More Large Health Care Corporations Are Again Funding Politicians Who Threatened Representative Democratic Governance

Introduction: Health Care Corporations' Political Contributions: From Bipartisan to Trumpian

 At one time, leadership of large health corporations were circumspect in their financial support for US politicians and political causes. They provided some funds directly to politicians and political organizations, but often amounts given to different parties and organizations with different ideologies were balanced. Presumably, the goal was to promote access to whomever was in power at any given time. 

 

With the rise of Donald Trump, things changed. Many leaders apparently went all in for Trump and his Republican supporters.  In June, 2018  we discussed how CVS channeled money to a "dark money group," that promoted Trump administration policies, including repeal of the Affordable Care Act (ACA). In October, 2018, we discussed important but incomplete revelations about corporate contributions to such dark money groups that mainly favored again right-wing ideology, the Republican party, and Trump and associates. In November, 2018, we noted that health care corporations funneled funds through dark money organizations to specifically attack designated left-wing, Democratic politicians. In March, 2019, we discussed how in the 21st century, health care corporate CEOs' personal political contributions were increasingly partisan, that is individual CEOs gave predominantly or exclusively to one party, and for the vast majority, to the Republican party. 

Some corporations paused some of their political giving after a mob whipped up by Trump at a January 6, 2021, rally violently stormed the US Capitol to try to prevent the certification of the 2020 election. However, within two months they started giving again in support of Republicans in Congress who voted not to certify the election (see this April, 2021, post, and this July 7, 2021, post).

Now yet another report shows continuing support by large health care corporations for Republican legislators who supported the nullification of the election.

 Health Care Corporate Funding of Politicians Who Would Overturn an Election

On August 17, 2021, Popular Information published The January 6 Corporate Accountability Index.  It promised to be results of a comprehensive monitoring efforts of corporate pledges to make changes in their political giving to the "147 Republicans who voted to overturn the election, setting the stage for the riot." It included several categories of pledge violations.  Its results included some of the companies who went back on their pledges as described in our April and July posts.  It also included many more companies that did not make it to previous reports.  The relevant results by category were as follows

Corporations that pledged to suspend donations to the 147 Republican objectors but directly donated to those Republicans

Not included in previous reports: none

Included in previous reports: Cigna, Eli Lilly

Corporations that pledged to suspend donations to all 147 Republican objectors but violated the spirit of the pledge

Not included in previous reports: 

"After January 6, Genentech [part of the "Roche group'] said it would suspend contributions to Republican objectors. Genentech donated $15,000 to the NRCC and $15,000 to the NRSC on June 30."

"After January 6, Sanofi said it would suspend contributions to Republican objectors. Sanofi donated $15,000 to the NRSC on 3/17."

Corporations that pledged to suspend all PAC donations and then directly donates to the 147 Republican objectors

Not included in previous reports:

DaVita 

Included in previous reports: Abbott Laboratories, Gilead, Novo Nordisk

Corporations that pledged to suspend all PAC donations and then indirectly donated to the 147 Republican objectors

Not included in previous reports:

Baxter International

Included in previous reports: United Healthcare

Corporations that pledged to reevaluate their donation criteria after January 6 and directly donated to GOP objectors

Not included in previous reports:

Amgen, Laboratory Company of America

Corporations that pledged to reevaluate their donation criteria after January 6 and then indirectly donated to the 147 Republican objectors

Not included in previous reports: none

Included in previous reports: CVS

Discussion

As we said before, most health care corporations publish high-minded aspirational statements that promise pluralism, support of the community, and of our representative democratic society.  For example, Sanofi Pasteur claims:

Sanofi’s social impact strategy aims to build a healthier, more resilient world by ensuring access to healthcare for the world’s poorest people

However, the new data revealed above, and data discussed in our two previous posts showed that leaders of  more and more large health care corporations saw fit to direct contributions to politicians who promoted anti-democratic policies. Funding political leaders who would challenge election outcomes in the absence of very clear evidence of election irregularities seem s to violate high-minded corporate pledges of inclusiveness like those above.   

Is it that health care corporate leadership just are more interested in making money than in bettering society, despite their aspirational mission statements? As we previously discussed, that is a plausible formulation.  For example, per the Washington Post in January, 2021,

'Their attitude was: ‘Let’s take the big tax cuts and hold our noses for the obvious xenophobia and authoritarianism.’ It was a classic Faustian bargain,' said Rep. Brendan Boyle (D-Pa.), a member of the House Ways & Means Committee.

On the other hand, maybe it is not just about money.  Again, as we said before, by virtue of being top managers corporations, particular individuals can control political funds far beyond what they would  be able to control as private persons, and to do so quietly and sometimes anonymously.  Corporate leaders may thus be able to promote their own interests through their corporations' political giving.  Those interests may go beyond just personal enrichment.   Some may also be interested in personal political power, or have other ways they might benefit from anti-democratic, authoritarian, even openly fascist national political leadership.  Big industrialists have backed authoritarian and openly fascist regimes in other countries before, some to make more money, but in retrospect, some for darker reasons. (See, for example, this article on how German industrialists financially bailed out the Nazi party in 1932.)

Leaders of large corporations now appear willing to wield large amounts of political power leveraged by the organizations they control.  Yet until recently they may have been able to do so without disclosure to society at large.  That society may be greatly affected by this power, but when it can be wielded quietly, have had little say in who has it and its uses.  

We as health care professionals, policy makers, patients and members of the public at large deserve to know how health care corporate leadership is directing money to political causes, and how they benefit from doing so. If they are not doing this in our interests, our we need to make sure things change.

Leadership of Big Health Care Corporations Go Back to Financially Supporting the Opponents of Democratic Governance

At one time, leadership of large health corporations were circumspect in their financial support for US politicians and political causes. They provided some funds directly to politicians and poltical organizations, but often amounts given to different parties and organizations with different ideologies were balanced. Presumably, the goal was to promote access to whomever was in power at any given time. 

With the rise of Donald Trump, things changed. Many leaders apparently went all in for Trump and his Republican supporters.  In June, 2018  we discussed how CVS channeled money to a "dark money group," that promoted Trump administration policies, including repeal of the Affordable Care Act (ACA). In October, 2018, we discussed important but incomplete revelations about corporate contributions to such dark money groups that mainly favored again right-wing ideology, the Republican party, and Trump and associates. In November, 2018, we noted that health care corporations funneled funds through dark money organizations to specifically attack designated left-wing, Democratic politicians. In March, 2019, we discussed how in the 21st century, health care corporate CEOs' personal political contributions were increasingly partisan, that is individual CEOs gave predominantly or exclusively to one party, and for the vast majority, to the Republican party. 

 

Some corporations paused some of their political giving after a mob whipped up by Trump at a January 6, 2021, rally violently stormed the US Capitol to try to prevent the certification of the 2020 election. However, within two months they started giving again in support of Republicans in Congress who voted not to certify the election (see this April, 2021, post).

Now two new reports show continuing support by large health care corporations for Republican legislators who also supported the nullification of the election, and legislation that might decrease voting by citizens who oppose Trump

Health Care Corporate Sponsorship of Voter Suppression

In April, 2021, Public Citizen published "The Corporate Sponsorship of Voter Suppression." It detailed support from direct corporate contributions and corporate political action committees (PACs) from 2015 through March, 2021, to state legislators who authored, sponsored or voted for 245 bills that could have made it more difficult for citizens to vote in elections. 

The 25 companies contributing the largest amounts of money to these legislators included UnitedHealth Group ($411,200 total); Pfizer ($308,085); and Centene Corp ($205,200).  Companies that gave somewhat less included Merck ($180,000),  CVS ($174,000), Anthem ($138,150) Eli Lilly ($124,000) and Cigna ($109,225).

Two health care related trade groups also gave significant funds to these legislators: the Virginia Dental Association ($223,000) and the  Pharmaceutical Research and Manufacturers Association of America/PhRMA ($200,000).   

Note that the data did not include personal contributions from corporate leaders, and could not include corporate money directed to dark money organizations that ended up supporting these legislators.

