Registration Open – Validation – Truly Successful Communication with Persons living with Dementia Workshop

To: Nursing Home Administrators

From: Edu-Catering

You’re invited to be a part of the Colorado Nursing Homes Innovations Grant awarded to Edu-Catering offering free education around the state on Validation in June of 2019. 

Learn how Validation can meet the CMS requirement for nursing homes to follow national guidelines for dementia care. Teams will learn how to go beyond “redirection” to successfully communicate, validate strong emotions, and stop “therapeutic lying” in order to build trust rather than lose it. The Validation method is found to be equally helpful to both the persons living with dementia as well as their care givers.

To participate, you would commit to:
– Register a team to participate in the all-day education (and send replacement team mates if original team cannot make it).
– Provide feedback after each workshop.
– Develop a realistic action plan to strategically share information learned with larger team as well as implement basic Validation techniques learned in order to offer proactive, successful communication with persons with dementia served.

Western Slope: 
The Commons of Hilltop, Community Room, 625 1/2 Road, Grand Junction 
Wednesday, June 5, 2019, 9:00 am to 4:00 pm (lunch on your own) (seating limited to 55)

Eastern Colorado: 
Eben Ezer Lutheran Care Center, Activity Room, 122 Hospital Rd., Brush
Friday, June 7, 2019, 9:00 am to 4:00 pm (lunch on your own) (seating limited to 100)

North Colorado: 
Good Samaritan Society – Fort Collins Village, Chapel, 508 Trilby Rd. Fort Collins
Thursday, June 13, 2019, 9:00 am to 4:00 pm (lunch on your own) (seating limited to 100)

South Colorado: 
Pueblo Rawlings Public Library, 100 E. Abriendo Ave. Pueblo
Friday, June 14, 2019, 9:00 am to 4:00 pm (lunch on your own) (seating limited to 60)

North Denver: 
Covenant Village Smith Fellowship Hall (Retirement Tower), 9153 Yarrow St. Westminster Tuesday, June 18, 2019, 9:00 am to 4:00 pm (lunch on your own) (seating limited to 60)

South Denver: 
Shalom Park, 14800 E. Belleview Dr., Community Room, Aurora 
Wednesday, June 19, 2019, 9:00 am to 4:00 pm (lunch on your own) (seating limited to 75)

Join primary faculty and project officer Carmen Bowman, Certified Validation Worker, Validation Group Practitioner and Validation Presenter. 

Each location has seating limitations, so trainings will operate on a first-come, first-served basis.

To register your team, contact Carmen at carmen@edu-catering.com or 303-981-7228.

Announcement Flyer

Reminder – Assisted Living Advisory Committee meeting on Thursday, May 23, 2019

To: Assisted Living Residence Providers and Stakeholders 

From: Dee Reda, Community Services Section Manager

The next Assisted Living Advisory Committee meeting is on Thursday, May 23, 2019 from 1:30 p.m. – 3:30 p.m. in Building A, Sabin/Cleere Room.

For meeting agendas, handouts, etc. please go to https://drive.google.com/drive/folders/0ByqZDBabyNVSR3pNejg2X2J0V2c?usp=sharing%20. Click on the folder labeled “2019 Meetings” and find the corresponding meeting date. We recommend that you return to this site on the day of the meeting to check for additional or revised meeting materials. 

To participate via Web using Zoom Meetings: 
Join from PC, Mac, Linux, iOS or Android: https://zoom.us/j/675245553 

Meeting ID: 675 245 553

Step #1: Go to https://zoom.us/j/675245553 
The Zoom meeting screen will appear entitled “Assisted Living Advisory Committee”
Step #2: For sound, choose Phone Call or Computer Audio.
Step #3: You will now be in the Virtual Meeting Room.

If you have never attended a Zoom meeting before:
Get a quick overview: https://support.zoom.us/hc/en-us/articles/204772869-Zoom-Rooms-User-Guide 

To participate by telephone:
Step #1: Dial (for higher quality, dial a number based on your current location): US: +1 669 900 6833+ or 1 408 638 0968 or +1 646 876 9923
Step #2: When prompted, enter the Meeting ID: 675 245 553
Step #3: You will be on hold until a few moments before the meeting.

If you have any questions, please contact Michelle Topkoff at michelle.m.topkoff@state.co.us or call 303-692-2848 at least a business day in advance of the meeting. 

Meeting information

At the Colorado Department of Public Health and Environment, we work hard to protect and promote your health and the environment. If you’re planning a visit to our campus and want to ride your bike here, we won’t take a second look at your helmet head, and if the bus you’re taking is running a little late, we won’t worry. We want you to be your healthiest you, and we appreciate your efforts to reduce pollution.
If you’re coming to our campus: Our campus is located at 4300 Cherry Creek Drive South, Denver, 80246.
If you’re riding your bike: Our campus is located just south of the Cherry Creek bike trail. Bicycle parking is available at multiple locations on the main campus. Covered bicycle parking also is available at several locations, as well as on the ground floor of the parking structure on Birch Street, which is just east of the main campus 
If you’re riding the bus: RTD’s Trip Planner is a great way to find the fastest route.
If you’re driving: Visitor parking is conveniently located in front of all of our buildings. Please check in with security in Building A so you can get a visitor badge.
You might also want to know:
We care about your health, so our campus is tobacco-free.
We are located just east of Glendale’s City Set, where there are several restaurants.
Lactation Rooms are available on the first floors of buildings A and B. 

