Healthy Care Program

Thursday, October 6, 2011

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

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We just discussed how leaders of big health care corporations with histories of ethical and legal missteps want to export our supposedly "wonderful technology, wonderful approaches" to the rest of the world. A story on the Huffington Post showed how big health care corporations, partnering with the US government, have already been doing that with not very pretty results. The article discussed two cases, connected by a single person who transited the revolving door from government to the pharmaceutical industry and then back to government.

The US Dispute with Brazil, on Behalf of Merck and Pfizer, About HIV Drugs

When [William] Daley was commerce secretary in the later years of the Clinton administration, Brazil rankled U.S. drug companies by opting to provide its citizens with a generic version of another HIV drug. Like Thailand, Brazil declared a public health emergency in an effort to lower the cost of treating roughly a half-million HIV infections. The U.S. government responded by sending Daley to Brazil with executives from U.S. pharmaceutical giants Merck & Co. and Pfizer to try to pressure the Brazilian government into reversing its decision.

Thus the US government appeared to be putting the revenues of US corporations ahead of the public health, at least in Brazil.
Daley soon made the transition to the private sector:

In a speech at Johns Hopkins University before leaving for Brazil, Daley encouraged students to enter the revolving door between big business and public policy-making. 'Let me say this: As one of the only members of the president's Cabinet to come from business, it's good when you mix both government and business in your careers,' he said. 'It makes better public servants, and it makes better businesspeople.'

It has certainly been good for Daley's career. His effort to twist arms in Brazil failed, but drug companies apparently took note. It was after leaving the Clinton administration that Daley was hired by Abbott, where he raked in more than $1.3 million as a board member from 2004 to 2010, according to Securities and Exchange Commission filings. Over the same period, he served on Boeing's board and was a top lobbyist for JPMorgan Chase.

Abbot's Dispute, Supported by the US Government, with Thailand About Kaletra

Soon Abbot was involved in a similar dispute.

The background is:

[HIV drug] Kaletra costs more than $10,000 a year for a patient living in the United States, a price that is reflective of the highly protective American patent system. The U.S. is the only country that grants long-term monopolies on life-saving medicine without regulating the price of monopolized drugs.

In addition

In countries that negotiate with companies on drug prices, the cost of medicine is often far lower. But though American pharmaceutical companies do supply drugs to developing nations at rates below those charged in the U.S., those discounted prices are still too high for many poor or hard-hit nations to afford.

'In many developing countries, it's a death sentence,'said Nobel Prize-winning economist Joseph Stiglitz, referring to high drug prices.

The core of the dispute:

In 2007 negotiations with the Thai government, Abbott Labs wouldn't budge below a price of $2,200 per person, per year for Kaletra. At the time, Thailand was classified as a 'lower-middle income' country by the World Bank -- the second lowest of four categories. With more than a half-million citizens living with HIV, Thailand considered that price beyond its budgetary capacity. So it declared a public health emergency and began importing a vastly cheaper generic version of Kaletra from India.

And then, by international trade standards, all hell broke loose.

'When countries declare the health emergency, they face a huge backlash, particularly from the USTR [US Trade Representative] and the drug companies,'said Tim Boyd, policy research coordinator with the AIDS Healthcare Foundation, a U.S. nonprofit dedicated to eradicating HIV.

Abbott responded by withdrawing pending applications to register drugs in Thailand, cutting its citizens off from other medications. The move was unprecedented: Never before had an American drug company attempted to punish a country during drug price negotiations by cutting off the supply of other medicines.

At the time, Brook Baker, a law professor at Northeastern University and a member of the board at the Health Global Access Project, called the move a 'ruly appalling example of corporate hubris'that 'irectly violates any conceivable norm of corporate responsibility.'

At that time, the US government went along with Abbott:

As for the USTR, it seemed to support the company, placing Thailand on its 'Priority Watch List 'of nations that do not respect U.S. intellectual property rights. 'In late 2006 and early 2007, there were further indications of a weakening of respect for patents, as the Thai Government announced decisions to issue compulsory licenses for several patented pharmaceutical products,' wrote the agency in its report announcing that Thailand had been added to the priority list.

Although the USTR blacklist is little known domestically, it is a major economic indicator abroad and can affect a country's ability to import everything from software to DVDs to automobiles. Thailand's new status as an international rogue sparked concern among the country's economic policy officials and corporate leaders. And 35 members of Congress wrote to the USTR to protest Thailand's blacklisting, noting, 'The move is being interpreted in the public health community as a warning and a threat to other countries.'