Health Care Corporate Sponsorship of the Attempt to Overturn the 2020 Election

In June, 2021, Citizens for Responsibility and Ethics in Washington (CREW) published "This Sedition is Brought to You By..." It detailed contributions from corporate PACS and trade groups to those in the US Congress who voted against certifying the results of the 2020 election and the two main party organizations that supported them, the National Republican Senatorial Committee (NRSC) and National Republican Congressional Committee (NRCC) since the vote not to certify.  

The largest contributions from health care corporate PACs included those tied to Fresenius Medical Care Holdings ($76,000); CVS ($45,000); Cigna ($42,500); Johnson & Johnson ($30,000); Pfizer ($20,000); and Humana ($15,000).

Note that the data also did not include contributions from corporate leaders, and could not include corporate money directed to dark money organizations that ended up supporting these legislators. 

Discussion

Most health care corporations profess to missions that are pluralistic and support the community and society as a whole.  For example, Pfizer's mission statement includes:

We partner with governments, non-profits, and other organizations to ensure that more people around the world have access to the medicine and resources they require.

UnitedHealthCare's mission statement includes:

UnitedHealthcare is dedicated to helping people live healthier lives and making the health system work better for everyone

Merck's mission statement includes:

We demonstrate our commitment to patients and population health by increasing access to health care through far-reaching policies, programs and partnerships

However, leaders of some large health care corporations saw fit to direct contributions to politicians who promoted anti-democratic policies. Funding political leaders who would restrict voting rights in ways likely to impact already disadvantaged groups, and challenge election outcomes without strong evidence of irregularities would seem to violate high-minded corporate pledges of inclusiveness like those above.    

Is it that health care corporate leadership just are more interested in making money than in bettering society, despite their aspirational mission statements? As we previously discussed, that is a plausible formulation.  For example, per the Washington Post in January, 2021,

'Their attitude was: ‘Let’s take the big tax cuts and hold our noses for the obvious xenophobia and authoritarianism.’ It was a classic Faustian bargain,' said Rep. Brendan Boyle (D-Pa.), a member of the House Ways & Means Committee.

However, there are problems with this formulation.  As we wrote before,  it is obvious why a pharmaceutical company might want to defeat legislation that would lower its prices or raise its taxes.  It is not obvious why it would want to consistently support actions by one party, or by people at one end of the political spectrum, even if some such people seem generally "pro-business."  After all, for years big corporations and their executives openly gave money to both US parties and their candidates, apparently in the belief that this would at least allow more visibility for the corporations' priorities no matter who was in power.

Maybe it is not just about money.  Again, as we said before, by virtue of being top management of a corporation, particular individuals can control political funds far beyond what they may be able to control as private persons, and to do so anonymously.  It may be that top corporate leaders are not just interested in making more money.  Some may also be interested in personal political power, or have other ways they might benefit from anti-democratic, if not openly fascist national political leadership.  Big industrialists have backed authoritarian and openly fascist regimes in other countries before, some to make more money, but in retrospect, some for darker reasons. (See, for example, this article on how German industrialists financially bailed out the Nazi party in 1932.)

At least health care professionals, policy makers, patients and the public at large deserve to know how health care corporate leadership is directing money to political causes, and how they benefit from doing so. 

 

    

A Few Leaders of Big Health Care Corporations Hesitate in Their Support of Extreme Politics and Insurrection, But Will Anything Really Change?

 Some recent but not well publicized articles suggests how big health care corporations are still enabling some of the worst aspects of health care and larger political economic dysfunction.

Introduction - Health Care Corporate Political Donations Become More Partisan and Ideological

A long time ago in a galaxy far, far away big health care corporations in the US had an apparently straightforward philosophy of political giving.  They gave contributions more or less equally to both major political parties.  Apparently the theory was that the corporate giving would be remembered favorably by whoever won elections and got governmental power.  Corporate contributions raised major concerns about their ability to purchase access and influence policy far beyond those of less wealthy groups and the public at large.  At least, however, it was overtly non-partisan, and ostensibly not ideological.

However, things changed, and health care (and larger corporate) political giving became more partisan, and and more ideological. As we discussed here, 

- In June, 2018, we first noted how the huge pharmacy chain CVS, had been secretly making contributions to America First Policies, an ostensibly non-profit organization.  CVS claimed that it helped fund AFP because it supported tax reform.  Actually, AFP acted to promote Trump administration policies. AFP encouraged repeal of the Affordable Care Act (ACA), and building a wall on the US southern border.  These seemed at odds with CVS claims about its social responsibility.  

- In September, 2018, we noted that big health care corporations often make high-minded public pledges about supporting patients' and the public's health, and sometimes social responsibility, but have been found to be covertly supporting policy initiatives that seemed to subvert these goals, using "dark money."  The dark money groups they used to channel this money often had explicitly partisan leadership and direction, usually right-wing and Republican.

 

- In October, 2018, we discussed important but incomplete revelations about corporate contributions to such dark money groups that mainly favored again right-wing ideology, the Republican party, and Trump and associates.

- In November, 2018, we noted that health care corporations funneled funds through dark money organizations to specifically attack designated left-wing, Democratic politicians.

- In March, 2019, we discussed a study of the personal political contributions of CEOs of large corporations.  In the 21st century, the CEOs' contributions were increasingly partisan, that is individual CEOs gave predominantly or exclusively to one party, and for the vast majority, to the Republican party. 

- In October, 2020, we discussed the apparent relationship between the support to Trump provided by large pharmaceutical corporations and his inclination to outsource his coronavirus pandemic management to them. 

Corporate leadership's enthusiasm for Trump, his policies, and his associates seemed to arise from  economic interests of the corporations and the self-interest of their top management, but without consideration of how Trump and associates' actions may have harmed larger corporate, social, or national interests.  As discussed in a Washington Post article on January 8, 2021:

Business groups big and small largely stuck by Trump as he broke one norm after another over the past four years, including insulting immigrants, appearing to empathize with white supremacists in Charlottesville and clearing a Black Lives Matter protest in Washington for a photo op. They stuck by him still after he pressured the Ukrainian president in a bid to help his own election chances, after his impeachment, after he intentionally downplayed the effects of the novel coronavirus and last week after he was recorded pressuring the Georgia secretary of state to overturn the election results.

Even Trump supporters admitted the corporate leaders' extreme compartmentalization:

'It isn’t going to affect tax rates. How about monetary policy? Allow me to stay pure to my turf,' Art Laffer, a supply side economist who is close with White House economic officials and speaks to the president, said in a brief interview.

One observer described their thinking thus:

'Their attitude was: ‘Let’s take the big tax cuts and hold our noses for the obvious xenophobia and authoritarianism.’ It was a classic Faustian bargain,' said Rep. Brendan Boyle (D-Pa.), a member of the House Ways & Means Committee. 'They should have known from the beginning.'

However, the Trump administration's actions and policies often seemed to directly contradict the stated values, visions and missions of health care corporations.  For example, Pfizer declares its values to be:

customer focus, leadership, quality innovation, collaboration, respect for people, integrity, and performance

How would the value "respect for people" align with Trump's hostility toward immigrants, or sympathy for white supremacists?  How would the value "integrity" align with Trump's pressure on the Ukraine to influence his election, or his pressure on officials in the state of Georgia to alter the election results in his favor?  

Nonetheless, until very recently, hardly anyone seemed to notice that large health care corporations had changed their political giving so as to make its effects antithetical to the corporations' declared principles and values.  

Trump's Attempt to Overturn the 2020 Election Inspire A Few in Corporate Leadership to Rethink Its Political Support for Him and His Associates

Yet things apparently changed after Trump's attempts to overturn the election, including claims that he actually won despite obvious evidence to the contrary, baseless legal challenges to the election results that were almost all dismissed by the courts, and an attempt by Trump supporters in Congress to challenge and possibly override the election results in congressional proceeding.  That crossed a line.

Within days, corporate leaders who had generally been quiet about Trump administration's actions and policies that ran counter to their organizations' stated goals and mission began to speak up.  Several hundred signed a statement:  

Congress should certify the electoral vote on Wednesday, January 6. Attempts to thwart or delay this process run counter to the essential tenets of our democracy.

