Thursday, March 15, 2018

In "Trump Town," the Revolving Door Runneth Over: Yet More Ex-Lobbyists as Political Appointees at the Department of Health and Human Services

We have accumulated a remarkable number of stories of people transiting the revolving door from high-level positions in health care corporations to high-level positions in health care policy or regulation for the Trump administration.  These stories may not always appear in the most prominent places, but their accumulation suggests they should be of prominent importance.

ProPublica's "Trump Town" Project

ProPublica has just made public its massive "Trump Town" project.  An accompanying article explains it thus,

When the Trump administration took office early last year, hundreds of staffers from lobbying firms, conservative think tanks and Trump campaign groups began pouring into the very agencies they once lobbied or whose work they once opposed.

Today we’re making available, for the first time, an authoritative searchable database of 2,475 political appointees, including Trump’s Cabinet, staffers in the White House and senior officials within the government, along with their federal lobbying and financial records. Trump Town is the result of a year spent filing hundreds of Freedom of Information Act requests; collecting and organizing staffing lists; and compiling, sifting through and publishing thousands of financial disclosure reports.

Here’s what we found: At least 187 Trump political appointees have been federal lobbyists, and despite President Trump’s campaign pledge to 'drain the swamp,' many are now overseeing the industries they once lobbied on behalf of. We’ve also discovered ethics waivers that allow Trump staffers to work on subjects in which they have financial conflicts of interest.

In other words, 'Trump Town' offers a detailed view of the most massive and far-reaching campaign to instill conflicted corporate insiders into federal agencies ever attempted.  For years, we at Health Care Renewal have been trying to highlight particular instances of people who transit the revolving door to or from US government agencies involved with health care.  We stepped up this effort when we realized that the Trump administration seemed intent on moving a record number of people from the health care "industry" to positions within the government which could regulate or influence policy affecting that industry.  But ProPublica has shown there were far more such people than we dreamed of.

The Latest Crop of Revolving Door Travelers Publicly Revealed

So here we will review people listed in the ProPublica database who went from lobbying for the health care "industry" to the Department of Health and Human Services (DHHS) under the Trump administration.  We will emphasize those whom we have not yet previously discussed.  In alphabetical order:

John J. Bartrum
Assistant Secretary for Financial Resources

Former Partner, Squire Patton Boggs

Former Compensation Sources

American International Group (AIG), Inc. Legal Services
Biotechnology Industry Organization (BIO) Legal Services
Cadmus Group Legal Services
Management & Training Corp (MTC) Legal and Lobbying Services
Micropact Legal and Lobbying Services
Squire Patton Boggs LLP (US) Partner, Attorney
The Coca Cola Company Legal Services
Thomas Jefferson University Hospital Legal Services
University of Georgia (UGA) Legal Services

Kimberly L. Brandt
Principal Deputy Administrator for Operations | $179,700

Lobbied for


Robert Charrow
General Counsel

from Greenberg Taurig LLP and Registered Lobbyist, Intrexon Corp to General Counsel, DHHS, see this post

Shannon Christian
Director, Office of Child Care | $150,000

Former Compensation Sources

BLH Technologies, Inc. Development/training re: online communications system, and meeting/membership support for Child Care Policy Research Consortium, a project of OPRE, ACF, HHS

Kelly Marie Cleary
Chief Legal Counsel, Centers for Medicare and Medicaid Services | $179,700

Former Positions Outside Government

Akin Gump Strauss Hauer & Feld LLP Attorney

Lobbied for

Alameda Alliance for Health
California Association of Physician Groups
Catalina Marketing
Guardian Life Insurance Company
Gundersen Lutheran Medical Foundation
Johnson & Johnson
Network for Regional Healthcare Improvement
ThedaCare Center for Healthcare Value
Wisconsin Medical Society

Eric D Hargan
Senior Adviser to the Secretary, Deputy Secretary, Health and Human Services

from from Lobbying for UnitedHealthcare for Greenberg Traurig Alston & Bird to Deputy Secretary, DHHS, see this post