Note that:

Abbott Labs declined to detail Daley's involvement in the Thailand episode, but as a member of the board, he should have been well informed about the strategy.

US Government Pressure to Protect Drug Companies' Patents

William Daley has transitioned the revolving door again in the other direction:

As commerce secretary under Bill Clinton, William Daley worked with U.S. pharmaceutical giants to curb the use of cheaper generic drugs abroad. As a board member for Abbott Laboratories, he had a front-row seat on a brutal clash between a major drug company and a developing nation over access to life-saving medication. And as White House chief of staff today, Daley has President Barack Obama's ear.

In his new government job,

Add up Daley's power and experience, and experts who follow public health policy suspect his influence in the U.S. stance in negotiations over a major international trade deal -- a stance with hugely profitable implications for giant American drugmakers.

The United States is in talks with eight other Pacific nations to establish the Trans-Pacific Partnership, which the administration hopes will serve as a template for other trade pacts. According to leaked documents from the negotiations, the Obama administration is using the deal to push hard-line intellectual property standards that could drive up medicine prices overseas, boosting the bottom line for U.S. drugmakers like Abbott Labs at the expense of public health.

Public health advocates are worried. 'If the point of the trade policy is not just to protect the interests of our companies, but the public health benefit and burden of research, then [the United States] is doing this all wrong,' said James Love, director of Knowledge Ecology International, a nonprofit that focuses on how patent laws affect the poor.

A White House spokesman said only that the negotiations -- which are being conducted behind closed doors with input from corporate lobbyists -- are being 'ably led' by the United States Trade Representative (USTR) and that Daley is 'not directing or participating in those negotiations.'

Note that the USTR leadership includes other travelers through the revolving door:

Daley's personal history with drug access is not unique among top-tier government officials with trade responsibilities. McCoy lobbied on intellectual property issues at the influential D.C. law firm Covington & Burling before moving to the USTR in 2006. His top deputy, Kira Alvarez, was a lobbyist for drugmaker Eli Lilly before joining the agency.

Summary

Per Zach Carter, the author of the Huffington Post article:

Daley, who previously lobbied for JPMorgan Chase, is a prominent examplar of a bipartisan phenomenon in American government in which corporate insiders, and the profit-driven perspective of the boardroom, have come to dominate formal and informal debate over public policy.

Another way to describe this is corporatism. The corporatism in this case is partly enabled by the continuation of the revolving door, the free transit of individuals from leadership positions in top corporations and in government. The government and big corporations have teamed up to produce solutions that may seem beneficial to the people making the decisions, and may benefit their long term career strategies, but may not be good for the US public, for patients' and the public's health in this case, and for the ability of the country to conduct foreign policy based on some ethical and moral principles.

By the way, note that combined with other cases we have discussed, this shows that the revolving door pheonomenon, and other aspects corporatism affecting health care are not linked with any one political party.

So,

There is no evidence that any of these players, including Daley, have done anything illegal or explicitly corrupt during the Trans-Pacific trade negotiations. But public health doesn't seem to be their first priority.

'The real concern is that the U.S. is using its international power and prestige to force poor countries to enforce our intellectual property standards, and the result of that is that access to medicine is denied and people are dying,' said Joseph Stiglitz.

Until we dispel the fog of corporatism that has spread over the government that was once supposed to be of the people, by the people, and for the people, expect no real health care reform, and expect continuing rising costs, declining access, and worsening patient care. Obviously, true health care reform would start with the government and its officials putting patients' and the public's health first, way ahead of the financial comfort of corporate leaders.
xx

noreply@blogger.com (Roy M. Poses MD) 06 Oct, 2011

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Source: http://hcrenewal.blogspot.com/2011/10/enabled-by-revolving-door-corporatistic.html
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Going to heaven with our stitches in

A team at the Harvard School of Public Health published a disturbing article in Lancet this week on "The intensity and variation of surgical care at the end of life."

The group studied the 1.8 million Medicare beneficiaries who died in 2008 to determine the frequency of surgery during the last year of life. 32% had an inpatient surgical procedure during their last year. 18% had surgery during their last month. And 8% had surgery during their last week.

This is a population study, so it doesn't tell us how often the surgery was required by the patients' true needs and wishes. But I'd bet dollars to pennies that most readers of this post have seen surgery done in situations where a better informed patient and family would have rejected the proposal.

My beloved late father-in-law was vigorous until he turned 90, at which time angina limited how far he could walk in New York City's Central Park. Early in his life he'd been in the plumbing supply business, so when a revascularization procedure was proposed to him he thought of it as a common sense plumbing repair. He didn't consult with his family before deciding to do it. The result was five months of intractable heart failure before his death.