Most of those who signed lead financial firms, but the list did include Albert Bourla, CEO of Pfizer, a firm that had been one of Trump's favorites (see above).

Then, Trump's exhortation to his supporters at a rally to march on the Capitol while congress was debating Trump's supporters' challenge to the election results, which led to an insurrection and armed occupation of the Capitol building,  which was eventually beaten back by law enforcement with significant casualties led some corporate leaders to rethink their positions. 

The next day, per the Washington Post:

The mob scenes at the Capitol attracted harsh and unusual criticism from business groups, including the chief executive of one of the nation’s largest banks saying he is 'disgusted' and a manufacturing trade group calling it 'sedition' and suggesting that President Trump must be removed from office immediately.

It was a stunning series of rebukes for a president who had received widespread support from corporate America for most of his turbulent term, especially for his efforts to cut government regulations and reduce corporate tax rates.

But what occurred Wednesday seemed finally to be too much. Trump staged a rally in Washington a short walk from where Congress was counting the electoral college votes, with Trump whipping up his followers with fabrications about election results and urging them to march to the Capitol to protest. Later, Trump appeared to sympathize with the mob and support the violent actions.

 The National Association of Manufacturers soon after released an extraordinary statement from its president, Jay Timmons, saying Vice President Pence 'should seriously consider working with the Cabinet to invoke the 25th amendment to preserve democracy.'

At that time, one more CEO of a pharmaceutical company that had been one of Trump's favorites spoke up:

Alex Gorsky, the chief executive of Johnson & Johnson, said in a statement that he is 'devastated by this assault on what our country has stood for since its founding: free, fair and peaceful elections.' He said it is time to stand for unity, 'not face-to-face in conflict — and to chart our path to a better and healthier future.'

Furthermore, some large corporations, including health care corporations, announced a review or freeze on political donations through their corporate political action committees (PACs). Per the New York Times, January 11, 2021:

A flurry of companies have since reviewed political giving via their corporate political action committees.... Blue Cross Blue Shield, Boston Scientific... are taking a similar, targeted approach to donation freezes.

On January 12, 2021, StatNews summarized responses by health care corporations:

 The list, so far, is short: the Blue Cross BlueShield Association, an insurer federation, said this week it would pause contributions specifically to candidates who effectively voted to overturn the results of the U.S. presidential election.  Drug manufactures Gilead Scientific and Amgen, as well as BIO, the biotech lobbying group, said they would pause contributions to all candidates regardless of how they voted on election certification, according to spokespeople.  UnitedHealth Group and Boston Scientific, the medical device giant, said the same.

Others, like CVS Health and the insurance lobby group America's Health Insurance Plans, were more cautious, saying they would review their future giving.

However,

Many other health care corporations and lobby groups... have not responded publicly.

The article also noted:

Many of the GOP lawmakers who voted against certifying the Electoral College results are those whom the drug industry and other health care sectors have long viewed as allied.  

The list included Republicans in Congress whom may be regarded as extreme supporters of Trump, eg Rep Devin Nunes (R-CA), and Rep Andy Harris (R-MD).

I found one other report of a big health care corporation which changed its political donation policy in response to the attempt to overturn the election.  Per the Kansas City Star, January 13, 2021:

Cerner Corp. will suspend political donations to Sen. Josh Hawley and other politicians who it determines helped to incite the violent mob that attacked the U.S. Capitol building last week.

The North Kansas City-based healthcare IT firm is the latest to seek distance from Hawley, a Missouri Republican, and others who have supported baseless allegations of voter fraud in the November presidential election. 

A company spokesperson said:

'Effective immediately, Cerner PAC will suspend contributions to any candidate or official who took part in or incited violence last week in Washington, D.C.,' the statement said. 'Focusing on the health and well-being of the American people transcends partisan politics, and we will continue working with all elected leaders to advance policies that put the patient at the center of their care.'

I found another report of a big industry group which planned a "review" of its giving.  The American Hospital Association announced on January 14, 2021:

The tragic events last week at the U.S. Capitol were an assault on our democracy. This prompted the AHA to begin an immediate review of our political giving practices to ensure they are guided by our Association’s vision and mission, as well as the democratic values we share as a nation.

But that was it, a total of six large health care corporations and three industry groups announced a pause or review of political contributions (apparently limited to those from corporate PACs) to some of the politicians who voted to challenge the election results.  The Potter Report, authored by health care insurance whistle blower Wendell Potter, noted: 

There’s been a lot of talk this week about big corporations such as Amazon, Verizon and Comcast deciding to stop giving money to House and Senate Republicans who voted to overturn last year’s election. 

Guess which giants aren’t on that list? America’s big for-profit health insurers. 

Over the past two election cycles, Big Insurance has donated to just about all the 147 House and Senate Republicans who voted against certifying the election. That includes Cigna and Humana, where I once worked, and Centene and CVS/Aetna. Plus, the industry’s lobbying group, the American Health Insurance Plans (AHIP).

 The Blue Cross Blue Shield Association, which represents a lot of nonprofit insurers and for-profit Anthem, says it’s suspending donations to those Republicans. And UnitedHealth says it will 'pause' its political donations. But let’s see how long these 'pauses' actually last. 

So far, we haven’t heard a peep from AHIP or the other big for-profits, all of which have made huge profits during the pandemic, thanks largely to having lawmakers on both sides of the political aisle in their pockets. 

Big Insurance donated more than $9 million to House and Senate candidates during the 2020 cycle. Among their favorites? Ted Cruz and Josh Hawley, who led the effort to overturn the election. All the big for-profits donated to Cruz, and all but CVS/Aetna donated to Hawley. 

Note that no health care corporation announced changes in the donations by its top management.  Certainly none even mentioned political contributions through dark money groups (like those that CVS had been revealed to be making, see above).  So the attempt at overturning the election to keep Trump in office, first by quasi-legal maneuvering, then by an armed insurrection, had little effect on continuing underwriting by big health care corporations of the politicians who acquiesced to or actively supported this assault on the fundamentals of our representative democracy 

Two Months Later, Health Care Corporations "Back to Bankrollling Insurrectionists"

Within months, some of the few health care corporations who paused donations again seemed ready to cozy up to anti-democratic politicians.  As reported by the Daily Beast, March 24, 2021:

After the Jan. 6 insurrection, more than 120 corporations swiftly vowed to suspend campaign donations to Republicans who objected to certifying the 2020 election....

But it took less than two months for Pfizer to break that pledge. Their PAC gave $15,000 to the National Republican Senatorial Committee, led by one of eight GOP Senators who voted to decertify election results—Rick Scott of Florida—on Feb. 23.

In total, The Daily Beast identified four companies that appear to have gone back on their suspension of donations to GOP election objectors: AT&T, Cigna Health, Ford Motors, and Pfizer.

[Note that I had not earlier found notice that Cigna Health, a for-profit insurance company, had suspended donations.]

Summary

So as far as I can tell, while Trump is out of office, the big health care corporations that provided plentiful financial support for his initial election and attempts at remaining in office, through electoral and anti-democratic means, are back to supporting the political party that has become his personal sandbox.

 It is increasingly evident that big health care corporations, despite their protestations of social responsibility and non-partisanship, now are actively supporting one wing, an extreme one, of the political spectrum.  This raises big questions: cui bono? Who benefits?

It is obvious why a pharmaceutical company, for example, might want to defeat legislation that would lower its prices or raise its taxes.

It is not obvious why it would want to consistently support actions by one party, or by people at one end of the political spectrum, even if some such people seem generally "pro-business."  After all, for years big corporations and their executives openly gave money to both US parties and their candidates, apparently in the belief that this would at least allow more visibility for the corporations' priorities no matter who was in power.

Now, the most obvious theory is that the new practice of secret donations only in right-wing, Republican, pro-Trump, and/or anti-democratic directions, which must be orchestrated by top corporate management, and which are not disclosed to employees or smaller corporate shareholders, are likely made to support the top managers' self interest more than the broad priorities of the corporations and their various constituencies. By virtue of being top management of a corporation, particular individuals can control political funds far beyond what they may be able to control as private persons, and to do so anonymously.  This could present many temptations, but the rationales for particular managers directing their corporations' fund to particular politicians or organizations remain unknown.  