Chapter 7 Assisted Living Regulation Updates and Resources:

Updates on the Chapter 7 Assisted Living Regulations can be found on the Assisted Living News & Resources web page at http://67.231.102.44/HFEMSD/ALR/index.html.

It is our hope that this resource will provide you with up-to-date and relevant tools, training, and information, as we move forward with implementing the new regulations under 6CCR 1011-1, Chapter 7 Assisted Living Regulations. Current features of the newsletter include on “What’s New”, “Important Dates,” “Training,” “Blog,” “FAQs”, “Help” and “Advisory Committee”. Our goal is to provide you with a clear understanding of the new portions of the regulation as well as training to help you comply. 

ALR IDR Committee Meeting

To: ALR providers

From: HFEMSD

The ALR IDR Committee will meet on 5/23/19 at 10 a.m. at the Department. The public is welcome to observe or listen to the committee discussion by calling 1.712.770.8066 and entering conference code 727084. Information on the location of the meeting will be available at the security desk in building A. 

Elaine Sabyan

TB Update and Skin Testing Practicum for Health Care Providers

To: Medical Directors and Directors of Nursing

From: The Denver Metro TB Clinic and CDPHE Tuberculosis Program 

SPACE STILL AVAILABLE!!!

The Denver Metro TB Clinic invite nurses and other health care providers from home health agencies, clinics, and long-term care facilities to attend a tuberculosis update and skin testing practicum on Thursday, May 30th, 2019 from 12:30pm – 5:00pm in the Public Health Auditorium, 2nd floor at Denver Public Health (605 Bannock Street, Denver). 

Course Objectives are: 
– Express an increased and updated knowledge of TB infection and TB disease
– Demonstrate their skill in placing and reading the TST

Who Should attend?: Health care providers working in hospitals, home health care agencies, jails and other long-term care facilities, occupation health, Civil Surgeon’s offices, and local public health agencies.

For more details and a link to register go to: http://denverpublichealth.org/home/clinics-and-services/tuberculosis-clinic/for-providers/tb-education.

Registration cost is $60 
Space is very limited so please register early. 

For more information please contact Carolyn Bargman at 303-602-7243 cbargman@dhha.orgwith any questions. 

OASIS D Classes *FREE*

To: Federally Certified Skilled Home Health Facilities Administrators, Directors of Nursing, OASIS Coordinators, Billing and Coding Personnel, Licensed Home Health Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

ETA will offer classes on specific OASIS topics in Pueblo, Montrose, Aurora and Colorado Springs featuring OASIS D items and guidance. Pueblo and Aurora are filling fast. You may choose to take sessions all at once or individually as your interest and needs dictate. All registration is first-come, first-served, even for sessions within a hosting facility.

ETA reserves the right to cancel classes with low registration. This is a possibility for Montrose. Early registration is helpful.

OASIS D Basics (One Session): Course ID 1082008
This beginning three-hour class is how to get started with OASIS D.

OASIS D Item-by-Item (2 Sessions): Course ID 1082009
This practical application class reviews item-by-item data set completion. We will follow Mrs. Green’s assessment, which will require two sessions to complete. Attendance at both sessions is required to complete this class.

OASIS Quality Measures (One Session): Course ID 1066910
This course assumes familiarity with the OASIS D Item Set, covering more advanced content and application.

To see additional session details and register for on-site attendance for one of these offerings:
1. Go to http://www.train.org/ 
2. Log in to your existing TRAIN account, or new users click “Create an Account”
3. Once you’ve logged in, or created an account, Search (top right) for the appropriate Course ID. (See above for desired training)
4. Click link for desired course.
5. Click the “Registration” tab.
6. Click the “Register” button for the session you wish to attend.
7. Remember to register separately for each desired course.

A detailed example of the above process (if needed)

Questions?: Please email betty.metz@state.co.us

From "Forced Injections" to "Sorcery," – More Examples of Partisan Ideology and Religious Sectarianism Trumping Evidence in Health Policy and Public Health

Evidence-based medicine (EBM) is about medical-decision making based on critical review
of the best applicable evidence from clinical research informed by
knowledge og biology and medicine, of the patient’s biopsychosocial
circumstances, the patient’s values, and of ethics and morality.  Advocating EBM, and evidence-based health care, public health, and health policy was sometimes slow going, but at least health care professionals often seemed open to these ideas.

Now we seem to be in an alternate universe.  We have discussed the rising tide of health care and public health policy unsupported by evidence, and sometimes supported only by nonsense.  This tide seems driven by ideology, partisanship, and religious sectarianism.  Furthermore, we see more and more examples of political leaders embracing such policies apparently without any input from health or public health professionals.  We discussed several relevant cases in March, and then April, and included them in an interval summary of the “new (ab)normal in health care dysfunction” in May.

Less than 10 days later, we have accumulated enough new examples to be worth summarizing, presented in alphabetical order by state.