He was a gentle, fair-minded man and forgave his physicians for a recommendation they shouldn't have made and he shouldn't have accepted: "They are young men and were thinking about young hearts, not my 90 year old heart."

Dr. Ashish Jha, leader of the Medicare study, told a similar story from experience at his own hospital:

A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine.

"No one had talked to him about how close he was to death," Dr. Jha said. "It's the worst kind of conversation to have."

Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. "We did all of this because we were trying desperately to find something we could fix," Dr. Jha said.

The man died of a complication from the surgery.

"The tragedy is what we should have done for him but didn't," Dr. Jha said. "We should have given him time to have the conversation he wanted to have with his family. You can't do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea."

Instead, Dr. Jha said, "we sent him to the O.R."

Our current public concern is with Medicare costs. But the primary problem for my father-in-law and the patient Dr. Jha describes is care, not cost. More appropriate care for the patient would have had the secondary benefit of reducing cost. That's better medicine,not "death panel rationing"!

(A previous post - "Is Death Optional?" - discusses our need for a national dialogue on the goals of our health care system.)

Jim Sabin 06 Oct, 2011

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Source: http://healthcareorganizationalethics.blogspot.com/2011/10/going-to-heaven-with-our-stitches-in.html
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Celery seeds may lower blood pressure and cholesterol

michael 06 Oct, 2011

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Source: http://myhealth-your-health.blogspot.com/2011/10/celery-seeds-may-lower-blood-pressure.html
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Wednesday, October 5, 2011

The American Medical Association Recognizes Shared Decision Making

Readers of the Disease Management Care Blog may be surprised to learn that the American Medical Association "recognizes" shared decision making. A document recommending precisely that is available for your reading pleasure here.

It's a good review of the topic and makes for interesting reading. While the DMCB knew that the term "shared decision making" was specifically mentioned in the Affordable Care Act, it didn't know that there was an group called the International Patient Decision Aids Standards (IPDAS) Collaboration that is developing and piloting standards. It also didn't know that there is an academic entity in Canada called the Ottawa Health Research Institute (OHRI) that is devoted to research on the topic. The one area in which the Americans seem to still be leading, however, is commercializing the concept.

The AMA also recognizes that shared decision making can make the physician-patient relationship stronger, opposes any effort to link it to insurance coverage and supports more pilot programs.

This makes the DMCB happy to be an AMA member.

noreply@blogger.com (Jaan Sidorov) 06 Oct, 2011

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Source: http://diseasemanagementcareblog.blogspot.com/2011/10/american-medical-association-recognizes.html
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There Are Still Some Medical Watchdog Organizations That Call a Spade a Spade

Seeking justice for healthcare errors is often a disconcerting, if not sleazy affair. This can be gleaned from recent posts such as here, here, here and here.

The civil justice system is slow, subject to legal spin, and not exactly easy to navigate.

Fortunately there are medical watchdog organizations that are not simply figureheads or puppets for large healthcare organizations. They call a spade a spade.

I had filed, at the request of my mother when she was still lucid and living, a complaint in Dec. 2010 with the Medicare Quality Improvement Organization (QIO) where my mother was treated and injured.

The QIO investigated and the records were reviewed by an independent expert physician of the appropriate specialty. There report is as follows (redacted of names, places and dates; emphases mine):

Dear Mr. Silverstein,

[QIO organization] is the Quality Improvement Organization authorized by the Medicare program to review medical services provided to Medicare patients in [state]. Our responsibilities include a review of medical records to determine whether services meet professionally recognized standards of health care, are medically necessary, and are delivered in the most appropriate setting. We also review written complaints about the quality of Medicare services received by Medicare patients. Where we identify quality concerns, we provide education and feedback to providers and their medical staffs to improve the quality of services they provide in their facilities.
In response to your initial written concern, a QIO physician has reviewed the medical records concerning the services your mother received on 05/##/10 at [YY Hospital].
You are concerned about the following:

Concern:

Your mother was admitted at [YY Hospital] on May ##, 2010. You are concerned regarding the failure of the staff to properly conduct medication reconciliation which resulted in denial of a critical heart rhythm maintaining medicine, Sotalol, to your mother who had been taking it for approximately 8 years.