Thus not only is more investigation needed, at the very least, "public" corporations ought to fully disclose all donations made to outside groups with political agendas.  This should be demanded by at least the corporations' employees and shareholders, but also by patients, health care professionals, and the public at large. Furthermore, it is not unreasonable to ask that all organizations disclose all political funding which allows their leaders and managers to leverage their own political intentions.

Meanwhile we are left with the suspicion that top health care corporate management is increasingly merging with the Trumpist movement in one giant corporatist entity which is not in the interests of health care, much less government by the people, of the people, and for the people.

 

ead more here: https://www.kansascity.com/news/politics-government/article248457745.html#storylink=cpy

 

Read more here: https://www.kansascity.com/news/politics-government/article248457745.html#storylink=cpy

 

 

Parlous Times—so Why Is My Dander Down?

Yes, these are parlous times, my friends, with all sorts of threat levels bouncing up and down and up again to all sorts of new heights. I've personally felt almost paralytic, in this present "Dander" series, about repeating the latest outrages from Trump-land and Corona-land.  (Lather. Rinse. Repeat.) What is there new to say? The outrages are all there, still, but with a single, over-arching theme.

To quote the great philosopher, Frankie Valli, "It's a sign!!!" The sign: a new system of governance run by a cabal of family and cronies, no inspectors-general in sight, and a whole lot of unconfirmed "acting" secretaries, under-secretaries, under-under-secretaries and under-under-under secretaries.

I've written about this syndrome in HCRenewal before, mainly in connection with the Veterans Administration. Look it up right here in HCRenewal (e.g. see here). It's a systemic neurological disorder we could call MS: Mar-a-Lago Syndrome. In this disorder the federal government is paralyzed not by the Deep State, but a pernicious Deep Nonstate of golf buddies, far-right pundits and other self-dealing defilers of democracy.

Oh, where are the mere managerialists we used to go after in HCRenewal? We do miss them so! Lather. Rinse. Repeat.

Anyway, we're in the summer of 2020 and lives have been lost. The system stays awash in waste and cronyism. But I just couldn't muster writing more about it: what was new? It's all MS and the thousand flushes of oppositional, know-nothing populist careerism that go along with it. All courtesy of a motley crew of hackers, sadly gullible flat-earthers and one particular political party busy pushing itself and the rest of us off the deep end. All exploiting the hell out of each other. Only one, the US Senate's leadership, has an internally-valid long-term goal—the judiciary—that purports to make the exercise worthwhile. Everybody else can just bump along in their miserable gerrymandered "corporations are people" lives, liking it and lumping it.

And yet: along the way, something strange seems to be happening. It's true that, yoked together and spurring on their steeds, our four horsemen of the apocalypse—America's flawed democracy, its corrupt GOP, the pandemic and its exposed systemic racism—just stay on the rampage. But look underneath all this, in health care and just maybe in the larger society, there are young hopeful shoots, sprouting somehow in the mud below. And that is something new and worth writing about.

So just now, oddly enough the dander's down. (Provisionally. Check in again in, oh, four to five months.)

Some years ago Dr. Poses, this blog's venerable editor, already pointed out how HCRenewal's message has begun to "go mainstream." Now and again, he points out further new examples.

Maybe this mainstreaming of the message—health care independence and integrity—somehow relates to a couple of major shifts in the medium, or mediums, that carry the message. The first, social networks, have worked in part to the detriment of good government. But they also enable ground-up protest in a new communications ecosystem.

Another part of this ecosystem, less evident to lay people and leaders but potentially a potent force, is the advent of a new and more independent-minded generation of science and medicine journal editors, with their accompanying editorial boards. Here we find some more of the tender young shoots, exemplifying the change that genuinely seems afoot. Let me cite three recent examples.

• The Annals of Internal Medicine has gone from strength to strength in recent years. Under its current editor, Christine Laine, the first woman to hold that post, Annals now boasts its highest-ever impact factor [C. Laine MD, personal communication]. That's an impact in general medicine, the nation's largest specialty, boasting over a million page views per month.
  
  The current number of Annals, for mid-June 2020, offers an article entitled "a cautionary tale," describing last year's "orphaning" of the entire house staff of Hahnemann University Hospital. Both the content and the very fact of the publication of this article are noteworthy. The article that follows, in its title, asks "is it time to more fully address teaching religion and spirituality in medicine?" (answer: "truly caring").
  
  
  
  But stick for the moment with the Hahnemann debacle. The article, written by three former Drexel University College of Medicine (DUCOM) faculty members who're now spread to the four winds, probes the "diametrically opposed goals of hospital owners and educational leaders" that led to an enormously disruptive hospital closure on the verge of a pandemic, a tsunami that orphaned nearly 600 trainees and that faculty quite simply "found hard to believe."
  
  Those of who were around in the 1990s didn't find it so hard to believe. The authors allude to the prehistory of the Hahnemann bankruptcy in the earlier one endured by Allegheny, or "AHERF" in the late 1990s. They don't insist on the earlier one prefiguring the later one, "the largest orphaning event" in medical history, in any causal or direct fashion. But I'd argue precisely that: at the least, it made it much more likely.
  
  The reason, simply, a circumstance to which to their credit the authors point, was the original sin of the deal that bailed out a medical school (pre-bankruptcy MCP-Hahnemann, post-bankruptcy Drexel) and a group of hospitals (originally Tenet Healthcare). That original sin was a quarter-century earlier when the Philadelphians did a deal-that-was-never-gonna-work with Tenet Healthcare, a for-profit based west of the Mississippi. The original sin fast-fowards a quarter-century to the present authors noting that at the critical moment in 2019, "Drexel and Hahnemann released separate talking points for P[rogram] D[irector]s, but these documents contained discordant information." But the discord started in 1995 and never stopped. Graduate Medical Education run by frenemies.
  
  The American system of GME, like the US Constitution, contains any number of these ill fated compromises. When this happens, only a few norms serve as guardrails against disaster: in this case, the manner in which hospitals—recall that Tenet was a for profit system, and one for which both education and research are distinctively secondary—control the medical education dollars coming to them from Medicare reimbursements. "Discordant information": how can you lose?
  
  The departure of hundreds of residents, with all its displacement of both faculty and trainees, and with all its emotional turmoil, hardly seems like something that would cheer one up. And on its face, it's not. One can hardly overestimate the pain these authors and their colleagues went through. But what strikes me is the fact that this whole crummy system is no longer anechoic: that those within it are out there on the hustings, stating the lessons learned, trying to create the antibodies that might protect against future such occurrences. And Annals gladly published this excellent exposition-cum-cautionary tale.
  
• In the same week that I received this number of Annals, I received the 25 June 2020 number of The New England Journal of Medicine. NEJM, also a super-high-impact journal, changed editorship—just a few months before the onset of the pandemic— much more recently than Annals. One waited to see whether it, too would be, shall we say, feminized. (Be clear: in this case "feminization" is for me an uncomfortable shorthand for what I dearly hope my commentators below will suggest a better word, and more or less an unmitigated good.)
  
  I grew up in a tradition of ritualistic CPCs—clinicopathologic conferences—in my own medical school and in key journals such as NEJM. A case would be presented of a patient who had to die. They had to die because the autopsy findings would be tortuously predicted by the academic physician as the solution to a diagnostic dilemma. This would be followed by a learned exposition of the histology and gross pathology of the disease that furnished the answer to the puzzle. Sometimes the clinician even got it wrong. The pathologist of course was always right, He—it was virtually always a he—always got the last word.
  
  But what the CPC model did was to reify the classic post-Laennec medical model of equating medical decision making to its laboratory-based problem-solving narrative. This began to change a bit beginning in the Journal's post-Ingelfinger and post-Relman eras, where editors began to stress correlations of clinical findings with those of the new molecular biology and immunochemistry. Now the patient didn't even have to always die! But the classic medical model, even then, was preserved. Riddle me a riddle: bench science, properly coupled with bedside wisdom, will provide the answer.
  