Arizona Republican State Legislators Push Vaccine Exemptions in the Face of a Measles Outbreak, While Decrying Pornography as a Greater Public Health Hazard

In February, 2019, Arizona state legislators were pushing to further relax requirements for and even discourage vaccination.  According to CNN,

Arizona lawmakers voted last week to advance three bills that would make it easier to get exemptions from the state’s vaccine requirements, and which would require doctors to provide much more information to patients and families about potential harms that vaccines pose.

The bills cleared the House’s Health and Human Services Committee on a 5-4 GOP-led, party-line vote, and head to the Rules Committee on their way to the floor.

HB 2470 adds a religious exemption to the existing law requiring vaccinations, and carries an amendment that would eliminate the requirement for parents to fill out an exemption form that informed them of potential consequences of not vaccinating their children. Those consequences can include requirements to keep children who haven’t received vaccinations out of school during disease outbreaks.

HB 2471 requires medical providers to give detailed information about vaccines, including the prescription’s package insert, to parents.

It was not clear that any of the legislators pushing these measures based their arguments on evidence about vaccines, the diseases they may prevent, or public health in general. Instead, for example:

the bills’ sponsor, Rep. Nancy Barto … told Capitol Media Services: ‘These are not, in my view, anti-vaccine bills. They are discussions about fundamental individual rights.’

In this case, was she expousing a fundamental right of a parent to increase the likelihood that the parent’s child would get an unpleasant, and dangerous disease, and to transmit such a disease to others?  Soon after, in March Arizona recorded its first case of the measles, affecting an 11 month old child.

Meanwhile, Arizona state legislators decided to worry about the public health hazards, not of the measles outbreak, but of … pornography.  We had noted also  in March that Republican legislators were pushing the notion, unsupported by evidence, that pornography is a public health crisis.  In May, CBS reported,

A Republican-backed measure in the Arizona State Senate to formally denounce pornography as a public health crisis has passed. The resolution, which does not require the governor’s signature for approval, will now go to the secretary of state to be certified. According to text of the bill, the legislation claims that pornography ‘perpetuates a sexually toxic environment that damages all areas of our society.’

It goes on to claim, without any medical citation, that pornography is ‘potentially biologically addictive and requires increasingly shocking material for the addiction to be satisfied’ leading to ‘extreme degradation.’

Again, the resolution seemed to have only Republican support. It was “Introduced by Republican Rep. Michele Udall and backed by six other Republican co-sponsors….”

While there is very good evidence that measles vaccination prevents the disease, that the disease can have serious, sometimes fatal consequences, and that measles is easily transmitted to others; and there is no good evidence that pornography is harmful, the legislators treated the latter is a more serious threat.  I saw nothing to suggest they had any personal experience in medicine, health care, or public health, or that they consulted anyone with any expertise in their areas.  Although they cited “individual rights” to support vaccine exemption, they were silent about rights to free expression that might have been affected by their crusade against pornography.  Finally, all the legislators prominently involved in these moves were from one party.  

Oregon Republican Party Derides Vaccinations as “Forced Injections”

This story comes via Vice News on May 8. In response to a bill sponsored by Oregon Democrats that would remove the “moral exemption” for vaccination,

Oregon’s Republican Party isn’t on board with this whole ‘forced injections’ thing — otherwise known as mandating kids get their shots against life-threatening illnesses like measles, mumps and rubella.

‘Oregon Democrats were just joking about ‘my body, my choice’ while rammimg (sic) forced injections down every Oregon parent’s throat,‘ the state’s official GOP account tweeted Monday night, apparently referencing the Democrats’ argument that Republicans shouldn’t interfere with a woman’s ability to access abortion.

Note that parents are making decisions about measles vaccinations, which are injections, for their children, not themselves in this context.  Although Oregon apparently has not had its own measles outbreak, there is one in neighboring Washington state.  According to Vice News, the vaccination rate in some parts of Oregon may be as low as 80%, reducing herd immunity and making the risk of an outbreak high.  Again, I could find nothing to suggest whoever in the state Republican party coined the perjorative “forced injections” had any understanding of the data about vaccine effectiveness versus adverse effects, or the severe consequences and transmissability of measles.  Finally, again this seems to be making a discussion of public health partisan.

Texas Republican State Legislators Also Advocate More Vaccine Exemptions, While One Accuses Public Health Authority of “Sorcery”

In April, the Corpus Christi, Texas, Caller-Times reported that four Texas state legislators were introducing bills to make it easier to avoid vaccination,

H.B. 3857: by Rep. Tony Tinderholt, R-Arlington, would prohibit doctors from refusing to see unvaccinated patients. Pediatricians tend not to want unvaccinated children in their waiting rooms, exposing other children and their parents to preventable deadly diseases like measles. Pediatricians are kind of funny that way. So are parents who believe in vaccination.

H.B. 1490: by Rep. Matt Krause, R-Fort Worth, would make it easier for parents to opt out of vaccinations. But perhaps of bigger concern is that it would prevent the Texas Department of State Health Services from tracking non-medical exemptions. This would make it harder to respond to outbreaks and certainly harder to predict them by identifying potential hotspots.

H.B. 4274: the ‘informed consent’ bill by Rep. Bill Zedler, R-Arlington, would require doctors to explain the benefits and risks in detail, including ingredients in the vaccines. That may sound like a good thing on face value. But this is technical information that is more likely to cause confusion and fear than understanding and appreciation. It’s like telling someone what’s in menudo first, then trying to get them to eat it.

