Health Care Dysfunction Makes it to the Presidential Debate


In last night’s debate which included leading candidates from the Democratic Party for its presidential nomination, as reported by Mother Jones, Senator Bernie Sander (D-VT) said (per Mother Jones).

the current health care system is not only cruel, it is dysfunctional

The video is here.

So the concept of health care dysfunction has officially made it to the big time.

You Heard It Here First

What took so long?

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

To better understand health care dysfunction, I interviewed doctors and health
professionals, and published the results in Poses RM.   A cautionary
tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here). 
In that article, I postulated that US physicians were demoralized
because their core values were under threat, and identified five concerns:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research stuides

After that my colleagues and I have
tried to raise awareness of these and related issues, now mainly
through the Health Care Renewal blog.  We also set up FIRM – the Foundation for Integrity and Responsibility
in Medicine,  a US non-profit organization, to try to
provide some financial support for the blog.

Health Care Dysfunction is Multi-Dimensional

Unfortunately, one sentence in a presidential debate hardly does justice to a huge and multi-faceted set of concerns.  

Since 2003 we have broadened our thinking about what constitutes and causes US (and more global) health care dysfunction. Early on we noticed a number of factors that seemed to enable increasing
dysfunction, but were not much discussed.  These factors notably
distorted how medical and health care decisions were made, leading to
overuse of excessively expensive tests and treatments that provided
minimal or no benefits to outweigh their harms.  The more we looked, the more complex this web of bad influences seemed.  Furthermore, some aspects of it seemed to grow in scope during the Trump administration.

A brisk summary of these often complex issues follows.

 Threats to the Integrity of the Clinical Evidence Base

The clinical evidence has been increasingly affected by manipulation
of research studies.  Such manipulation may benefit research sponsors, now
often corporations who seek to sell products like drugs and devices and
health care services.  Manipulation may be more likely when research is
done by for-profit contract research organizations
(CROs). When research manipulation failed to produce
results to sponsors’ liking, research studies could simply be suppressed or hidden
The distorted research that was thus selectively produced was further
enhanced by biased research dissemination, including ghost-written
articles ghost-managed by for-profit medical education and
communications companies (MECCs). Furthermore, manipulation and
suppression of clinical research may be facilitated by health care
professionals and academics conflicted by financial ties to research sponsors.

 Deceptive Marketing

The distorted evidence base was an ingredient that proved useful in deceptive marketing of health care products and services. Stealth marketing
campaigns became ultimate examples of decpetive marketing.  Deceptive
marketing was further enabled by the use of health care professionals
paid as marketers by health care corporations, but disguised as unbiased
key opinion leaders, another example of the perils of deliberate generation of  conflicts of interest affecting health care professionals and academics. 

Distortion of Health Care Regulation and Policy Making

Similarly, promotion of health policies that allowed overheated selling
of overpriced and over-hyped health care products and services included
various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest
due to their funding from companies selling health care products and
services, or to the influence of conflicted leaders and board members. 
Some deceptive public relations campaigns were extreme enough to be
characterized as propaganda or disinformation.

More recently,  as we noted here, we became aware of efforts by foreign powers to spread such disinformation for political, not just financial gain, e.g., in April, 2019,
we discussed evidence that Russia had orchestrated a systemic
disinformation campaign meant to discredit childhood vaccinations,
particularly for the measles, which was likely partly responsible for
the 2019 measles outbreak

Furthermore, companies selling health care products and services further enhanced their positions through regulatory capture,
that is, through their excessive influence on government regulators and
law enforcement.  Their efforts to skew policy were additionally
enabled by the revolving door,
a species of conflict of interest in which people freely transitioned
between health care corporate and government leadership positions. 

In the Trump era, we saw a remarkable increase in the incoming revolving
door, people with significant leadership positions in health care
corporations or related groups attaining leadership positions in
government agencies whose regulations or policies could affect their
former employers (look here).   We found multiple managers from and lobbyists for big health care
corporations being put in charge of regulation of and policy affecting –
wait for it – big health care corporations, a staggering
intensification of the problem of the revolving door.

Bad Leadership and Governance

Health care leadership was often ill-informed
More and more people leading non-profit, for-profit and government have
had no training or experience in actually caring for patients, or in
biomedical, clinical or public health research.  Lately, during the Trump administration, we began to find striking examples of top government officials expressing ill-informed,
if not outright ignorant opinions about medical, health care and public
health topics look here).  We had not previously expected leaders of government to
be personally knowledgeable about health related topics, but
traditionally they consulted with experts before making pronouncements.

Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations’ health care mission, and/or health care
professionals’ values. Often business trained leaders put short-term revenue ahead of patients’ or the public’s health.  In addition, we began to see evidence that leaders of health care corporations were
using their power for partisan purposes, perhaps favoring their personal
political beliefs over their stated corporate missions, patients’ and
the public’s health, and even  corporate revenues. Then, we started seeing appointed government health care leaders who lacked medical, health care or public health background
or expertise but also whose agenda also seemed to be overtly religious or
ideological, without even a nod to patients’ or the public’ health (look here).
 
Leaders of health care organizations increasingly have conflicts of interest.   Moreover, we have found numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions,
albeit usually of corporate entities, not individuals. 

In the Trump administration, corrupt leadership extends from the corporate world to the highest levels of the US government.  We discussed the voluminous reports of conflicts of interest and corruption affecting top leaders in the executive branch, up to and including the president and his family (look here).  One cannot expect effective enforcement of ethics rules and anti-corruption laws in such an environment

Abandonment of Health Care as a Calling

A US Supreme Court decision was interpreted to mean that
medical societies could no longer regulate the ethics of their members,
leading to the abandonment of traditional prohibitions on the commercial
practice of medicine. 
Until 1980, the US American Medical Association had  ruled that the
practice of medicine should not be “commercialized, nor treated as a
commodity in trade.”  After then, it ceased trying to maintain this
prohibition. Doctors were pushed to be businesspeople, and to give
making money the same priority as upholding their oaths. Meanwhile, hospitals and other organizations that provide medical care are increasingly run as for-profit organizations. The physicians and
other health care professionals they hire are thus providing care as
corporate employees, resulting in the rise of the corporate physician.  These health care professionals may befurther torn between their oaths, and the dictates of their corporate managers.

Perverse Incentives Put Money Ahead of Patients, Education and Research

We have extensively discussed the perverse incentives
that seem to rule the leaders of health care. Financial incentives may
be large enough to make leaders of health care organizations rich.  Incentives often prioritize financial results over patient care.  Some
seem to originate from the shareholder value dogma promoted in business
school, which de
facto translates into putting current revenue ahead of all other
considerations, including patient care, education and research (look here).

 Cult of Leadership

Health care CEOs tend
now to be regarded as  exalted beings, blessed with brilliance, if not
true “visionaries,” deserving of ever increasing pay whatever their
organizations’ performance.  This pheonomenon has been termed “CEO disease” (see this post). 
Afflicted leaders tend to be protected from reality by their
sycophantic subordinates, and thus to believe their own propaganda.

Managerialism

Leadership of health care organizations by managers with no
background in actual health care, public health, or biomedical
science has been promoted by the doctrine of managerialism which
holds that general management training is sufficient for leaders of  all
organizations, regardless of their knowledge of the organizations’
fundamental mission.

Impunity Enabling Corrupt Leadership

Most cases involving corruption in large health care organizations are resolved by legal settlements
Such settlements may include fines paid by the corporations, but not by
any individuals.  Such fines are usually small compared to the revenue
generated by the corrupt behavior, and may be regarded as costs of doing
business.  Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements.  The former were originally meant to give young, non-violent first offenders a second chance (look here).  However, in most instances in which corruption became public, are no negative
consequences ensue for the leaders of the organizations on whose watch
corrupt behavior occurred, or who may have enabled, authorized, or
directed the behaviors.

Taboos

Some of the above topics rarely appeaedr in the media
or scholarly literature, and certainly seem to appear much less
frequently than their importance would warrant. We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who
personally profit from the status quo in health care.  Those involved in the leadership
and governance of health care organizations and their cronies, also have
considerable power to damp down any public discussion that might cause
them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.

However,in the Trump administration,  we began to also note examples of government officials attempting to squelch discussion of scientific topics that did not fit
in with its ideology, despite constitutional guarantees of speech and
press free from government control (look here).

What a witches’ brew, surely leading to a cruel and dysfunctional system.

Discussion

In 2017, we said that it was time to consider some of the real causes of health care dysfunction that
true health care reform needs to address, no matter how much that
distresses those who currently most personally profit from the status
quo.

Furthermore, in 2019 we asserted that all the trends we have seen since 2017 are towards tremendous government dysfunction, some of it overtly
malignant, and much of it likely enabling even worse health care dysfunction.

Now that health care dysfunction is in the headlines, we hope health care and public health professionals, patients, and all citizens
will have a much more vigorous response to it.  US health care dysfunction was
always part of the broader political economy, which is now troubled in
new and dangerous ways.  We do not have much time to act.

If not now, when?

If not us, who?