  Imagine my surprise then to find the CPC of a few weeks ago, entitled "a girl with severe psychological distress after family separation," focused on "trauma-informed care" in which the clinical outcome was not "a post-mortem examination was performed" or "a diagnostic procedure and laboratory study were performed." Here "a diagnosis and management decisions were made" and both clinical and patholgocial diagnoses were "post-traumatic stress disorder."
  
  The graphic is that of a cartoon pediatrician with an immigrant child, blowing bubbles together.
  
  Make no mistake: this is both a scientific and literary breakthrough, and a political statement. It is enormously heartening to view such a sea change in one of our most august journals. It tell us that a new, younger leadership in academic medicine is stepping up to address the socioeconomic problems that are now—far more than whether or not SARS-CoV-2 does or does not interact with ACE inhibitor agents—threatening health care in the more dire existential fashion.
  
  Can we extrapolate from these straws-in-the-wind? Is medicine becoming less anechoic and able to counter the threats against it? I know of no other recent precedent, but there's one from classical antiquity: the very bedrock of our medicine today, the Hippocratic tradition. In his magisterial 1995 work Hippocrates in an Age of Pagans and Christians, Owsei Temkin of Johns Hopkins showed how the classical traditions of independent medicine were able to persevere even in a later era in which they were threatened by religious authority. It was a close call then and it's a close call now: viz., the decision by a mere five to four, just a few days ago, preserving the physician's right without hindrance to provide services to a pregnant woman.
  
  Sometimes it comes down to one vote. And, granted, it ain't over until it's over: in November, voters in the United States will, in momentous fashion, decide the future direction not just of their own people but of the healthcare they're going to get going forward.
  
• What's going on here? In truly extraordinary circumstances, leaders in medicine seem to be not abandoning the scientific model, but expanding it to incorporate insights and perspectives drawn from ethics and the social sciences, including economics. (The Allegheny-Hahnemann case is a classic example of business-economics-gone-wrong through failures of basic socioeconomic analysis.) Even in the non-clinical literature, if you take even a cursory look, you can find these tender young sprouts of freedom.
  
  The journal Cell, in a number published last month, began with an editorial entitled "Science has a racism problem," stating that "We are the editors of a science journal, committed to publishing and disseminating exciting work across the biological sciences. We are 13 scientists. Not one of us is Black." Cell also boats an editor of recent vintage (2018).
  
  But what followed was even more astounding. Amidst articles discussing matters such as how "Epitope pools detect CD4+ and CD8+ T cells," in the very next number of the journal, Duke neuroscientist and MD-PhD Kafui Dzirasa provides his account of how "[f]or Black scientists, the sorrow is also personal." This article has been widely reprinted and sent out to many thousands of physicians who practice in domains as far away from cell biology as orthopedics. It is worth quoting in extenso, and speaks for itself.

I am a medical doctor and a scientist; the first African American awarded a PhD in neuroscience at Duke University. I have led a National Institutes of Health-funded research lab for almost a decade, and I was awarded the Society for Neuroscience Young Investigator Prize in 2019. I am an American Association for the Advancement of Science Alan I. Leshner Public Engagement Fellow, and I have hosted TEDMED three times. I am a scholar, teacher, mentor, speaker, and mental health advocate. I have served on national commissions, I have advanced federal policy, and I have even held court with a president of the United States. I have published in Cell scientific journals, and as a peer reviewer, I have worked to advance the scientific rigor of my colleagues. Yet, most days, I am unseen and unknown. As I watched a knee slowly, mercilessly, and inhumanly extinguish yet another black life, I was overwhelmed by anger and sorrow, and at this very moment, I am terrified to run on the trail near my home. I am a black academic in America.

That these three examples of medical communication all point to inherent problems in American medicine, no doubt in world medicine as well, is daunting in one sense. But in another it is undaunting. It shows us how far we have left to go. By looking in the mirror and recognizing that they share the challenges of the larger society, medicine and science have at least a fighting chance of transcending them—and in doing so, regain their independence. The manner in which these authors have taken the knee, and in doing so stood very, very tall, shows us a path of speaking truth to power. In doing so, and in our anticipation of their being heard, they give us hope.

Health Care Corporate Leaders Have Pledged Their Support for Racial Justice and Harmony: Will They Renounce Their Previous Support of a Very Racially Divisive Politician?

Leaders of big health care organizations frequently profess their social responsibility, and traditionally have avoided political partisanship.  However, their actions have not always been consistent with these sentiments.

Now, in response to the police killing of George Floyd and subsequent protests, many health care leaders pledged their support for racial peace and justice.  However, some of these leaders have previously supported  political leaders whose actions may have contributed to the current crisis.

Recently there were two cases showing vivid contrasts between health care leaders' pronouncements and their and their organizations' recent actions.

CEOs Condemn Racism

CVS CEO Larry Merlo

Early out of the gate was Larry Merlo, CEO of CVS, who released a statement to his employees on June 1, 2020:

The turmoil we are witnessing grows out of a long and deep history in our country, and as a nation we must focus on the injustices and discrimination that continue to divide us. I remain hopeful that we can find a way to move forward in unity to solve the nation’s most pressing issues.

In our workforce and in our communities, CVS Health’s commitment to inclusion and belonging is unwavering. It is critical to those we serve and grounded in our company values. We are a diverse community here at CVS Health – all 300,000 of us – and that diversity is one of our key strengths. It shows up in how we care for one another – walking in each other’s shoes, joining forces for the greater good and respecting one another no matter what our race or ethnicity. We will continue to uphold the commitment of mutual respect in everything we do. Discrimination and intolerance have no place in our business and will not be permitted in any form.

Johnson and Johnson CEO Alex Gorsky

On June 3, 2020, CNBC reported:

Johnson and Johnson CEO Alex Gorsky said Wednesday that white men need to 'do more listening' in the wake of George Floyd’s death at the hands of Minneapolis police.

'I realize that can be difficult,' Gorsky said during an interview with CNBC’s 'Squawk Box.' 'I think there’s no way you can just move through a checklist without I think demonstrating empathy and an understanding of some of the deep-seated nature and experiences the [black] community has had and is currently experiencing.'

Gorsky announced Tuesday that J&J is committing $10 million over the next three years 'to fighting racism and injustice in America' as people across the United States and other parts of the world protest against police killings of blacks.

'As the CEO of the world’s largest health-care company, I must state unequivocally that racism in any form is unacceptable, and that black lives matter,' he said in a LinkedIn post. 'And as a white man, I also need to acknowledge the limits of my own life experience and listen to those who have faced systemic injustice since the day they were born.'

CEOs' Friendliness with and Support for President Donald Trump


President Trump's recent actions have fanned the flames of racial discord. Here are just a few examples of news about what is still an evolving story: He called for a tough, militarized response to peaceful protests after the killing of George Floyd.  He tweeted "when the looting starts, the shooting starts," and  called protesters "thugs" (see Washington Post, May 29, 2020.)  He told governors to "dominate" the streets (see Washington Post, June 1, 2020.)  His Attorney General arranged the clearance of peaceful protesters out of Lafayette Square near the White House using teargas and flash bang grenades so Trump could have a photo opportunity at a nearby church (see New York Times, June 3, 2020.)  He pushed to call out 10,000 active duty US troops to quell a protest in Washington DC that was largely peaceful (see Reuters, June 7, 2020).

That seems like the opposite of "focusing on injustice and discrimination," or "fighting racism."  However, in contrast with their current proclamations about racial harmony and inclusion, and against racism, these two CEOs have shown their friendliness to and support for President Donald Trump.


CVS CEO Larry Merlo

Merlo's stance on racial inclusivity and harmony, and against racism does not seem to fit with the CVS track record of quietly supporting a dark money non-profit organization whose main mission seemed to be providing political support for Trump, and was once led by people with very different views on race, as we posted in 2018.

CVS was revealed to have been contributing to a "dark money" organization called America First Policies (AFP), ostensibly a "social welfare" charity, but actually an organization devoted to promoting the Trump agenda.  While CVS said its support for AFP was related to the organization's tax reform agenda, it also promoted various policies that seemed to contradict the CVS ethics and social responsibility policies.  In addition, the relationship between CVS and AFP only came to light after some AFP leaders were found to have made racist and pro-Nazi proclamations.  When the unsavory nature of the AFP leaders' utterances came to light, a CVS spokesperson announced the company would sever ties with AFP.  However, to my knowledge, CVS never clearly explained why it was giving money to the group in the first place, and how doing so was consistent with its stated policies and goals.