H.B. 4418: by Rep. Jonathan Stickland, R-Bedford, would let nurses rather than only doctors sign off on vaccination exemptions.

The reporters tried to understand the rationale for these bills.  The best they could do was to write

that it appears to be a mix of political opportunism and ignorance. Suspicion of vaccinations is suspicion, period, and suspicion helps drive votes. The ignorance part is best summed by Zedler, who told the Texas Observer that concerns about measles are overblown because it’s beatable ‘with antibiotics and that kind of stuff.’ The punchline is that antibiotics don’t kill viruses and measles is a virus.

Note that we had discussed Rep Zedler’s remarkably wrong headed statement that measles can be treated with antibiotics here.

The Caller also noted that

not one of these bill sponsors is a medical professional or scientist. Nor are they acting on the advice of medical professionals or scientists. If they had listened to and heeded medical advice, they would not have filed these bills.

In May, a follow to this story was a bit wilder.  The Washington Post reported on the latest antics of Rep Strickland, who introduced the fourth bill in the list above,

 A Texas state legislator unleashed a vilifying attack on a leading vaccine scientist Tuesday, accusing the doctor of ‘sorcery.’

It started with a report published Monday by the Texas Department of State Health Services that noted the state recorded a 14 percent rise in parents opting out of their children’s vaccinations. It was a new statistic that alarmed Peter Hotez, professor and dean of the National School of Tropical Medicine at Baylor College of Medicine.

‘We have more than 64,000 kids not getting vaccinated in the state of Texas, and that doesn’t account for the over 300,000 home-schooled kids,’ Hotez said during an interview with The Washington Post.

Hotez took his concerns about the report to Twitter. And then he received an unexpected, seething personal attack from the Republican state legislator, Rep. Jonathan Stickland.

New school #vaccine exemption numbers reported yesterday by @TexasDSHS. Now >64,000 kids not vaccinated, with #Austin schools, which can no longer be considered safe for kids. All to benefit outside #antivax groups from CA NY DC monetizing the internet. Where is our leadership? pic.twitter.com/x92gIZT3m9
— Prof Peter Hotez MD PhD (@PeterHotez) May 7, 2019

‘You are bought and paid for by the biggest special interest in politics,’ Stickland wrote. ‘Do our state a favor and mind your own business. Parental rights mean more to us than your self enriching ‘science.’’

In a tweeted response, Hotez, a pediatrician and vaccine scientist, noted to Stickland that he does not receive money from the vaccine industry; instead, his work focuses on ‘neglected disease vaccines for the world’s poorest people.’

Stickland, who told The Post he is ‘not anti-vaccination,’ tweeted his response to Hotez.

‘Make the case for your sorcery to consumers on your own dime,’ the Republican, who represents an area of suburban Fort Worth, snapped back Tuesday. ‘Quit using the heavy hand of government to make your business profitable through mandates and immunity.’

(Hotez is not part of a for-profit business, either as a dean at the Baylor College of Medicine or as an endowed chair at the nonprofit Texas Children’s Hospital.)

What was the rationale for Strickland’s position?

‘It comes down to whether the government should be mandating what’s right for us,’ Strickland said. ‘I side with the individual.’

So note that Rep Strickland not only apparently falsely accused Dr Hotez, a recognized public health expert, of a conflict of interest, but of “sorcery,” that is, witchcraft  The latter was apparently not clearly satirical, or metaphoric.  This suggests that underlying the ideology may be some very extreme religious sectarianism.  It looks like the idea of a witch hunt is not dead.

Discussion

As we noted above, here are three more cases in which politicians in three states, all Republican, none of whom had any obvious background or expertise, in medicine, health care, or public health, pushed public health policies that were unsupported by evidence and poentially harmful.

Their rationale seemed at best ideological, based on “individual rights.”  Yet while focusing on the rights of parents to not vaccinate the children, they ignored how these rights could adversely affect the children, and anyone who might be exposed to disease the children might acquire.  In the case of Arizona, they also simultaneously ignored rights of free expression while they denounced pornography.

Since all the polticial leaders involved were Republicans, and in some cases their advocacy was in the context of deriding their Democratic political opposition, it seemed that their public policy stances were also partisan.  Such ideologically based and partisan arguments should alarm health care professionals who are sworn to
put the patients’ and the public’s health ahead of other concerns,
including political ideology.

Finally, the last case, which included a state legislator accusing a physician and public health expert not only of having a conflict of interest (which he apparently did not have), but of “sorcery,” their public health stances also seemed to come from religious sectarianism, at its most extreme. Such  arguments are also concerning because they seem to
be an attempt to use the govenrment to promote a particular set of
religious beliefs ahead of patients’ and the public’s health, and to
impose these beliefs on people of other faiths.  This apparently
contradicts the US constitutional prohibition against governmental
establishment of religion.

True health care reform would require government officials to use
evidence, rather than personal ideology and particularly rather than
their own religious beliefs when making health care and public health
policy. 

    

HHA IDR Committee Meeting

To: HHA providers

From: HFEMSD

The HHA IDR Committee will meet 5/21/19 at 10:00 a.m. at the Department. The public is welcome to observe or listen to the committee discussion by calling 1.712.770-8066 and entering conference code 666158. Information on the location of the meeting will be available at the security desk in building A.