Jenifer Lynn Healy
Chief of Staff, Office of Global Affairs | $161,900

Lobbied for

Adapt Pharma
American College Health Association
American Osteopathic Association
Bay Area Council
Braeburn Pharmaceuticals, Inc.
Coalition to Advance Medical Resident Training in Community Hospitals
Friends of the Global Fight
General Genetics Corporation
International Contrast Ultrasound Society
Kognito Solutions, LLC
L.A. Care Health Plan
Local Health Plans of California, A state wide trade association that represents publicly- financed, not-for-profit health
Maximus, Inc., Healthcare and business services company.
Mobilex USA
Physicians and Surgeons Association of Puerto Rico
Voices for National Service

Laura Holland Kemper
Deputy Assistant Secretary for Legislation (Public Health and Science) | $179,700

Lobbied for

American Academy of Adoption Attorneys
American Academy of Family Physicians
Association of Air Medical Services
C2C Solutions, Inc.
 Caravan Health (formerly known as The National Rural ACO)
Federal Hearings & Appeals Services, Inc.
 Horty, Springer & Mattern
ICOT Hearing Systems LLC
National Academy of Elder Law Attorneys, Inc.
National Association for the Support of Long Term Care, Trade assoc. representing ancillary of services and products to post-acute care settings
National Association of Community Health Centers
 Society of Hospital Medicine
U.S. Renal Care
Vital Decisions, LLC

Sery Kim
Senior Advisor | $149,337

Lobbied for

Budco Health Service Solutions
Dutko Grayling (on behalf of HSA Bank)

Courtney Austin Lawrence
Deputy Assistant Secretary for Legislation (Human Services) | $155,000

Lobbied for


Lance Leggitt
Senior Advisor to the Secretary | Chief of Staff | SES

from Baker Donelson Bearman Caldwell & Berkowitz to Chief of Staff for the Secretary of DHHS, see this post.

Keagan Resler Lenihan
enior Advisor to the Secretary | Senior Counselor to the Secretary | $179,700 |

a director of government relations at McKesson Specialty Health, a firm that supports independent health providers. Disclosure records show Lenihan directly lobbied HHS, see this post.

Christopher Edward Meekins
Senior Advisor, Office of the Assistant Secretary for Preparedness and Response | $161,900

Former Compensation Sources
FBR Capital Markets: Offered investment advice based on analysis of policy actions occurring in Washington, D.C.

 Lobbied for

American Society of Anesthesiologists

Sara Nur Morse
Deputy Assistant Secretary for Legislation (Congressional Liaison) | $155,000

Lobbied for

American College of Surgeons
American College of Surgeons Professional Association

Maya Michelle Noronha
Special Advisor, Office of Civil Rights | $131,767

Maya M. Noronha is an associate at Baker & Hostetler LLP in Washington, D.C. As a member of the Political Law Team, she focuses on redistricting litigation, voting rights cases, and campaign finance law. She has advised Members of Congress, federal candidates, state officials, state legislatures, campaigns, and political committees on election law. Ms. Noronha also works on Baker & Hostetler’s Public Policy Team, where she analyzes Congressional legislation and executive branch priorities to advise clients on political affairs.

Ashley Morgan Palmer
Deputy Assistant Secretary for Legislation (Health Care Reform) | $124,406

Lobbied for

Health Industry Distributors Association

Rebecca Kathleen Wood
Chief Legal Counsel FDA | $179,700

Former Positions Outside Government

Sidley Austin LLP Partner

Former Compensation Sources

AT&T Corp. Legal services
AbbVie, Inc. Legal services
American Chemistry Council Legal services
Arthrex, Inc. Legal services
Association Of American Railroads Legal services
Baker & McKenzie LLP Legal services
Bayer Pharma Legal services
Bayer USA Legal services
CSX Transportation, Inc. Legal services
 Duke Energy Corporation Legal services
Electric Insurance Company Legal services
Helmerich & Payne, Incorporated Legal services
 Medical Information Working Group Legal services
 NII Holdings Legal services N
ew Enterprise Asociates Legal services
Norfolk Southern Corp. Legal services
PhRMA Legal services
Sidly Austin LLP Legal services
St. Jude Medical, Inc. Legal services
The Timberland Company Legal services
Union Pacific Railroad Company Legal services


On and on it goes.  The revolving door has been a chronic problem for the US federal government, but the level of revolving door activity in the current regime seems way beyond anything we have seen before.  It seems we chronical multiple instances of people going from important health care corporate positions to government positions that regulate or make policy affecting those same corporations for every instance of someone coming from the previous administrations to industry.