CVS past support for an organization led by professed racists seems inconsistent with Mr Merlo's recent commitment to inclusion and belonging.  One wonders if he will renounce his company's previous actions.

In 2018, we also noted that CVS was making substantial contributions to the US Chamber of Commerce, which despite its bland name, some asserted had become a major source of "dark money" support for politically right-wing and pro-Trump causes.  In 2019, we noted that CEO Merlo, like many of his fellow health care corporate CEOs at the time, had become very partisan in his personal political giving.  All the money he gave around the time of the 2018 election to organizations identified with either major political party went to the Republican party.

Now that he has proclaimed his anti-racist credentials, one wonders if Mr Merlo will renounce his previous direct and indirect support of Mr Trump and his associates?

Johnson and Johnson CEO Alex Gorsky

Again, Johnson and Johnson CEO Gorsky's stance on racial inclusivity and harmony, and against racism does not seem to fit well with the company's and Gorsky's track record of coziness with Trump.

In 2017, after a rally by white nationalists in Charlotte, Virginia lead to conflicts between them and counter-protesters. Many of the latter were injured, and one was killed, Trump initially refused to take any stand against the rally, and suggested that both sides were equally responsible.  After that, some corporate leaders broke with Trump, but  at first not Gorsky.  As the outrage about Charlottesville grew, Gorsky dropped his membership in Trump's Manufacturing Council, but one year later, but then returned to Trump's in-group, as reported by CNBC:

The manufacturing council was also disbanded in August of 2017, following a wave of public resignations from its CEO members in the wake of Charlottesville.

One of these came from Alex Gorsky, who leads Johnson and Johnson. Gorsky called Trump’s response to the rally 'unacceptable,' and said in a statement that it 'has changed our decision to participate in the White House Manufacturing Advisory Council.' Nonetheless, Gorsky is on the guest list Tuesday for dinner at [Trump's] Bedminster [golf club]. A spokesman for the company did not respond to a request for comment.

In February, 2020, Vanity Fair reported that the meeting that included Trump and Gorsky at Bedminster resulted in some very suspicious activity.  Trump seemed to assume the role of salesman for a drug Johnson and Johnson just put on the market:

On March 5 [2018], Trump signed a little-noticed order to create “a national roadmap to empower 'veterans and end suicide.' That was the same day, it turned out, that the Food and Drug Administration approved the sale of Spravato, an antidepression drug manufactured by Janssen Pharmaceuticals, a J and J subsidiary.

Then,

Trump continued to be a booster of Spravato, which analysts have estimated could earn some $600 million for J and J by 2022. At a June 12 White House meeting convened to discuss the opioid crisis in America, Trump urged Robert Wilkie, who replaced Shulkin as the secretary of veterans affairs, to essentially back the truck up for Spravato at the V.A. because, Trump said, it would result in an “incredible” drop in suicide among veterans. He even offered to negotiate the price of the drug with J&J. 'I think they’ll be very generous with you,' Trump told Wilkie. 'And if you like, I’ll help you to negotiate.'

The next year,

But Trump, being Trump, was not done trumpeting the drug. In August 2019, at an AMVETS conference in Louisville, Kentucky, he repeated his view that Spravato was 'incredible' and said he’d ordered the Department of Veterans Affairs to 'get as much of it as you can from Johnson and Johnson.'

The Trump promotion of the Johnson and Johnson drug is now under investigation. 'the House Committee on Veterans’ Affairs has demanded documents and information from the V.A.

Finally, the Vanity Fair included a reminder that Trump has not only been cozy with Gorsky, but a member of the family that founded Johnson and Johnson who also may be one of the company's bigger investors:

Trump’s ambassador to the U.K., Woody Johnson, is the great-grandson of one of the founders of J and J and, reportedly, continues to own more than 1.5 million shares in the company, worth around $217 million. His net worth is said to be around $4 billion. He donated $1 million to Trump’s inaugural committee.

So it appeared that the CEO of Johnson and Johnson, and a big shareholder in the company who is descended from its founder went out of their way to cozy up to Trump, who appears to have reciprocated by doing some marketing for its drug, and possibly improperly using his executive powers to increase its use.


Furthermore, in 2018 we noted that Johnson and Johnson, like CVS, was making substantial contributions to the US Chamber of Commerce, which despite its bland name, some asserted had become a major source of "dark money" support for politically right-wing and pro-Trump causes.


Now that Gorsky is so devoted to "fighting racism and injustice," given all that Trump has done to fan the flames of racial conflict after the death of George Floyd, one wonders if Gorsky will denounce his previous coziness with Trump?


Discussion

After the killing of George Floyd, the CEOs of two large health care corporations publicly espoused  racial harmony and inclusion and condemned racism.  Both these CEOs had become very friendly with President Trump, and appeared very comfortable with his policies, despite the history of non-partisanship among leadership of the health care field.

Trump, however has sought to amplify racial conflict since protests began in response to the death of Mr Floyd.  Will these CEOs now renounce their previous coziness with and support of President Trump? 

There are bigger questions. Will there now be more attention to how health care corporations have preached social responsibility, and lately racial harmony while they were quietly pushing their own agendas, which often undermined these worthy goals?  Will health care organizations disclose their ties to political leaders, including contributions to "dark money" groups? Will there be new calls for accountability for those who lead the most powerful organizations in health care?  Will there be investigations into this or other forms of regulatory capture? Will there be penalties for resulting conflicts of interest?  Or will the leaders once again manage to make even discussions of their failings taboo?    


 

The ACP Leadership Stands Up to Health Care Dysfunction: A Good Beginning, but the Problems May be Even Bigger than They Realize

Introduction: Health Care Dysfunction Has Been With Us for a Long Time

The American College of Physicians (ACP) is the largest physician specialty society in the US.  So it was news when outgoing ACP  President Dr Robert M McLean's article, "Battling the Hydra of the Medical-Industrial Complex" in the ACP Internist, decried "the dysfunction that has become our [health care] system's status quo" and noted "how our health care delivery system is so dysfunctional and fragmented."

[Gustave Moreau, Hercules and the Lernaean Hydra, Art Institute of Chicago]

Better late than never. We have been decrying health care dysfunction since 2003, and on this blog since 2004.

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 studies

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.

Now the ACP seems to have embraced some of our concerns.

Putting Financial Concerns and Management Dogma Ahead of Patients

Dr McClean started by asserting that:

Smart minds have taken business models to the extreme in health care-related corporations. Decisions on resource allocation or new initiatives are driven by the critical concept of return on investment (ROI).

Also

budget items that we know are clinically necessary for better patient care don't get resourced and as other initiatives of dubious clinical value move forward, all due to the omnipotent ROI calculation.

Furthermore,

Corporations of many types (insurance, pharmaceuticals, pharmacy benefit managers, and medical devices, to name just a few) are making millions and billions in profits that are pulled out of the health care system instead of being used to provide better care to our patients.

These are clearly major issues.  Let me take this opportunity to enlarge upon Dr McClean's essay, based on our experience writing for Health Care Renewal.

Dr McLean briefly noted the problem of "business models" driving health care leaders' decision making. This has been called managerialism. As discussed in an article from the June, 2015 issue of the Medical Journal of Australia (which we noted here)
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business, and in a health care context, not necessarily having any experience or background in biomedical science, medicine, health care, or public health
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism in health care undermines the health care mission and the values of health care professionals


Managerialism is not limited to the list of organizations mentioned by Dr McLean.  