Elaine Sabyan

MDS 3.0 Classes *FREE*

To: Federally Certified Skilled Nursing Facilities Administrators, Directors of Nursing, MDS Coordinators, Billing and Coding Personnel, Licensed Nursing Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

Classes on specific MDS topics are available in Pueblo, Montrose, Denver and Colorado Springs. You may choose to take them all at once or individually as your interest and needs dictate. All registration is first-come first-serve, even with sessions held within a hosting facility site.

ETA reserves the right to cancel sessions without adequate participation. This is a possibility for Pueblo and some Montrose sessions. Early registration is recommended.

MDS Basics (One Session): Course ID 1066903
This beginning three-hour class is how to get started with MDS.

MDS Item By Item (2 Sessions): Course ID 1066907
This practical application class reviews item-by-item data set completion. We will follow Miss Scarlett’s assessment, which will require two sessions to complete. Attendance at both sessions on subsequent days is required to complete this class.

MDS Quality Measures (One Session): Course ID 1066904
This course assumes familiarity with the MDS Item Set, covering more advanced content and application.

To see additional session details and register for on-site attendance for one of these offerings:
1. Go to http://www.train.org/ 
2. Log in to your existing CO.TRAIN account, or new users click “Create an Account”.
3. Once you’ve logged in, or created an account, Search (top right) for the appropriate Course ID. (See above for desired training)
4. Click link for desired course. Note open session options.
5. Click the “Register” button for the session you wish to attend.
6. Remember to register separately for each desired course.

Detailed Instructions for Using Train.org (if needed)

Questions?: Please email betty.metz@state.co.us

Licensure Fee Increases Effective 7/1/2019

Dear Licensed Provider,

Fees for most facilities licensed by the Health Facilities and Emergency Medical Services Division will be increasing effective July 1, 2019. The new fees will apply to any renewal of a license expiring on or after July 1st (regardless of when the fee is paid) and to any other license application (such as an application for an initial or amended license) filed and paid on or after July 1st.

For most fees the changes are based on the consumer price index. As an example the fee for a Change of Name will increase from $75.00 to $77.38.

For Assisted Living Residence providers July 1st is also the effective date for fee changes in Chapter VII, including license renewal and change of ownership fees.

Summary sheets with the current fee structure and fees effective July 1 may be found at:

https://drive.google.com/drive/folders/17gYsbhV_yHaoEWVNkbvQcXg8mOgALPGv 

If you have any additional questions, please contact the division at (303) 692-2836 or cdphe.healthfacilities@state.co.us.

The New (Ab)normal in Health Care Dysfunction

Introduction: The Issues Ignored by Discusisons of Health Care Reform

After the failed attempt to “repeal and replace” the Affordable Care Act (ACA, Obamacare) in 2017, we summarized what we thought were the main issues that traditional discussions of health care reform in the US (and sometimes in other countries) did not address.Despite some protestations to the contrary (e.g., here), the US health care system has been plagued by dysfunction.  According to a recent Commonwealth Fund study,
the US was ranked 11 out of 11 in health care quality, but 1 out of 11
in costs.  Traditionally, health care reform has targeted ongoing
problems in the cost, accessibility and quality of health care.  The ACA
notably seems to have improved access, but hardly addressed cost or quality.

Now, in 2019, these issues also seem to only be getting more so.  So a little more than two years into the Trump regime, I thought we should assess the new (ab)normal in health care dysfunction, trying as best as possible to use the framework from our 2017 summary, with examples from our blog posts.

Distortion of Health Care Regulation and Policy Making: the Rise of the Incoming Revolving Door

We had previously noted that companies selling health care products and services further enhanced their positions through regulatory capture,
that is, through their excessive influence on government regulators and
law enforcement.  Their efforts to skew policy were additionally
enabled by the revolving door,
a species of conflict of interest in which people freely transitioned
between health care corporate and government leadership positions.  Up to the Trump era, nearly all those cases involved people who left government who were offered corporate positions in firms that might have been affected by regulations or policies influenced by the government agencies for which they formally worked, the outgoing revolving door.

However, in the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers.

– We noted a stealth marketer for health care corporations becoming a key Trump economic adviser (look here)

– We found numerous more examples in October, 2017, including two people from the same lobbying firm, Greenberg Traurig Alston & Bird, which that year had  “earned more than $4.4 million lobbying so far this year for
health care companies and trade groups including Novartis AG, Verax
Biomedical, the American Hospital Association, St. Jude Children’s
Research Hospital, and Aetna….,” given top Department of Health and Human Services (DHHS) positions.

– A little later that month, we noted that one of those two former lobbyists, Mr Eric D Hargan, had become acting Secretary of DHHS (look here).

– Slightly later that month, there was an even more striking example, the new (permanent) Secretary of DHHS, Mr Alex Azar, who replaced Mr Hargan, was a former top executive of pharmaceutical company Eli Lilly.

– In November, 2017,
an advocate for the discredited former CEO of UnitedHealth become an
Assistant Secretary of DHHS. 

–  Later in November, we found two more examples of the incoming revolving door, including a lobbyist for pharma/ biotech company Gilear becoming director of health programs for the Office of Management and the Budget (OMB) here.