Response:

A QIO physician reviewer has reviewed the complete medical record for this admission and previous admissions. It was noted that the medication Sotalol was on the 4/##/10 discharge summary and the [later] 4/##/10 ER visit, current medications listed Sotalol 120mg every 12 hours.
It appears that on the 05/##/10 ER visit the current medication list does not include Sotalol and it does not appear that the patient received Sotalol on admission on 5/##/10. Also, the cardiology consult note on 5/##/10 states Sotalol was on hold but that is not clear from the ER note or admission H&P. It appears that Sotalol was not given from 05/##/10 - 05/##/10. Appropriate medication reconciliation of this medication appears not to have been performed. Therefore, a quality of care concern has been identified and confirmed.

Concern:

You are concerned that this failure resulted in lack of continuity of care and many medical complications your mother suffered which include, permanent CNS and cardiac injury as well as increased risk for CVA.

Response:

The QIO physician determined that there is a lack of continuity of care based on the review of the medical records submitted. It appears that the failure to administer Sotalol resulted in the recurrent atrial fibrillation on 5/##/10 and other subsequent medical complications. Therefore, a quality of care concern has been identified and confirmed.

As required by Federal regulations, prior to reaching our decision we gave [YY Hospital] an opportunity to discuss the services your mother received.

After a thorough review of your medical records and any additional information provided by the facility, we determined that the services your mother received did not meet applicable professionally recognized standards of health care. [That phraseology might be considered a technical description of malpractice - ed.]

In addition to determining whether or not care met professionally recognized standards of health care, we have reviewed the medical records pertaining to the services provided to your mother to see if there were any opportunities for improvement.

We share your concern about the quality of service your mother received and have initiated appropriate action as warranted by our review findings. [I was told the hospital was required to develop and/or follow a remediation plan to prevent further errors of this kind, and report back to the QIO for several quarters on their progress - ed.]

Before reaching our decision, we gave all involved practitioners and providers an opportunity to review our response concerning the services your mother received.

Please note that the information concerning individual practitioners contained in this letter is confidential and cannot be given out to anyone else, unless that practitioner's identity is not disclosed or he/she) has given consent.

If you have other concerns regarding this matter, please contact us.

Sincerely,

[Doctor Name]
QIO Medical Director

(It's regrettable that my mother left this earth before seeing this report.)

So, there are in fact organizations that will not tolerate substandard medical care.

These organizations need to receive increased influence and authority.

Of course, I mentioned early in this post that seeking justice is not a linear process.

It seems part of the problem is that many hospitals have problems with basic honesty, accountability, and medical expertise.

Exhibit one in that regard is the statements from the hospital's representatives even after Medicare found them to have not met applicable professionally recognized standards of health care:

"Defendant is unable to determine what plaintiff's claims are."

On issues of health IT's role in the errors, the response was Blame the Vendor:

"Claims are more appropriately brought against the software manufacturer." [Which could likely have a "hold harmless" agreement with the hospital - ed.]

This is reminiscent of the hemming and hawing in the aforementioned cases, and leads me to conclude many hospitals are, through legal games and technicalities, burying their mistakes with little accountability.

I submit that if after Medicare finds hospitals to have not met applicable professionally recognized standards of health care resulting in patient injury, yet the hospitals profess they "cannot determine plaintiff's claims", then those hospitals needs to find themselves new medical and Board-level leadership.

-- SS

scotsilv@aol.com (InformaticsMD) 06 Oct, 2011

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Source: http://hcrenewal.blogspot.com/2011/10/there-are-still-some-medical-watchdog.html
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Spend Billions More on HIT When Public-Health Services Get Crunched by Budget Woes?

I have the answer to these cutbacks of pubic health services.

Let's spend more tens or even better, hundreds of billions of dollars on experimental healthcare IT. (It worked out so well for the UK's NPfIT, we should follow the NHS's example of how to wisely spend our crucial healthcare billions.)

I will comment no further:

Wall Street Journal Health Blog
October 5, 2011, 10:00 AM ET
Public-Health Services Get Crunched by Budget Woes
By Betsy McKay

Immunizations, emergency preparations for hurricanes, and restaurant inspections are among local public-health services being cut back or eliminated amid budget constraints.

Some 55% of the nation's county and city health departments reduced or eliminated at least one program between July 2010 and June 2011, and the public-health workforce continued to shrink, according to a new survey by the National Association of County and City Health Officials.

The cuts hit maternal and child health services (at 21% of the departments reporting cuts), personal health services (20%), emergency preparedness (20%), chronic disease screenings (17%), and food safety (11%), among other programs.