Managerialists are often greatly influenced by currently fashionable management dogma.  A dominant dogma in management is that pursuit of shareholder value comes before all else, and thus that the pursuit of short-term revenue comes before all else. Managerialists running nominally non-profit organizations, like non-profit hospitals, still often put short-term revenue ahead of all other concerns.  As we posted here in 2012, quoting Lazonick:

in 1983, two financial economists, Eugene Fama of the University of Chicago and Michael Jensen of the University of Rochester, co-authored two articles in the Journal of Law and Economics which extolled corporate honchos who focused on 'maximizing shareholder value' — by which they meant using corporate resources to boost stock prices, however short the time-frame. In 1985 Jensen landed a higher profile pulpit at Harvard Business School. Soon, shareholder-value ideology became the mantra of thousands of MBA students who were unleashed in the corporate world.

Lazonick added:

When the shareholder-value mantra becomes the main focus, executives concentrate on avoiding taxes for the sake of higher profits, and they don’t think twice about permanently axing workers. They increase distributions of corporate cash to shareholders in the forms of dividends and, even more prominently, stock buybacks. When a corporation becomes financialized, the top executives no longer concern themselves with investing in the productive capabilities of employees, the foundation for rising living standards for all. They become focused instead on generating financial profits

Thus the influence of business thinking on health care (and public health) leadership is even greater than what Dr McLean discussed.

Furthermore, Dr McLean issued the following apologia:

We cannot blame health care system executives solely for this ROI focus; they are merely playing by the existing rules of the game, dysfunctional as those rules are

In  my humble opinion, they do not deserve the only blame.  However, hospital system executives are part of the larger community of executives who run pharmaceutical/ biotechnology/ device companies, health insurance companies, organizations that provide direct patient care, consulting firms, medical societies, health care charities, etc, etc, etc  Most of them have been trained in these "rules of the game." 

These executives often reap considerable personal benefits from these rules.  For example, hospital system executives, even those of non-profit hospital systems, have become rich in the currently dysfunctional health care system. Our latest example of hospital executive compensation that seems wildly disproportionate to the value of their work appeared here in 2019.

We have long contended that a major reason for health care dysfunction is perverse incentives, including those that allow top health care leaders to become rich by putting money ahead of patient care.  We have presented case after case supporting this point.

The plutocratic compensation given leaders of non-profit hospitals is usually justified by the need to competitively pay exceptionally brilliant leaders who must do extremely difficult jobs.  Yet even leaders whose records seem to be the opposite of brilliance, or whose work does not seem very hard, often end up handsomely rewarded.

Other aspects of top health care managers' pay provide perverse incentives.  While ostensibly tied to hospitals' economic performance, their compensation  is rarely tied to clinical performance, health care outcomes, health care quality, or patients' safety.  Furthermore, how managers are paid seems wildly out of step with how other organizational employees, especially health care professionals, are paid.

I can understand the leadership of the ACP may feel very uncomfortable challenging the executives of hospitals in which most of the ACP membership's patients receive care.  Nonetheless, we need to reconsider the downsides of a health care system in which paying generic managers enough to make them rich now seems to be the leading goal of hospitals.

Private Equity as an Egregious Example

Dr McClean noted the

entry of private equity and venture capital firms into the health care space and the expansion of pharmacy chains into retail health clinics.... whose leadership] see ripe potential to disrupt the dysfunctional status quo quasi-marketplace, increasingly treat patients like consumers, develop systems of improved efficiency, at least on the surface, and in the process destroy or undermine the patient-physician relationship.

We have been writing about the nefarious role private equity has been playing in health care since 2010.  Private equity firms have been buying up for-profit hospital systems and other firms that employ physicians to provide direct patient care, like physician staffing firms.  They also may own medical education institutions, including offshore medical schools that  train physicians for the US (and Canada), and even for-profit medical schools in the US (look here).

We first discussed the perils of private equity takeovers of hospitals here in 2010, and of physicians providing direct patient care as employees of corporations owned by private equity here in 2011.   The private equity business model seems particularly unsuitable for organizations which provide patient care, as we discussed in some detail in 2012.

For a quick modern summary of why it is bad to have private equity involved in direct patient care, see Merrill Goozner writing in Modern Healthcare, September 5, 2019,

The private equity business model in healthcare parallels other industries: Use highly leveraged private capital to roll up a number of small firms into one entity, with the private equity firm providing collective management. In addition to hefty fees for arranging the transaction (generally 1% to 2% of the purchase price), the private equity firm typically demands a 20% return on its investment after paying interest on the debt.

After three to seven years, assuming all goes well in achieving the promised efficiencies, the private equity firm and its junior partners (who are the specialty physicians in this latest wave of takeovers) earn a windfall by taking the company public or flipping it to another set of private equity investors. If things don’t work out as planned, the firm cuts its losses and declares bankruptcy (most of its capital will have been recouped through the 20% annual returns).

The management company has two paths to achieve its financial targets. It can either reduce costs sharply or look for ways to increase revenue.

A private equity firm running a hospital is likely to be even more focused on putting short-term revenue ahead of all else, including patient's and the public's health, and ahead of health care professionals' safety and welfare.

The Role of Corporate Propaganda and Disinformation

Dr McClean noted:

The disinformation media blitz has already begun. Organizations with altruistic-sounding names such as Partnership for America's Health Care Future, a coalition representing insurers, pharmaceutical companies, and hospitals, assert that we should 'build on what's working in our health care system.' Do you remember the success of the Health Insurance Association of America at turning public opinion against the Clinton health plan back in 1994, using its year-long advertising campaign of 'Harry and Louise' commercials in which a couple expresses dismay at their dwindling insurance options and rising costs? We should expect a new generation of that type of commercial in the near future. 

Again, this is a severe, long-standing issue that involves are more than just health care insurance companies and related issues.

We had previously noted that 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.

As of 2019 we noted the participation of foreign powers, some potentially hostile, in the dissemination of health care related disinformation.  Even more disturbing, we began to see the dissemination of health care related disinformation by the executive branch of the US government under the Trump administration (look here).   In particular, disinformation is distorting the conversation about and maybe the response to coronavirus (look here). 

Thus countering the negative, and now often dangerous effects of propaganda and disinformation in health care and public health will require taking on far more bad actors than just health care insurance companies.

Conclusion: Issues Not Discussed

We have been cataloging aspects of US (and sometimes global) health care dysfunction for a long time.  There are many more issues than those about which Dr Cleary wrote.  In late 2019 I provided an updated summary of them. Reprinting it here would double the length of this post, so let me simply summarize the list of topics

Threats to the Integrity of the Clinical Evidence Base

Deceptive Marketing

Distortion of Health Care Regulation and Policy Making


Bad Leadership and Governance

Abandonment of Health Care as a Calling
 
Perverse Incentives Put Money Ahead of Patients, Education and Research

Cult of Leadership

Managerialism

Impunity Enabling Corrupt Leadership

Taboos

We strongly welcome the active participation of the ACP in the fight against health care dysfunction. Unfortunately, it may turn out to be a much more difficult and complex task than many would expect.

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?  

The Mother of All Mission-Hostile Management: During the Coronavirus Pandemic Trump Shows He is the Enemy of the Public's Health

Introduction: Health Care Dysfunction

We have been talking about health care dysfunction for a very long time, starting with a publication in 2003: 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 studies

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 (look here).

Mission-Hostile Management as a Cause of Health Care Dysfunction


We had found that 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).

Today, the Trump administration is confronted with the threat of a global pandemic of a virus that can be lethal. 

[1918 influenza pandemic - Oakland, CA]


Unfortunately, the administration's response has exemplified many of the aspects of health care dysfunction we have discussed, particularly mission-hostile management. This is a situation in which mission-hostile management could be uniquely dangerous.  However, it seems to have brought out the worst tendencies of President Trump and his cronies in that regard.  Below are examples that came to light only in the last week, presented in chronological order.


Trump Administration Blocked Official Recommendation for Older People to Avoid Flying, Despite The Contagiousness of the Virus and Data That Seniors are More at Risk of Adverse Effects from It

Per the AP, March 7, 2020:

The White House overruled health officials who wanted to recommend that elderly and physically fragile Americans be advised not to fly on commercial airlines because of the new coronavirus, a federal official told The Associated Press.

The Centers for Disease Control and Prevention submitted the plan as a way of trying to control the virus, but White House officials ordered the air travel recommendation be removed, said the official who had direct knowledge of the plan.