– In March, 2018, we posted a long list of industry figures, including a slew of lobbyists appointed to DHHS leadership positions.

– in April, 2018, we posted the next list, of top industry executives going to major executive branch positions.  The most striking example was a vice president at CVS, formerly at Pfizer, becoming a senior advisor to the Secretary of DHHS (who is a former Eli Lilly executive) for drug price reform. Pfizer and Eli Lilly alumni in charge of drug price reform, what could possibly go wrong?

– In July, 2018, the next list included a senior advisor at again Eli Lilly appointed to head an FDA division.

– In February, 2019,
the list included a person with multiple leadership positions in
for-profit health insurance companies, including WellPoint, and most recently a Medicaid managed care insurance provider, appointed to lead “health care
reform” for DHHS.  Again, from the insurance industry to lead health care reform, what could possibly go wrong.

– In March, 2019, we noted that the newly appointed acting director of the FDA had founded and/ or was on boards of directors of multiple biotech companies.

This was a staggering record of managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting – wait for it – big health care corporations, a staggering intensification of the problem of the revolving door, which some have already asserted should be regarded as not merely severe conflicts of interest, but of corruption.  

Distortion of Health Care Regulation and Policy Making: Stealth Policy and Advocacy Morphing into Propaganda and Disinformation, Now may be Orchestrated by a Hostile Foreign Power

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.  Now this information may be connected to, or even organized by a hostile foreign power  

In March, 2018, based on revelations of what appeared to be an organized disinformation effort engineered by Cambridge Analytica and associates, using large amounts of personal data liberated from Facebook, to promote the Trump campaign, we started to ask how we could address deceptive public relations, propaganda, and disinformation in health care under a regime that had so benefited from foreign based disinformation efforts?

In April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak, and possibly for some of the unsupported assertions made about measles and measles vaccinationa by government leaders (see below).  The Soviet Union, which of course then included Russia, had orchestrated a disinformation campaign about HIV in the 1980s.  Erroneous beliefs generated by this campaign persist to this day.  The USSR had a principle role in the development of disinformation and other active measures meant to destablize western democracies.

 As recently documented in the redacted version of the Mueller report, Russia launched a disinformation campaign to swing the election to its preferred candidate, Donald Trump.  The role of a hostile foreign power which had used active measures during the election also using active measures to spread disinformation about medicine and public health should not be dismissed. 

Bad Leadership and Governance: Ill-Informed Leadership Now Approaching Flagrant Ignorance While Eschewing Expertise

We have long decried leaders of big health care organizations who seemed to have little background in or knowledge of biology, medicine, health care, or public health.  Typically, these were leaders of big health care corporations, such as pharma/device/ biotech companies, health insurance companies, hospitals and hospital systems, etc who were trained in management, and thus could be called managerialists.  

However, during the Trump regime we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics.  We had not previously expected leaders of government to be personally knoweldgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

Since the Trump regime began, perhaps inspired by examples from Trump himself, various political/ government leaders began to publicly say ignorant or downright stupid things about such topics.

–  For example, in September, 2017, we noted a series of examples showing some basic ignorance of health policy, including fundamental confusion about the nature of health insurance.

– In August, 2018, we noted that Trump had long been an apologist for asbestos, which is known to cause asbestosis, lung cancer, and mesothelioma, claiming that those opposing use of asbestos were associated with organized crime, while more recently Trump’s EPA seemed willing to relax regulation of asbestos, at a time when Russia seemed ready to become the major US supplier of it.

Bad Leadership and Governance: From Incompetence (in the Colloquial Sense) to Cognitively Impaired or Demented Leadership

Again, previously we had discussed  ill-informed and incompetent leadership in terms of
leaders who had no training or experience in actually caring for patients, or in
biomedical, clinical or public health research.

However, we began to note concerning examples suggesting that the top leader of the US executive branch, President Trump himself, could be cognitively impaired perhaps from a dementing, neurological or psychiatric disorder.

– In October, 2017, we first started cataloging
pronouncements by President Trump on health care and related topics
that started with a grossly cavlier attitude toward health policy (e.g., it is only about fixing somebody’s back or their knee or something,” and ended with word salad:

Well, I’ve — I have looked at it very, very strongly. And pretty much, we can do almost what they’re getting. I — I think he is a tremendous person. I don’t know Sen. Murray. I hear very, very good things.

I know that Lamar Alexander’s a fine man, and he is really in there to do good for the people. We can do pretty much what we have to do without,
you know, the secretary has tremendous leeway in the — under the Obama
plans. One of the things that they did, because they were so messed up,
they had no choice but to give the secretary leeway because they knew
he’d have to be — he or she would have to be changing all the time.

And we can pretty much do whatever we have to do just the way it is. So this was going to be temporary, prior to repeal and replace. We’re going to repeal and replace Obamacare.

As we were taught in medical school, word salads may be produced by patients with severe neurological or psychiatric disorders.

– In January, 2018, we discussed more examples of Trump’s confused, incoherent comments on health care.

– In May, 2018,
we noted attempts by Trump Organization functionaries to intimidate
Trump’s former personal physician, presumably to prevent him from
revealing details of the president’s medical history.