So, as I have said before, e.g.,  in August, 2017,

The revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,
The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door from industry to the Trump administration once again suggests how the revolving door may enable certain of those with private vested interests to have excess influence, way beyond that of ordinary citizens, on how the government works, and that the country is still increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

So, as we have said before [before, before...] The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.

Saturday, March 10, 2018

Quattro! More from the DOG Patch.

Some more offerings in our fourth effort in these pages to get rid of this damned dander. It's still up! Here in the DOG Patch, D is for Dander, and the dander, in spite of smatterings of good new lately, has still got itself up.

Vive le Québec! Nodbody's taking sides in Canadian separatism, if it's still brewing north of the border. But a certain sense of fairness surely prevails, and we have to give them a rousing "jolly good" (whoops) among Canadian physicians. At least in the one province.  As reported by the WaPo, a large group of doctors there have produced a petition (interesting to read here) asking that their proposed recent salary increases be rolled back. They're concerned about the sorry state of care and salary support throughout their province and nation. Pretty astonishing. It remains for those of us suffering from DTs (dander-toting) to investigate how it's being received in places like Ontario, or even moreso, Alberta and Saskatchewan. It's also intriguing that the signatories include almost half subspecialists--not just a bunch of lefty primary-care types. Ah, but there are 700 or so signatories here. And Quebec has over 17,000 physicians. 'Nuff said. Let's take back that explanation point above. Make it a question mark, and nonetheless hats-off to those young and resident physicians who signed the petition.

Should Textbook Authors Declare Conflict of Interest? Have to admit, this hadn't exactly been uppermost in our minds--I've no recollection that we at HCRenewal ever really discussed it at meetings--but now a scholarly journal has reported out some fascinating findings on COI among the authors of Harrison's venerable textbook of internal medicine, and several others. (Hell, some of us even knew Dr. Harrison: what would he say, and does it even matter?) In any case, this was reported recently in one of the STAT newsletters. They found an important piece in the journal AJOB Empirical Bioethics about potential COI problems with over a quarter of authors on patents, and almost a third on up to 800,000 dollars per author in pharmaceutical company payments. Seems that journal editors, especially in the top tier, do better than this in requiring declarations from submitting authors. After all, quite a few years ago the editors all got together and created a COI policy that many of us know first-hand when we try to publish. But tetbook editors seem to have, still, a sort of noblesse oblige about their solicited authors. When Harrison's successors anoint a certain individual as her resident expert on a given disorder, it's almost as though that expert is automatically considered above reproach. Or, is it the case, for example in the instance of McGraw-Hill and Harrison's, that the publishers haven't gotten to the same point of transparency as the journal editors did years ago? Either way, it needs to change.

Two Trump HHS Secretaries: the Doc and the Pharma Exec. Who's Choosing Wiselier?  In that order. Dr. Price first, and now Mr. Azar. What does it mean when, pitting them head-to-head for decision-making and general comportment, the latter looks a damn sight better than the former? Says something about the ethics of a lot of physicians in our country, and especially so about those those who choose to run for elective office. On the one side we have Dr. Price, the orthopedist whose wife (herself a physician and state representative) inquired a few months ago whether HIV patients could be quarantined. And who himself did everything he could to weaken Obamacare, according to Politico and others. Comes now Azar, and remarkably, he's made some very adequate middle-of-the-road decisions. First that comes to mind: backing away from the radioactive attempts in Idaho (see an earlier DOG Patch Report on this) to gut the Affordable Care Act by skewering its structuring of insurance. It's all technical and full of legalese, but the eight-page letter Azar had Seema Verma write to Governor "Butch" Otter is a master stroke. And long. And canny. (Shows why Azar is where he is--wonder whether any ultra-right plants from the White House are in HHS as they are in the VA, undermining their own secretary. Time will tell.) In essence, despite its Vermoid verbosity, we can boil it down to this: Verma says, and by proxy Azar says to old Butch, and in part we quote: "As you know ... ACA is failing to deliver quality health care options to the American people and has damaged health insurance markets across the nation." This must have felt good to read for those in Idaho afflicted with Trumpist ideology. But Butch, (s)he goes on to say, the law is the law. We're going to enforce it.

