to patients (patient-centered outcomes), and comparing clinical strategies that may be widely used but poorly evaluated (<a href="http://hcrenewal.blogspot.com/search/label/comparative%20effectiveness%20research">comparative effectiveness research</a>) would help dissipate the fog.  An attempt to promote such research in the US appeared in our recent health reform legislation, the Affordable Care Act.  It authorized the creation of the <a href="http://www.pcori.org/">Patient Centered Outcomes Research Institute </a>(PCORI). However, as we <a href="http://hcrenewal.blogspot.com/2010/03/health-care-reform-bill-and-health-care.html">observed</a>, how good a solution this would be would depend on the details.  Our concerns were that PCORI, which is an independent although government sponsored institute, not a government agency, might be too beholden to "stake-holders" including the large organizations, device and pharmaceutical companies, insurance companies, hospital systems, etc, that already dominate health care and may promote their and particularly their executives' interests ahead of patients. Recently, Merrill Goozner, the editor of Modern Healthcare, <a href="http://www.modernhealthcare.com/article/20130427/MAGAZINE/304279990">raised similar concerns</a>, <blockquote class="tr_bq">there is the law's requirement for stakeholder boards to set PCORI research priorities. They must include representatives of researchers, clinicians, patients, providers, insurers, employers and industry. The interests of those groups are not the same. Priority-setting by stakeholder boards could turn into a prescription for steering clear of the most controversial, and therefore most significant, questions.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> So,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq">There is no shortage of drug and device firms, specialty hospitals and medical specialty societies with a vested interest in leaving certain questions unasked or muddying the waters with methodological quibbles. They shouldn't be allowed to hijack or soften the agenda.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div></div> PCORI is now in operation, but has seemingly not gotten a lot of scrutiny. What scrutiny it has received as not allayed these concerns. The PCORI Advisory Panels Recently, the publication of the membership of four key advisory panels for PCORI got the attention of  Michael Millenson, <a href="http://thehealthcareblog.com/blog/2013/04/05/why-the-pcori-picks-matter/">blogging on</a> the Health Care Blog.  He noted that initially the members of the panels were identified only by name and city of residence, without any information on their other affiliations or characteristics.  He suggested, <blockquote class="tr_bq"> PCORI isn’t a church, where all are created equal in the eyes of God, but a politically created, politically governed, controversial dispenser of a very large amount of money that a host of interest groups would like to control. PCORI staff chose the panel members in part by looking at their affiliations, and those connections (or lack of them) should be an immediate part of the public record when the appointments are announced. By being vague, PCORI obfuscates political and power relationships and makes it more difficult for the public and industry stakeholders to either approve of or criticize those choices.</blockquote> Eventually, PCORI did release somewhat more information on membership of these panels, on <a href="http://www.pcori.org/get-involved/pcori-advisory-panels/advisory-panel-on-addressing-disparities/">Addressing Disparities</a>, <a href="http://www.pcori.org/get-involved/pcori-advisory-panels/advisory-panel-on-assessment-of-prevention-diagnosis-and-treatment-options/">Assessment of Prevention, Diagnosis, and Treatment Options</a>, <a href="http://www.pcori.org/get-involved/pcori-advisory-panels/advisory-panel-on-improving-healthcare-systems/">Improving Healthcare Systems</a>, and <a href="http://www.pcori.org/get-involved/pcori-advisory-panels/advisory-panel-on-patient-engagement/">Patient Engagement</a>.  Mr Millenson was able to review the membership of one panel, and noted some strange anomalies in a comment to his original blog post.  One panel member who supposedly represents "patients, caregivers, and patient advocates" had a full time position with a pharmaceutical company.  Another worked for a big consumer organization which is heavily funded by the pharmaceutical industry. This raised concerns that PCORI may get guidance from people whose interests are actually different from those they are supposed to represent. Therefore, I attempted to review the stated affiliations of all PCORI advisory panels. Review of the what was made public about the membership of the advisory panels revealed several additional important anomalies.  Members said to be representing "patients, caregivers, and patient advocates" appeared to have positions working for organizations who might have their own, and different interests from the group they were supposed to be representing.  Let me summarize the apparent anomalies by advisory panel.  In each case, in alphabetical order by panel,  I will list the panelists name, supposed representation, and affiliation, with my comments.  