– In December, 2018,
we cataloged Trump’s counter-factual, and often severely incoherent
pronouncements – basically more examples of word salad – about public health,
health care and other topics, at times interspersed with claims of his
high intelligence.

Health care led by people with business or legal training who are willing to get advice from health care, public health and medical specialists may be as good as it gets.  Health care led by such people who do not consult experts if worrying.  Health care led by people who report to a cognitively impaired, demented or psychotic leader is extremely worrying (as is government with such leadership.)

Bad Leadership and Governance: Mission-Hostile Management Now Driven Less by Pecuniary Considerations, More by Ideology, Partisanship, and Religious Sectarianism

We had previously noted 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.  The example we cited then was a
hospital CEO who allegedly over-ruled medical leadership to hire a
surgeon despite reports that his patients died more frequently than
expected, gamed reports of clinic utilization, and associated with
organized crime (look here).  Most such examples seemed to be generated by leaders who put their organization’s revenue, often in parallel with their own compensation ahead of patients’ and the public’s health.

We also began seeing examples of how politically appointed officials of health related government agencies who had no experience or expertise in health care or related fields began to assert control over health care professionals in the agencies to facilitate the Trump regime’s political agenda apparently regardless of the effects on health. Sometimes the problem seemed to carry over from the leaders’ previous management, rather than medical, health care or public health experience.  For example, in February, 2018,
we noted that the physician who was Secretary of the Veterans
Administration was challenged by a political a political appointee who
used to run a brewery.

However, we then began noting leaders who also lacked medical, health care or public health background or expertise whose agenda seemed to be overtly religious or ideological, without even a nod to patients’ or the public’ health.

– In April, 2018, we noted a host of appointments of people who flagrantly lacked any health care or public health related experience or expertise to leadership positions in government agencies whose agenda seemed to be overtly religious or ideological, without even a nod to patients’ or the public’ health. For example, a 23-year old whose only experience after college was in Trump’s campaign was given a significant position in the Office of National Drug Control.

– In April, 2018, we posted another such list, including a blogger who promoted racism and conspiracy theories given the Deputy Directorship of Communications for DHHS.

– In July, 2018,
we noted the appointment of a physician to a leadership position in
family planning within the DHHS who cited “facts” completely unsupported
by evidence to justify religiously based health care policies, e.g.,
using her argument that adopting a child is like a “second death” to argue
that mothers should not give their children up for adoption.

– In August, 2018, we discussed  three political appointees to DHHS, none of whom had any health care or public health related experience or expertise, all of whom made pointedly political public comments after their appointments, from deriding their political opponents as “clueless” and “crazy”to alleging Hillary Clinton arranged a murder.

 – In November, 2018,
we noted pronouncements about health care or public health by federal
agencies under the Trump regime, right-wing politicias who back Trump,
and propagandists who back Trump which were unsupported by evidence, but
seemed designed to support right-wing ideology or sectarian religious
belief.  These included assertions that immigrants and asylums seekers
carried infectious disease, that intersex patients do not exist, that
contraception causes cancer and violent death, that pornography is a
major public health hazard, etc.

– In March, 2019, our list included examples of multiple leaders at the state level, all Republicans, including the Kentucky Governor asserting that zombie television shows cause mass shootings, but exposure to extreme cold does not harm schoolchildren; and numerous unsupported pronouncements by state legislators about measles, including the Texas state representative who stated antibiotics can treat measles.

– In April, 2019, we discussed another batch of bizarre statements about the measles and vaccination policy made by President Trump, again the Republican Governor of Kentucky, and various Republican state legislators.  

Again, basing health care and public health decisions primarily on money seems likely to be bad for patients’ and the public’s health, but basing them purely on political ideology or religious belief seems worse. In some cases, the resulting mission-hostility seems to translate into violations of the US constitution.  For example, making health care decisions based on a particular religion’s beliefs could be harmful for patients or citizens who do not share these beliefs, plus violate the Constitution’s guarantee of freedom of a government establishment of religion.

Bad Leadership and Governance: Mission-Hostile Management by Now Partisan Corporate Leadership  

Again, previously the mission-hostile management we noted at the corporate level seemed mainly driven by pecuniary concerns, putting corporate revenues and resulting management compensation ahead of patients’ and the public’s health.  However,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.

– In June, 2018,
we first noted how a large health care corporation, the huge pharmacy
chain CVS, had been secretly making contributions to an ostensibly
non-profit organization which actually served solely to promote Trump
regime policies, including some that seemed to subvert claims the
corporation had made about social responsibilty.  The contributions
themselves seemed to conflict with the corporation’s charitable giving
policies.

– 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 noted a Transparency International study of policies on political
engagement of multinational pharmaceutical companies, all of which
operate in the US.  Only one disavowed the revolving door, and only two
eschewed direct corporate political contributions.

– Also, 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.

This suggests yet another route towards government putting ideology and partisanship ahead of patients’ and the public’s health.

Bad Leadership and Governance: Conflicted, Corrupt Corporate Leaders Now in the Context of Flagrant Conflicts of Interest and Corruption at the Highest Levels of the US Government

We had previously discussed numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions,
albeit usually of corporate entities, not individuals.  One would
hardly expect corrupt leadership to put patients’ and the public’s
health ahead of the leaders’ ongoing enrichment.