Tuesday, March 06, 2018

How Corporate Health Care Leaders Maintain Their Impunity: The Case of Purdue Pharma's Funding of the Washington Legal Foundation to Attempt to Weaken the Responsible Corporate Officer Doctrine

The ongoing epidemic of narcotic (opioid) abuse, and the resulting rise in the deaths due to overdoses, has focused attention on pharmaceutical companies' aggressive promotion of these drugs which minimized their substantial risk. A recent article in the Intercept showed how the leadership of one such company tried to insulate itself from responsibility for such actions even while such promotions were continuing.

Background: Impunity of Top Leaders of Big Health Care Organizations

For years, we have railed against the impunity of top leaders of health care organizations.  We have noted that despite numerous legal settlements made by health care organizations of alllegations like fraud, bribery, and kickbacks, almost never do top leaders who presided over these actions face any negative consequences.  Lack of deterrence caused by such impunity appears to be a major cause of  the epidemic of continuing unethical behavior, crime and corruption on the part of large health care organizations. How executives got to the point of having such impunity has never been clear.

Timidity and lenience by regulatory agencies and law enforcement seem to be factors. For example, in 2014, we noted  that Attorney  General Eric Holder had previously been reluctant to go after big organizations because of the economic consequences of their failure:

The attorney general angered many last year when he reiterated those concerns at a congressional hearing, admitting 'that the size of some of these institutions becomes so large that it does become difficult for us to prosecute' because of the potential nasty economic effects of a major company failure.
In general we have seen much tougher enforcement directed against relatively small health care players than against bigger ones.  For example, we noted in 2014 that settlements by  Merck, Eli Lilly, Takeda, and Teva, all large pharmaceutical companies, allowed the companies to pay fines to settle allegations that they pushed dangerous products, while none of the executives who authorized, enabled, or directed these actions faced negative consequences.  In contrast, at that time, the CEO of a relatively tiny Sheffield Pharmaceuticals was convicted of a felonious wastewater discharge (see this post).

However, this rationale does not address the failure to pursue enforcement actions against organizational leaders who who enabled, authorized, directed or implemented misbehavior.  It is not that there are no good legal tools available to do so.  We wrote in 2012,

As we noted here, a Supreme Court case from 1943 empowered the government to seek penalties against responsible corporate officers (the "responsible corporate officer doctrine") who were in a position to stop a fraud that resulted in a guilty plea or conviction, particularly for the selling of misbranded or adulterated drugs into interstate commerce under the US Food and Drug Act.    Despite a threat made in 2010 by the chief counsel of the Inspector General's office of the US Department of Health and Human Services to use such legal authority to "get high level executives out of companies," nothing of the sort has happened.

Later, in 2015, under the previous administration, there was a tiny sign of progress against impunity.  Then, Attorney General Holder authorized the creation of a Corporate Strike Force to take strong actions in response to health care corporate fraud.  However, last year the Trump administration gutted even that small effort  (look here).  The use of the Responsible Corporate Officer doctrine remains at best extremely rare.  Why?  

How Leaders of Purdue Pharma Tried to Undercut the Responsible Corporate Officer Doctrine

A recent article in the Intercept provided one explanation.  It provided a telling example of top health care corporate leaders who took active, but stealthy measures to preserve their own impunity by attempting to undermine the Responsible Corporate Officer Doctrine,

Executives at Purdue [Pharma]were once charged using the corporate office doctrine in 2007, in a case that found that the company had 'misbranded' its drugs as less likely to be abused than other narcotics. The company agreed to pay a settlement of $634.5 million.

As reported then by the New York Times, three corporate executives pleaded guilty of misdemeanor charges of misbranding Oxycontin.  It appeared that corporate leadership wanted to try to prevent further efforts to hold them accountable.

