Yves here. We’ve been republishing posts from Health Care Renewal for a very long time, but the recap below of the many causes of health care industry dysfunction is staggering. There is a lot of work that needs to be done.
By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal
In last night’s debate which included leading candidates from the Democratic Party for its presidential nomination, as reported by Mother Jones, Senator Bernie Sander (D-VT) said (per Mother Jones).
the current health care system is not only cruel, it is dysfunctional
The video is here.
So the concept of health care dysfunction has officially made it to the big time.
You Heard It Here First
What took so long?
We have been talking about health care dysfunction for a very long time, starting with a publication in 2003.
To better understand health care dysfunction, I interviewed doctors and health professionals, and published the results in Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14(2): 123-130. (link here). In that article, I postulated that US physicians were demoralized because their core values were under threat, and identified five concerns:
1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3. perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5. attacks on the scientific basis of medicine, including manipulation and suppression of clinical research stuides
After that my colleagues and I have tried to raise awareness of these and related issues, now mainly through the Health Care Renewal blog. We also set up FIRM – the Foundation for Integrity and Responsibility in Medicine, a US non-profit organization, to try to provide some financial support for the blog.
Health Care Dysfunction is Multi-Dimensional
Unfortunately, one sentence in a presidential debate hardly does justice to a huge and multi-faceted set of concerns.
Since 2003 we have broadened our thinking about what constitutes and causes US (and more global) health care dysfunction. Early on we noticed a number of factors that seemed to enable increasing dysfunction, but were not much discussed. These factors notably distorted how medical and health care decisions were made, leading to overuse of excessively expensive tests and treatments that provided minimal or no benefits to outweigh their harms. The more we looked, the more complex this web of bad influences seemed. Furthermore, some aspects of it seemed to grow in scope during the Trump administration.
A brisk summary of these often complex issues follows.
Threats to the Integrity of the Clinical Evidence Base
The clinical evidence has been increasingly affected by manipulation of research studies. Such manipulation may benefit research sponsors, now often corporations who seek to sell products like drugs and devices and health care services. Manipulation may be more likely when research is done by for-profit contract research organizations (CROs). When research manipulation failed to produce results to sponsors’ liking, research studies could simply be suppressed or hidden. The distorted research that was thus selectively produced was further enhanced by biased research dissemination, including ghost-written articles ghost-managed by for-profit medical education and communications companies (MECCs). Furthermore, manipulation and suppression of clinical research may be facilitated by health care professionals and academics conflicted by financial ties to research sponsors.
The distorted evidence base was an ingredient that proved useful in deceptive marketing of health care products and services. Stealth marketing campaigns became ultimate examples of decpetive marketing. Deceptive marketing was further enabled by the use of health care professionals paid as marketers by health care corporations, but disguised as unbiased key opinion leaders,another example of the perils of deliberate generation of conflicts of interest affecting health care professionals and academics.
Distortion of Health Care Regulation and Policy Making
Similarly, promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns. Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or to the influence of conflicted leaders and board members. Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.
More recently, as we noted here, we became aware of efforts by foreign powers to spread such disinformation for political, not just financial gain, e.g., in April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak
Furthermore, companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement. Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.
In the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers (look here). We found multiple managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting – wait for it – big health care corporations, a staggering intensification of the problem of the revolving door.
Bad Leadership and Governance
Health care leadership was often ill-informed. More and more people leading non-profit, for-profit and government have had no training or experience in actually caring for patients, or in biomedical, clinical or public health research. Lately, during the Trump administration, we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics look here). We had not previously expected leaders of government to be personally knowledgeable about health related topics, but traditionally they consulted with experts before making pronouncements.
Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations’ health care mission, and/or health care professionals’ values. Often business trained leaders put short-term revenue ahead of patients’ or the public’s health. In addition, we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients’ and the public’s health, and even corporate revenues. Then, we started seeing appointed government health care leaders who lacked medical, health care or public health background or expertise but also whose agenda also seemed to be overtly religious or ideological, without even a nod to patients’ or the public’ health (look here).
Leaders of health care organizations increasingly have conflicts of interest. Moreover, we have found numerous examples of frank corruption of health care leadership. Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud. Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.
In the Trump administration, corrupt leadership extends from the corporate world to the highest levels of the US government. We discussed the voluminous reports of conflicts of interest and corruption affecting top leaders in the executive branch, up to and including the president and his family (look here). One cannot expect effective enforcement of ethics rules and anti-corruption laws in such an environment
Abandonment of Health Care as a Calling
A US Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members, leading to the abandonment of traditional prohibitions on the commercial practice of medicine. Until 1980, the US American Medical Association had ruled that the practice of medicine should not be “commercialized, nor treated as a commodity in trade.” After then, it ceased trying to maintain this prohibition. Doctors were pushed to be businesspeople, and to give making money the same priority as upholding their oaths. Meanwhile, hospitals and other organizations that provide medical care are increasingly run as for-profit organizations. The physicians and other health care professionals they hire are thus providing care as corporate employees, resulting in the rise of the corporate physician. These health care professionals may befurther torn between their oaths, and the dictates of their corporate managers.
Perverse Incentives Put Money Ahead of Patients, Education and Research
We have extensively discussed the perverse incentives that seem to rule the leaders of health care. Financial incentives may be large enough to make leaders of health care organizations rich. Incentives often prioritize financial results over patient care. Some seem to originate from the shareholder value dogma promoted in business school, which de facto translates into putting current revenue ahead of all other considerations, including patient care, education and research (look here).
Cult of Leadership
Health care CEOs tend now to be regarded as exalted beings, blessed with brilliance, if not true “visionaries,” deserving of ever increasing pay whatever their organizations’ performance. This pheonomenon has been termed “CEO disease” (see this post). Afflicted leaders tend to be protected from reality by their sycophantic subordinates, and thus to believe their own propaganda.
Leadership of health care organizations by managers with no background in actual health care, public health, or biomedical science has been promoted by the doctrine of managerialism which holds that general management training is sufficient for leaders of all organizations, regardless of their knowledge of the organizations’ fundamental mission.
Impunity Enabling Corrupt Leadership
Most cases involving corruption in large health care organizations are resolved by legal settlements. Such settlements may include fines paid by the corporations, but not by any individuals. Such fines are usually small compared to the revenue generated by the corrupt behavior, and may be regarded as costs of doing business. Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements. The former were originally meant to give young, non-violent first offenders a second chance (look here). However, in most instances in which corruption became public, are no negative consequences ensue for the leaders of the organizations on whose watch corrupt behavior occurred, or who may have enabled, authorized, or directed the behaviors.
Some of the above topics rarely appeaedr in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant. We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.
Public discussion of the issues above might discomfit those who personally profit from the status quo in health care. Those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.
However,in the Trump administration, we began to also note examples of government officials attempting to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control (look here).
What a witches’ brew, surely leading to a cruel and dysfunctional system.
In 2017, we said that it was time to consider some of the real causes of health care dysfunction that true health care reform needs to address, no matter how much that distresses those who currently most personally profit from the status quo.
Furthermore, in 2019 we asserted that all the trends we have seen since 2017 are towards tremendous government dysfunction, some of it overtly malignant, and much of it likely enabling even worse health care dysfunction.
Now that health care dysfunction is in the headlines, we hope health care and public health professionals, patients, and all citizens will have a much more vigorous response to it. US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways. We do not have much time to act.
If not now, when?
If not us, who?