Prior to July, 2017, we had discussed some particular cases in which Donald Trump and his family had been involved in ethically questionable activities prior to his becoming president.  However, by  August, 2017, we started to discuss the corruption at the top of the regime. 

– In January, 2018, we first discussed the accumulating evidence of pervasive corruption at the top of the US executive branch, based on articles in the media, and the launch of a website devoted to tracking such corruption.

– In July, 2018, we summarized new sources of evidence about top level government corruption.

– In October, 2018, we posted yet another update, including summarizing a new and very lengthy report about the scope of Trump and associates’ conflicts of interest and corruption, which at the time required 26 pages to print. It documented multiple ongoing instances of the Trump Organization, whose biggest owner is Trump, receiving large ongoing payments from foreign governments, the US government, and state governments.  The former payments seemed to explicitly violate the “foreign emoluments clause” of the US  Constitution, which bans presidential conflicts of interst involving foreign governments, and the “domestic emoluments clause,” which bans those involving the federal and state governments.

– In October, 2018, we discussed the latest advances in understanding of global corruption, via Tranparency International’s global meeting, which included description of trans-national kleptocratic networks, which now seems to describe Trump and the Trump Organization.

– In April, 2019, we posted our latest discussion of pervasive high-level corruption, which referenced updates from sources mentioned earlier, plus three new sources.

Prior to the Trump regime we had criticized law enforcement for a lack of interest in vigorously prosecuting health care corruption.  We documented numerous examples of the impunity of top health care corporate executives who almost always escaped any negative personal consequences even when their organizations paid large fines for bribery, kickbacks, fraud and the like.  We often attributed this laxity to excessive sensitivity respect of the value of these corporations and their products.  However, the potential for encouraging health care (and other kinds of) corruption under a regime that is itself frankly corrupt is mind boggling.

[picture of Trump International Hotel in Washington, which is frequently patronized by foreign government officials, whose payments to Trump via the Trump Organization appear to amount to the “foreign emoluments” prohibited by the US Constitution.]

Overarching Issue: Taboos Previously Enabled by Private Organizational Behavior, Now by Government Agencies and Officials, Despite the First Amendment

When we started Health Care Renewal, such issues as suppression and
manipulation of research, and health care professionals’ conflicts of
interests rarely appeared in the media or in medical and health care
scholarly literature.  While these issues are now more often publicly
discussed, most of the other topics listed above still rarely appear in
the media or scholarly literature, and certainly seem to appear much
less frequently than their importance would warrant.  For example, a
survey by Transparency International showed that 43% of US resondents
thought that American health care is corrupt.  It was covered by this blog,
but not by any major US media outlet or medical or health care
journal.  We have termed the failure of such issues to create any echoes
of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who
personally profit from the status quo in health care.  As we noted
above, the people who profit the most, those involved in the leadership
and governance of health care organizations and their cronies, also have
considerable power to damp down any public discussion that might cause
them displeasure. In particular, we have seen how those who attempt to blow the whistle
on what really causes health care dysfunction may be persecuted.  But,
if we cannot even discuss what is really wrong with health care, how are
we going to fix it?

Since the beginning of the Trump administration,  we began to note more examples of government officials under Trump
attempting to squelch discussion of scientific topics that did not fit
in with its ideology, despite constitutional guarantees of speech and
press free from government control.

– In September, 2017, we
noted
an attempt for Trump political appointees to blockade information
released from the Department of Health and Human Services (DHHS) that
the regime found offensive.

– In February, 2018,
we noted attempts by a consultant for the Center for Medicare and
Medicaid Services (CMS), a major component of DHHS, to intimidate a
health care journalist.

– In April, 2018,
it became apparent that the head of CMS has directed millions in
contracts to a Republican public relations firm, partly to burnish her
image, and that firm had hired the consultant noted above.

– We also found attempts to squelch attempts by current or former government workers to criticize Trump and his policies.  In August, 2018,
we noted Trump had White House staffers sign non-disclosure agreements,
which seems to expressly violate first amendment protections of free
speech and federal law.

Given how hard it was to reverse the anechoic effect in the past, how much harder will it be to open discussion of what is really wrong with health care when the power of the US government is used to censor ideas which the regime dislikes?

Discussion

For years, I thought that health care dysfunction was primarily about individuals and private organizations, including but not limited to pharmaceutical, biotechnology and device companies; hospitals and hospital systems; insurance companies, academic medical institutions; physicians and their practices; etc, etc, etc.  Consequently, I thought these individuals and organizations needed better awareness of health care dysfunction to provoke them to improve matters.  I thought of the government as being involved, but mainly because of well-intentioned, sometimes bumbling government actions and policies that often had unintended effects, and sometimes excess coziness with the health care industry.  While I knew that the government was subject to regulatory capture and various leadership problems, its role, at least in the US, seemed almost secondary.

But in the Trump era, there is a new (ab)normal.  All the trends we have seen since our last discussion of health care reform are towards tremendous government dysfunction, some of it overtly malignant, especially in terms of corruption of government leadership of unprecedented scope and at the highest levels, and overt influence of government-favored political ideology and religious beliefs on health care policy and other policies and actions.

I hope that the above attempt to summarize these new trends will urgently point health care and public health professionals, patients, and all citizens towards a much more vigorous response.  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?