Addressing Disparities Monique Carter MS - Dallas, TX representing: patients, caregivers, and patient advocates affiliation: Senior Research Scientist, AROG Pharmaceuticals Inc So this person would appear to be more of an industry (pharmaceuticals) representative. Venus Gines, MA, P/CHWI - Manvel, TX representing: patients, caregiver, and patient advocates affiliation: Instructor, Chronic Disease Prevention and Control Research Center, Department of Medicine, Baylor College of Medicine So this person appears to be more of a clinician, or health system representative Doriane C Miller MD - Chicago, IL representing: patients, caregivers, and patient advocates affiliation: Director, Center for Community Health and Vitality, University of Chicago Medical Center So this person also appears to be more of a clinician, or health system representative. Carmen E Reyes, MA - Whittier, CA representing: patients, caregivers, and patient advocates affiliation: Center and Community Relations Manager, Los Angeles Community Academic Partnership in Research in Again, UCLA So this person appears to be more of a health system representative. Mary Ann Sander, MHA, MBA, NHA - Pittsuburgh, PA representing: patients, caregivers, and patient advocates affiliation: Vice President, Aging  and Disability Services, UPMC Community Provider Services So this person appears to be more of a health system representative Deborah Steward, MD, MBA - Jacksonville, FL representing: clinicians affiliation: Florida Blue So in summary, this panel included five people who ostensibly represent patients, caregivers, and patient advocates but who actually work for large academic medical centers or health systems, and one who was there to ostensibly represent patients, caregivers, and patient advocates who works for a pharmaceutical firm.  (In addition, one person supposedly representing clinicians apparently works full time for a health insurance company.) Assessment of Prevention, Diagnosis, and Treatment Options Karen Chesbrough, MPH - Annandale, VA representing: patients, caregivers, and patient advocates affiliation: Scientific Program Administrator, Foundation for Physical Therapy. Note that the <a href="http://foundation4pt.org/get-involved/about/">stated mission</a> of the Foundation for Physical Therapy is that it "supports the physical therapy profession’s research needs," and the foundation is funded in part by companies that make physical therapy devices and supplies  (look <a href="http://foundation4pt.org/get-involved/partners/">here</a>).  Therefore, this person appears to be more of a representative of clinicians, or perhaps industry (devices). Bettye Green RN - South Bend, IN representing: patients, caregivers, and patient advocates affiliation: Community Outreach Nurse and Associate Director of Advocacy, Alliance for Clinical Trials in Oncology, Saint Joseph Regional Medical Center So this person appears to be more of a health system representative. Debra Madden - Newtown, CT representing: patients, caregivers, and patient advocates affiliation: Clinical Applications Systems Analyst, Associated Neurologists So this person appears to be more of a clinician representative. Daniel Wall - Spencer, WI representing: patients, caregivers, and patient advocates affiliation: Analyst, Biomedical Informatics Research Center, Marshfield Clinic Foundation So this person appears to be more of a clinician or health system representative So in summary, this panel included four people who ostensibly represent patients, caregivers, and patient advocates but who actually work for health systems or clinician organizations, and one of the latter organizations appears to be heavily funded by the medical device and supplies industry. Improving Healthcare Systems Susan Diaz MPAS, PA-C - Jacksonville, FL representing patients, caregivers, and patient advocates affiliation: Physician Assistant in Liver Transplant, Mayo Clinic in Florida So this person appears to be more of a clinician, or health system representative. Anne Sales PhD-  Ann Arbor, MI representing: patients, caregivers, and patient advocates affiliation: Professor, School of Nursing, University of Michigan So this person appears to be more of a clinician, or health system representative. Jamie Sullivan MPH - Silver Spring, MD representing: patients, caregivers, and patient advocates affiliation: Director of Public Policy, COPD Foundation. Note that the COPD Foundation receives support at least from "Boehringer-Ingelheim/Pfizer Inc. and Grifols" (look <a href="http://www.copdfoundation.org/Home/AboutUs/PartnersSponsors.aspx">here</a>).  . So this person appears to be at least somewhat an industry (pharmaceutical) representative. So in summary, this panel includes three people who ostensibly represent patients, caregivers, and patient advocates, two of whom actually work for large health system, and one who works for a foundation with significant pharmaceutical industry support.   