Purdue didn’t attach its name to the recent effort to weaken the responsible corporate officer doctrine. Instead, the company provided funding to the Washington Legal Foundation, a legal nonprofit that litigates in support of business interests, to petition the Supreme Court last year to accept a case that would give it the opportunity to weaken the RCO doctrine. The foundation closely protects the names of its donors and the drugmakers’ ties to the group were unclear until recently.

The legal strategy was confirmed by former staffers at the Washington Legal Foundation who spoke to The Intercept on the condition of anonymity. The foundation did not respond to a request for comment.

The effort revolved around a case known as DeCoster v. United States, one of the most significant challenges to the responsible corporate officer doctrine in four decades.

The lawsuit challenged the conviction of executives at Quality Egg LCC, an Iowa-based company, who were found guilty for shipping salmonella-tainted eggs that sickened 56,000 people. The federal prosecution shocked the business community because it represented a rare case of corporate executives held criminally responsible for actions committed by subordinates. The Department of Justice prosecutors relied on the RCO doctrine, which has historically been used for food- and drug-related offenses in cases in which companies have caused widespread health problems, to sentence executives at Quality Egg to three months in jail.

Business interest groups watched the case with interest, and the foundation filed a brief to overturn the decision after the case was upheld by an appellate court.

In its petition to the Supreme Court to take up the Quality Egg case, the Washington Legal Foundation called the responsible corporate officer doctrine 'a peculiar anomaly in criminal law' that allows imprisonment of corporate executives 'based on little more than his supervisory role in the company.' The foundation urged the Supreme Court to take up the case as an “opportunity to revisit the very notion of Park doctrine liability.”

"Little more than his supervisory role?"  Corporate executives command huge compensation specifically justified by their "supervisory" role.

The Intercept provided more detail about the role of Purdue Pharma leadership in this challenge,

According to a former Washington Legal Foundation official, an attorney with Purdue Pharma reached out to thank them for the work being done on the RCO doctrine. Another former foundation employee noted that the Washington Legal Foundation has long worked to weaken the doctrine, and that Purdue Pharma was one of several donors that had supported the effort.

While the foundation says all of its funding comes in the form of unrestricted grants, former employees told The Intercept that donors had effectively influenced briefs and others filings made by the Washington Legal Foundation. Connie Larcher, president of the foundation, has long coordinated the nonprofit’s legal strategy in close coordination with donors, the sources said. Some of the Purdue Pharma money was intended to promote the legal strategy around the RCO doctrine.

Asked for comment, Purdue Pharma did not speak directly to the relationship with the Washington Legal Foundation.

The Intercept also provided more details about the ongoing relationship between Purdue Pharma leadership and the Washington Legal Foundation,

Ties between Washington Legal Foundation and Purdue Pharma were reported by The Intercept in 2015 in a story detailing how the foundation had helped Purdue Pharma attempt to block the Centers for Disease Control and Prevention from issuing voluntary guidelines to discourage the overprescription of opioid narcotics.

Last week, Sen. Claire McCaskill, D-Mo., confirmed the prior relationship and released a report revealing that Purdue Pharma had donated $500,000 to the Washington Legal Foundation. The report noted that the foundation had taken the unusual step of lashing out at the CDC opioid guidelines.

Finally, the Intercept suggested that the Washington Legal Foundation

has long faced accusations in the past that the nonprofit operates as a legal front for corporations to undercut public health and safety standards.

The group figured prominently in the tobacco wars that raged throughout the ’90s. The group routinely filed briefs supporting the tobacco industry’s lawsuits challenging government regulations on tobacco products. A 1994 memo by Philip Morris executive Roy Marden noted that he was '[w]orking with the Washington Legal Foundation (WLF) in the development of a strategy to counteract and attack the efforts of the antis,' a reference to public health advocates. The group also sponsored advertisements criticizing 'anti-smoking zealots in government' without disclosing that the group was being funded by several major tobacco firms.