Health departments lost 5,400 jobs in the first half of this year, after losing 6,000 in all of 2010. There are currently about 120,600 local health department employees across the country after those cutbacks. While the workforce has been shrinking since 2008, the downsizing "is now eating into program capacity," says Robert Pestronk, NACCHO's executive director.
Particularly worrying are the cutbacks in emergency-preparedness programs, he says. "It's troublesome given what we're seeing in terms of weather conditions and threats in communities," he tells the Health Blog. Health-department employees help plan for emergencies such as hurricanes, make sure supplies are in place and work as responders.

Meantime, cutbacks in immunization programs are making it harder for some children to get needed polio, tetanus and other preventive vaccinations, while reductions in food-safety programs mean fewer restaurant inspections or staff to interview people sickened in a food-borne illness outbreak, Pestronk says,
These woes aren't limited to local health departments. The Centers for Disease Control and Prevention has seen its budget for preparedness and response fall by more than $350 million since 2005, to about $832 million in fiscal 2011. That challenges the CDC's ability to respond to a pandemic like the type featured in the recent bio-thriller "Contagion," Rear Admiral Ali Khan, the CDC's chief of public health preparedness and response, told the Health Blog at a screening of the film.

-- SS

scotsilv@aol.com (InformaticsMD) 06 Oct, 2011

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Source: http://hcrenewal.blogspot.com/2011/10/semd-billions-more-on-hit-when-public.html
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Tuesday, October 4, 2011

Predictive Modeling: The Second Most Important Ingredient for Provider Accountability

When accountability fails

"Accountability." Everyone wants it, right?

While it's one thing for health care providers to be "accountable" for costs, it's another for them to actually make money at it. The Disease Management Care Blog is continuously amazed at how many physicians and administrators believe that dollops of "primary care," "prevention" and "wellness" will empty hospital beds and cause insurance money to appear like the morning dew on a windshield of a physician specialist's BMW.

Believe that and the DMCB has an ORD-SFO United Airlines upgrade "departure management card" it would like to sell you.

If the DMCB could do only one thing to reduce costs within one fiscal year for a health care system , it wouldn't be PCPs, wellness or prevention. Instead, it would place one vastly overpaid case manager in every emergency room in the network. His or her job would be to find alternative levels of care for persons that don't really need to be in the hospital and begin discharge planning for those who do.

The second thing the DMCB would do is implement predictive modeling. That's why it's immodestly tooting its horn and suggesting research like this is so important. In this web first publication, Chris Hollenbeak, Mark Chirumbole, Benjamin Novinger, Frank Din and your humble DMCB examined the baseline demographic data and medical conditions that can predict the likelihood of a future high cost hospitalization within a Medicaid population. Armed with knowing which of its patients are at risk ahead of time is a critical level of intelligence for any newly "accountable" hospital, clinic, IPA, PHO or IDN. By reaching out to high risk individuals prior to any crisis, physicians and administrators can engage these patients in outpatient settings and keep them away from the emergency room.

The good news is that the art and science of predictive modeling is within reach of most data bases, desk-top computers, statistical software packages and trained analysts. The bad news is that interpreting and executing on that information remains a daunting challenge.

Health systems like HealthCare Partners is a good example of how it can work well. As this "accountability" movement in health care evolves, the DMCB will undoubtedly learn about other good examples.

The systems that rely on vague notions about primary care, fail to understand the role of case management and ignore the business case for predictive modeling will form the bad examples.

noreply@blogger.com (Jaan Sidorov) 05 Oct, 2011

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Source: http://diseasemanagementcareblog.blogspot.com/2011/10/predictive-modeling-second-most.html
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Exporting the US "Health Ecosystem" and its "Wonderful Technology, Wonderful Approaches," or Exporting "A Parasite Eating Its Host?"

Last week, an article in the Minneapolis Star-Tribune suggested that our US corporate health care giants think they are doing such a good job they want to export the "world's best health care system" overseas:

A coalition of U.S. health care businesses, including Minnesota-based UnitedHealth Group and Medtronic, proposes to rebuild America's battered economy by selling the country's 'health ecosystem' internationally.

The Alliance for Healthcare Competitiveness (AHC) wants the U.S. government to build its foreign free-trade policy around the health care industry, noting that the sector has been a significant jobs creator since the recession began in 2008. Breaking down tariffs and other forms of international discrimination against America's 'health ecosystem' will allow developing countries such as China, India and Brazil to improve medical care while allowing U.S. companies to rescue the American economy by hiring more people, AHC leaders said Monday.

The worldwide need for health care in aging populations will lead to a demand for goods and services that can drive sales of American insurance, medical devices and record-keeping technology, said Simon Stevens, UnitedHealth's president of global health and an AHC member.