Patient Engagement Stephen Arcona MA PhD - East Hanover, NJ representing patients, caregivers, and patient advocates affiliation: Executive Director, Outcomes Research Methods & Analytics, Department of Health Economics and Outcomes Research, Novartis Pharmaceuticals Corporation So this person appears to be more of a researcher, and industry (pharmaceutical) representative. Marc Boutin JD - Washington, DC representing patients, caregivers, and patient advocates affiliation: Executive Vice President and Chief Operating Officer, National Health Council  Note that while the National Health Council <a href="http://www.nationalhealthcouncil.org/pages/page-content.php?pageid=53">claims</a> to be an advocate for people with chronic disease and disability, its core membership includes "major pharmaceutical, medical device, health insurance, and biotechnology companies." and it receives considerable industry support.  For example, it <a href="http://www.nationalhealthcouncil.org/pages/corporate-partners.php">disclosed</a> contributions in the $100,000 - $300,000 range from Amgen, Astra-Zeneca, Eli Lilly, Novartis, Pfizer, and the Pharmaceutical Research and Manufacturers of America (PhRMA), and smaller but still significant contributions from other pharmaceutical companies and other industry associations.  So this person appears to be at least somewhat of an industry (pharmaceutical) representative. Charlotte W Collins JD - Elkridge, MD representing patients, caregivers, and patient adovcates affiliation: Vice President of Policy and Programs, Asthma and Allergy Foundation of America Note that while the Asthma and Allergy Foundation of America claims to be a patient advocacy organization, it <a href="http://www.aafa.org/display.cfm?id=10&sub=27&cont=250">disclosed</a> financial support from many pharmaceutical, device, and health insurance companies, and from major health care systems So this person appears to be at least somewhat an industry, health insurance, and/or health system representative. Amy Gibson, RN MS - Washington, DC representing patients, caregivers, and patient advocates affiliation: Chief Operating Officer, Patient-Centered Primary Care Collaborative (PCPCC) Note that the PCPCC has an <a href="http://www.pcpcc.net/executive-members">executive committee</a> that includes multiple pharmaceutical, device, and health insurance companies, and health systems.  So this person appears to be at least somewhat an industry, health insurance, and/or health system representative. Julie Ginn Moretz - Augusta, GA representing patients, caregivers, and patient advocates affiliation: Associate Vice Chancellor, Patient- and Family-Centered Care, University of Arkansas for Medical Sciences So this person appears to be more of health system representative. Sara Triagle van Geertruyden - Washington, DC representing patients, caregivers, and patient advocates affiliation: Executive Director, Partnership to Improve Patient Care (PIPC) (Note: this affiliation appears incomplete.  Sara van Geertruyden is <a href="http://thornrun.com/contact">listed</a> as a <a href="http://thornrun.com/sara-van-geertruyden">current partner </a>of Thorn Run Partners, a <a href="http://thornrun.com/">lobbying firm</a>, with a major <a href="http://thornrun.com/practice-areas">practice area</a> in health care, boasting, "Thorn Run Partners offers one of Washington, DC’s most comprehensive, competent and effective health policy practices." Note also that PIPC has <a href="http://www.improvepatientcare.org/pipc-member-list-0">membership</a> that includes many specialty physician societies, and a <a href="http://www.improvepatientcare.org/steering-committee">steering committee</a> that includes the Biotechnology Industry Organization, and PhRMA.  So this person appears to be more of an industry (pharmaceutical and biotechnology) representative. So in summary this panel includes six members who ostensibly represent patients, caregivers, and patient advocates, but who work for either patient advocacy organizations that get considerable industry support, or a health system, or a pharmaceutical company.  One person whose affiliation was listed as a patient advocacy organization also somehow appears to be a full-time lobbyist.   Summary While PCORI has set up advisory panels that seem to strongly emphasize representation of patients, caregivers, and patient advocates, a substantial fraction of the people who are supposed to provide this representation seem to work for patient advocacy groups with considerable industry support, or directly for industry or health care systems.  Some of them may work as clinicians or researchers, but many appear to have high level executive positions with these organizations.  One appears to be a full-time lobbyist at a firm that has a strong health care practice.  Thus it appears that PCORI advisory panels actually may be as much about the interests of big health care organizations, including pharmaceutical and device companies, health insurance companies, and large hospital systems, as they are about patients, caregivers, or patient advocates.   I am afraid my and Merrill Goozner's original fears that PCORI may end up being more about industry-centered interests than patient-centered outcomes may not be paranoid.  I do hope that PCORI leadership manages to put improving patients' and the public's health ahead of making industry executives happy.  by Roy M. Poses MD, for Health Care Renewal

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