Note that:

Dr. Peter Hotez, dean of tropical medicine at Baylor College of Medicine, last week warned U.S. lawmakers against minimizing the viruses risk for vulnerable people. During a Congressional hearing, he said the coronavirus 'is like the angel of death for older individuals.'

Some experts said they’ve been hoping for clearer and louder guidance from the government, to prod vulnerable people to take every possible step to avoid settings where they might more easily become infected.

'The clear message to people who fit into those categories is; ‘You ought to become a semi-hermit. You’ve got to really get serious in your personal life about social distancing, and in particular avoiding crowds of any kind,’' said Dr. William Schaffner, a Vanderbilt University expert on infectious diseases.

Nonetheless, there was no clear rationale for the administration to block the recommendation against flying.  However, at least

On Friday, the CDC quietly updated its website to tell older adults and people with severe medical conditions such as heart, lung or kidney disease to 'stay home as much as possible' and avoid crowds. It urges those people to 'take actions to reduce your risk of exposure,' but it doesn’t specifically address flying.

Trump Tried to Keep Passengers on Board Coronavirus Infected Cruise Ship to Reduce the Apparent Number of People in the US Affected by the Virus

Per the Independent, March 8, 2020:

A cruise ship on which at least 21 people are infected with coronavirus will dock in Carlifornia and unload its passengers – despite Donald Trump saying he wanted them to stay on board to keep the number of US cases down.

The Grand Princess is expected to arrive in Oakland on Monday. It has been anchored off San Francisco for several days.

So far 19 employees and two passengers have tested positive for Covid-19. Another 24 people tested negative and one case was inconclusive. There are about 3,500 passengers on board.

On Friday, Mr Trump said he wanted to keep passengers and crew on board so that US cases would not 'double'. He said: 'They would like to have the people come off. I'd rather have the people stay. But I'd go with them. I told them to make the final decision. I would rather – because I like the numbers being where they are. I don't need to have the numbers double because of one ship that wasn't our fault.'

Trump blocked disembarkation despite the inadequacy of medical care on board, and the lack of provisions available to keep the virus from spreading, especially to the crew.  So Trump appeared willing to sacrifice the health of those on board in a  simple-minded scheme to make the epidemic look less severe for his own political benefit.


Despite Public Health Advice to Avoid Large Crowds, Trump Promoted Safety of Large CPAC Conference, Which Was Shown to Have Included a Coronavirus Positive Attendee

After the conference, as reported by CNN on March 8, 2020:

When asked by reporters if he was worried about being exposed to coronavirus after he attended CPAC, Trump said, 'I'm not concerned at all.' Trump, who was speaking alongside Brazilian President Jair Bolsonaro ahead of their dinner at his Mar-a-Lago resort in Florida, also noted that the administration would not cancel any political rallies as the virus spreads.

'We'll have tremendous rallies. We're doing very well. We've done a fantastic job, with respect to that subject, on the virus,' Trump said.

Since then, multiple attendees, have self-quarantined, including fervent Trump supporters such as  Rep Gaetz (R-FL), Dep Collins (R-GA) , and incoming White House Chief of Staff, Rep Meadows (R-NC) (per the NY Times, March 9, 2020).  Thus Trump appeared to be willing to risk the health of Americans, including some of his strongest supporters, to give the appearance that his administration was controlling the epidemic.

Despite Public Health Advice to Avoid Crowds, Trump Defended Plans for a Large Rally

Similarly, from the Independent, March 11, 2020:

Despite his own administration advising people to avoid events with large crowds to help stop the spread of coronavirus, President Donald Trump has announced he’ll hold a campaign event in Wisconsin.

Mr Trump will attend a 'Catholics for Trump' event in Milwaukee, Wisconsin on 19 March.

The event is now apparently postponed, but Trump's promotion of it showed his disregard for the health of the people, including many of his most devoted supporters.


Trump Sought to Delay Testing for Coronavirus Due to Fear that Higher Numbers of Positive Cases Would Decrease His Chances of Re-Election

Per the Independent, March 13, 2020:

the US president is also reported to have been reluctant to launch a campaign of 'aggressive testing', which could have identified key outbreak areas.

'That’s partly because more testing might have led to more cases being discovered of coronavirus outbreak,' said Dan Diamond, a Politico health reporter who has been investigating the Trump administration’s response to the coronavirus outbreak.

Speaking to NPR, he added: 'The president had made clear – the lower the numbers on coronavirus, the better for the president, the better for his potential re-election this fall.'

Many public health experts felt that earlier aggressive testing could have possibly allowed containment of the virus.  Failure to do such testing in the political interest of the president again  appears to be an egregious example of mission-hostile management.

Trump Flouts CDC Recommendations for Social Distancing, Self-Quarantine

At an event at his own Mar-a-Lago resort, Trump had close contact with at least two individuals from Brazil who later tested positive for the coronavirus, hardly exemplifying CDC recommendations for social distancing.  Then he refused to self-quarantine.  Per the Washington Post, March 13, 2020:

Trump suggested the risk of exposure from a Brazilian official was low, even though the two had posed for a photo together. Trump said he had posed for so many photos, and shaken so many hands, that he did not remember the man.

Note that

Trump seemed to defy two basic practices that the rest of his government has been urging Americans to follow to prevent the spread of the virus. People who were exposed to an infected person are urged to quarantine themselves and seek testing. And everyone — exposed or not — should stop shaking hands.

Most public health experts believe that public health campaigns require leaders setting good examples.

Now more Mar-a-Lago guests have tested positive, per the New York Times, March 14, 2020:

four others at Mar-a-Lago that weekend have since tested positive, including three who accompanied President Jair Bolsonaro of Brazil for a dinner with Mr. Trump before Ms. Guilfoyle’s birthday party that Saturday night: Fabio Wajngarten, his press secretary, Nestor Forster, his top diplomat in Washington, and Nelsinho Trad, a senator.

By failing to set a good example in this case, Trump again showed disdain for the health of the people, particularly those who attend events at Mar-a-Lago, including  his supporters and the patrons of his business.

Discussion

We have discussed  cases in which top health care leadership took actions that ignored or directly challenged health care professionals' core values, that is, mission-ignorant or mission-hostile management.
 
 A major reason was the rise of  "generic managers." Increasingly, health care organizations, including hospitals, pharmaceutical companies, health insurance companies, government agencies, etc are now led by people with management training, but not necessarily with any training or background in medicine, biomedical research, epidemiology, public health, or health care policy. We began noting how such generic managers often prioritize short-term revenue over all other concerns, presumably based on the shareholder value dogma taught in business schools (look here).  Worse, generic managers may be ignorant of, misunderstand, or be frankly hostile to the core values of health care professionals. Finally, generic managers often are subject to perverse incentives that put short-term revenue and managers' self-interest ahead of core values.

In other words, health care is now in the grip of "managerialism," as characterized in   an article that in the June, 2015 issue of the Medical Journal of Australia (look here)(7) :
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals


We have identified breathtaking cases of mission-hostile management by managerialists leading health care organizations primarily to maximize current revenue and/or their own income and self-interest.  Some recent examples:
-  A proud teaching hospital ended up bankrupt after it was traded back and forth by for-profit hospital chains and private equity firms (look here).
- Hospitals offered better care to wealthier patients, and thus worse care to poorer one, or spent  money on achieving market dominance rather than quality patient care (look here and here)
- A pharmacy chain donated to a political organization supposedly to advocate for tax reform, but whose positions contradicted the chain's pledge of social responsibility (look here).
- A health care focused charity directed most of its revenue to a company owned by the charity's leaders (look here)
- Hospital management influenced timing of patient discharge to maximize revenue, regardless of the benefits to patients of shorter or longer stays (look here) etc, etc, etc
Here are more examples.

However, I cannot recall any modern examples of mission-hostile management which so grievously threatened the population of an entire country, nor any modern US examples of a national politician willing to so threaten the country's population for his own political purposes.  Even more astounding is his apparent disdain for the health and safety of his closest supporters and business patrons.

Our chances of survival in this now a global pandemic will remain low until we can replace this dangerous national leader.  Note that the chances of his supporters' and business patrons' may be even worse than those of the general public.