AHC members seem really convinced of the value of what they have to sell:

'We've got a lot of wonderful technologies, wonderful approaches,' said Alex Gorsky, Johnson & Johnson's vice chairman.

The Star-Tribune did note that our "health ecosystem" is

beset with skyrocketing costs and inefficiencies. Americans currently pay more for health care and rank lower in life expectancy and infant mortality than much of the developed world.

The article also managed to find one slightly dissenting expert,

'It seems ironic, at best,' said Jean Abraham, a professor of health policy and management at the University of Minnesota

Let me add a little more irony. The AHC advocates are top leaders at UnitedHealth and Johnson and Johnson.

UnitedHealth Group's Sorry Record

UnitedHealth would be the company whose CEO once was worth over a billion dollars due to back dated stock options, some of which he had to give back, but despite all the resulting legal actions, was still the ninth best paid CEO in the US for the first decade of the 21st century (look here). UnitedHealth would be the company whose current CEO made a cool $106 million in 2009 (look here). Howver, UnitedHealth would also be the company known for a string of ethical lapses:
- as reported by the Hartford Courant, "UnitedHealth Group Inc., the largest U.S. health insurer, will refund $50 million to small businesses that New York state officials said were overcharged in 2006."
- UnitedHalth promised its investors it would continue to raise premiums, even if that priced increasing numbers of people out of its policies (see post here);
- UnitedHealth's acquisition of Pacificare in California allegedly lead to a "meltdown" of its claims paying mechanisms (see post here);
- UnitedHealth's acquisition of Sierra Health Services allegedly gave it a monopoly in Utah, while the company allegedly was transferring much of its revenue out of the state of Rhode Island, rather than using it to pay claims (see post here)
- UnitedHealth frequently violated Nebraska insurance laws (see post here);
- UnitedHealth settled charges that its Ingenix subsidiaries manipulation of data lead to underpaying patients who received out-of-network care (see post here).
- UnitedHealth was accused of hiding the fact that the physicians it is now employing through its Optum subsidiary in fact work for a for-profit company, not directly for their patients (see post here).

Johnson and Johnson's Sorry Record

Johnson and Johnson also would be the company known for recalling heroic numbers of products, 26 different recalls since 2009, the latest, of Eprex, two weeks ago (see the WSJ Health blog recall watch here.).

Johnson and Johnson also has an amazing recent record of ethical lapses and guilty pleas, including:
- Convictions in two different states in 2010 for misleading marketing of Risperdal
- A guilty plea for misbranding Topamax in 2010
- Guilty pleas to bribery in Europe in 2011 by J+J's DePuy subsidiary
- A guilty plea for marketing Risperdal for unapproved uses in 2011 (see this link for all of the above)
- Accusations that the company, which makes smoking cessation products, participated along with tobacco companies in efforts to lobby state legislators (see post here)
- A guilty plea to misbranding Natrecor by J+J subsidiary Scios (see post here)

With the justification that "he met expctations," so despite, or maybe because of all this, Johnson and Johnson paid its CEO $29 million in 2010 (see post here).

Summary

So maybe UnitedHealth Group and Johnson and Johnson want to quickly export their brilliance before someone else realizes how bad their corporate records are, and takes action in response. Note that the "international discrimination" against such companies noted above could simply be another description of better regulatory systems in other countries which are more able to defend against the sorts of sleazy behavior that has plagued US health care. If US "free-trade" policy succeeds in challenging such regulation, other developed countries, which provide generally better health care at lower costs, could become more susceptible to catching the US health care dysfunction syndrome.

For more pithy comments, Minneapolis Public Radio published a commentary by David Durenberger in which he noted:

A physician I know read a story in Tuesday's newspaper at about the same time I did, 6 a.m. By 8 we'd found that we were having identical reactions to this absurdity. But he had a better way of expressing it: 'It's like a parasite eating its host.'

'They have bankrupted our culture, so now they want to try and bankrupt China and India,' he said.

Of course, if maybe we could export all of Johnson and Johnson, UnitedHealth Group, and other corporations with similarly bad records of crimes, legal settlements, ethical missteps, and bad leadership to India and China, maybe our health care system would start recovering from its dysfunction (but then pity the poor Chinese and Indians).

Maybe the corporate leaders quoted above suffer from the same apparently complete lack of insight that another health care CEO (actually former CEO) exhibited recently (look here). However, such glaring inability to perceive one's own problems surely will lead them to grief in the near future. Our corporate health care giants have already lead our dysfunctional health care system to enough grief.

True health care reform would favor leaders of health care organizations who understand the health care context, and uphold health care professionals' values, and have enough insight to realize when they are falling short of these standards.

Meanwhile, rest assured that US health care is the system where nothing can go wrong, go wrong, go wrong.

noreply@blogger.com (Roy M. Poses MD) 05 Oct, 2011

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Source: http://hcrenewal.blogspot.com/2011/10/exporting-us-health-ecosystem-and-its.html
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Monday, October 3, 2011

Commerical Insurers' Research vs. The Patient Centered Outcomes Research Institute

Government researchers get to work

The Disease Management Care Blog confesses that, from time to time and only when it's alone, it enjoys listening to Taylor Swift, watching cage fighting and taking Newt Gingrich's bombast seriously. During a typical superlative-laced ("Enormous!" "Monumental!") New Contract update on CSPAN, the quixotic Presidential candidate pointed out that Medicare (the poster child for government incompetence) will never be able to match the private sector's golden boys Visa and Mastercard's fraud-fighting expertise. He argues CMS should "outsource" catching crooks.

The Speaker may have a point and it doesn't apply to just fraud. How about the conduct of research?

Check out this update on the ACA's Patient Centered Outcomes Research Institute, a $3 billion federally-funded not-for-profit "aiming to assist people in making choices that are consistent with the values, preferences and goals" of patients everywhere. Its Board of Governors and Methodology Committee has been appointed by the GAO, it's been meeting every other month on "framework," "consensus," "priorities," "processes" and "agenda." It has a mission statement, stakeholders, understanding, speakers bureau and a fix on the landscape that will "inform national priorities." State-of the art methods are currently being reviewed and summarized.

Contrast the progress of this PCORI baronage with the likes of a 14-plan integrated database involving 33 million persons that can churn out four-year studies like this. The authors compared the fracture rates of tens of thousands of persons taking 3 different anti-osteoporosis drugs and found one drug appeared to perform better than the two others. Even without outside the ~~interference~~ support of any pharma or government, the authors came up with an important insight that has implications for the coverage of osteoporosis drugs in the commercially insured population.

While good intentions and the talent in the PCORI are considerable, the DMCB has to wonder if this slow-motion PCORI suzerainty will ever be able to clearly and efficiently match the research speed and skill of the commercial health insurance industry. Time will tell, but if the PCORI fails to give taxpayers their money's worth soon, perhaps they should be "Newted" and completely outsourced.

noreply@blogger.com (Jaan Sidorov) 04 Oct, 2011

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Source: http://diseasemanagementcareblog.blogspot.com/2011/10/commerical-insurers-research-vs-patient.html
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How the Rich and Influential Get Health Care Different from You and Me: Data About How Very Influential Persons Get Expedited Care

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

Expedited Care for the Influential

In a letter published in this week's Annals of Emergency Medicine, Dr. A.J. Smally of Hartford Hospital and the University of Connecticut reports that more than half of the 33 emergency department medical directors in his state said they routinely provide so-called 'expedited' care to influential people.

The influential people here include "corporate donors, hospital administrators, or, say, the brother-in-law of the president of the board of directors."

This was corroborated by "a survey of 100 emergency doctors nationwide" which showed that "84 of them had given or would given extra attention to an influential person, such as a famous person or a hospital donor."

Dr Smally asserted, "emergency triage protocols mandate treating the sickest patients first, no matter their social status." However, he also acknowledged that influential people will get treated more quickly,

'Somebody calls and says so-and-so is coming in, can you make sure they get good care,' Smally said. 'We bump them up a notch. If everyone is waiting four hours, they might just wait one hour.'

Better "Hotel Services"

The article also noted that influential people are likely to get better "hotel services" from hospitals, presumably at no extra cost to them:

to the head of the Association for Healthcare Philanthropy, a 5,000-memeber organization dedicated to boosting donations, tending to contributors when they're sick or injured is just part of doing business.

'It is true, we pay attention to our donors,' said Bill McGinly, president and CEO of AHP, who says most development departments are alerted when VIPs enter their hospitals. 'They've gone above and beyond. We recognize that their contributions can make a difference to the community.'

In some cases, that care can border on coddling. At Norwalk Hospital in Norwalk, Conn., donors who contribute $100,000 or more are known as 'Navigators' who receive not only a place at the front of the line, but top-tier attention as well.

'We help the family in any which way that we can,' said Carol Brennan-Smith, communications manager for the Norwalk Hospital Foundation. 'If their cell phone has no juice or they need a battery charger. It can be 'I want lemonade, I want a Ben and Jerry's Cherry Garcia ice cream.' If we can do it, we will.'

Grumbling and a Little Dissent
The ER docs involved also seemed unwilling to question the practic, although they did not seem perfectly comfortable with it:

grumbling is common, but to Smally and other ED docs, there's little moral dilemma. Dr. Michael Carius, chair of the emergency department at Norwalk Hospital, home of the 'Navigators,' said he's confident that no one is harmed by the practice — and that it actually may wind up doing greater good.

'This is a way of building good will so that when there is a need the hospital has, there's this favor bank,' he said.

The article only noted briefly that not all would agree with him:

ethicists and patient advocates worry that improved access for VIPs undermines the public mission of community emergency rooms and raises sharp questions about health care equality.

'It's not fair at the micro-level and I'm not sure it's fair at the macro-level,' noted Laura Weil, former director of the Health Advocacy Program at Sarah Lawrence College in Bronxville, N.Y.

In my humble opinion, the data and anecdotes summarized in the article raise a host of issues that deserve further thought.

Can the Self-Interested Be Donors, and Should They Receive Favored Treatment from the Government?
First, let us address the issue of donors receiving better "hotel services." I am not sure there are problems with offering better hotel services, as long as they have no direct effect on medical care, for a price to anyone who is willing to pay.

However, the article suggests that the donors receive special services that might not be available to anyone else, even for a price. If so, that challenges their claim to be donors. Donation implies a lack of self interest, and is honored socially, and financially by the US Internal Revenue Service in the form of a tax deduction. If donors are receiving special consideration in return for their donation, their donations may actually be self-interested means to get services they could not buy on the open market, and do not deserve honor.

Even if the donation was given expecting a partial quid pro quo in the form of a service that could otherwise be obtained by others for a price, to the extent that the donations included money paid for services, they may not deserve tax deductions. If the hospitals did not report the donation less the price of the services received in exchange for it, or if the donors did not subtract this amount from their donation before deducting it from their taxes, it might be worth an IRS investigation, perhaps both of the hospitals' non-profit status and the donors' personal tax returns.

I hope the IRS is paying attention to this issue.

Is It Ethical to Give Patients Who Are Not Donors Slower Care for Acute Illnesses?

A much bigger problem is the data suggesting donors, hospital executives, and their relatives may get not only cushier hotel services, but more rapid emergency department care. Since emergency departments are often operating near capacity, this rapid care for some may mean slower care for others. In many cases, slower care means more pain, more suffering, more morbidity, and in certain cases, a higher likelihood of dying.

Physicians have an ethical obligation to put each patient's interests ahead of other concerns (like attracting more donations to the hospital). It seems unethical to me to put a less sick patient ahead of a more sick patient because the former is an influential person.

Knowing that sick patients sometimes get delayed care to make way for a VIP may open a whole new area of legal discovery for plaintiffs' lawyers seeking to litigate against hospitals when patients suffer from slow care in the Emergency Department.

I hope plaintiffs' attorneys are paying attention to this issue.

There may also be legal issues for hospitals if the law requires them to make emergency care available to all acutely ill patients. If some hospitals delay emergency care for some acutely ill patients to provide expedited care for some less acutely ill patients because they are influential, there may be legal ramifications.

I hope the US Department of Justice, state attorneys general, and state departments of health are paying attention to this issue.

Does Insulating the Rich and Powerful from the Dysfunctional Health Care System Make for Bad Health Care Policy?
Finally, there is a larger health policy issue. At least a few of my fellow health care dissenters has been known to grimly opine that no real health care reform will take place until some big-wig, or his or her child, spouse, lover, sibling, or parent gets really bad care at the hands of our dysfunctional health care system. However, it appears that the rich and powerful have found ways to make this improbable.

In a number of ways, the rich and powerful have found ways to engineer a deluxe health care system for themselves. We have posted how big corporate executives have access to "executive health insurance" which provides benefits beyond what any normal person can obtain, even from seemingly the best employer paid policy. In 2007, we posted about how one academic medical center had an "A-list" of influential people who got special amenities and more rapid care. Now there is data to suggest this may be common practice.

If the rick and powerful can insulate themselves from the dysfunction of the current health care system, do not expect their sympathy or support in reforming this system. It appears that to truly reform health care, we will have do something about the context, call it a new gilded age, new age of the robber barons, oligarchy, plutocracy, or age of crony capitalism, in which it exists.

noreply@blogger.com (Roy M. Poses MD) 04 Oct, 2011

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Source: http://hcrenewal.blogspot.com/2011/10/how-rich-and-influential-get-health.html
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Healthy Care Program

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

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