So this suggests that leaders of large health care corporations have actively attempted to preserve their impunity.  Furthermore, their methods have been aimed not just at increasing their personal impunity, but the impunity of all corporate leaders, which has implications beyond health care. In that they resemble efforts of leaders of other big corporations, like tobacco companies, to combat specific regulations by campaigning against regulation in general.  Finally, they have deliberately obscured their efforts to dodge responsbility by using third parties paid with concealed funds.


The Intercept noted that the strategy employed by Purdue Pharma and the Washington Legal Foundation to change the results of DeCoster vs United States failed.  However, this case raises the possibility that health care and other corporate leaders are using other deceptive strategies to preserve their own impunity in other contexts.  Furthermore, these strategies could have the effect of increasing impunity widely for other corporate and top organizational leaders, thus reducing deterrence of corruption.   If we ever want to have really responsible corporate leaders, we will have to uncover the schemes current leaders use to avoid responsibility and maintain impunity.

Meanwhile, there is justified public anger about the narcotic (opioid) epidemic, and in the works are multiple legal cases against the drug companies that sold and aggressively marketed these drugs.  Will any hold responsible the drug company executives who presided over these companies?  As the man said, we will see....

To conclude with the usual exhortation,

True health care reform requires well-informed leaders who uphold health care professionals' values, put patient's and the public's health ahead of all other considerations, avoid self-interest and conflicts of interest, are honest and ethical, and surely are not corrupt.  They need to work in the context of a government that is of, by and for the people, not of, by and for a demagogic leader.

Tuesday, February 27, 2018

Dander Gathering Again: Terzo

It's hard these days to rid oneself of the rising dander. Dander Omnium Gatherum Patch Numero Terzo. To put it more simply, here are more tales from the DOG Patch. And a smattering of actual good (how's this possible?) news.

Double Back on Politics at the VA. There's a guy now installed under Secretary David Shulkin by the name of Darin Selnick. He carries the title of Senior Advisor, and also works (with the same title) in the White House. Selnick was a California consultant when he fell in with the Koch Brothers and their deep pockets. Together they fostered an organization called Concerned Veterans for America. Check out its Website. Slanted to a remarkable degree toward finding wrongdoing within the VA. Cherry-picking the worst behaviors of VA staff (allegedly including Shulkin) as examples of its systemic inadequacy. And then privatizing it. Right in line with Ronald Reagan's "government is the problem," but in this case creating a huge power struggle within the agency itself. Who'll win is an interesting question. Right now it appears both the President and his Chief of Staff are betting on the popular Shulkin. We wish him well.

Again with the "Idaho Rebellion." Lame duck governor Butch Otter (yep, tha's aptly his nickname) is sticking to his guns with what WaPo calls an "alternative insurance universe." Can the Affordable Care Act be flouted by an individual state within legal bounds. Looks like this will get tested in weeks and months to come. Reverting to "shoddy [and] unfair practices" on the state level might give Butch a dopamine rush on his way out the door. (And perhaps into some cushy lobbying, consulting or law firm?) Well, secretary Alex Azar may have something to say about this, and it'll sure be an interesting litmus test of how he balances the interests of patients against his bosses' ideological leanings. Will Butch go a'ridin' out the door on a horse named Sassy? Oh, no, wait, sorry, that was in Alabama.

Some Good News: Zeke Emanuel on Hospitals' Future. For a change, something to be hopeful about. "Hospitals are disappearing," avers oncologist-ethicist Dr. Ezekiel Emanuel in his latest NY Times op-ed. Hospital CEOs, of whom we've heard here often and eloquently mainly from Chief Blogger Dr. Poses, have garnered (in every sense) an outsized share of the medical care dollar through their late stage capitalism muscle. But today they're sliding down a new razor blade of anachronism. Emanuel, in an unusually candid assessment, notes that after generations of hospital-based progress, "in a throwback to the 19th century, hospitals now seem less therapeutic and more life-threatening." And meanwhile the admission levels of patients into inpatient settings actually maxed out over a quarter of a century ago, in 1981. That dollars didn't max out at the same time is actually a source of pressure, we could add, in the same direction. Not just complex procedures, but also admissions criteria, now more and more they all often point to use of out-patient facilities. Having experienced both, we can only ratify this conclusion. For every risk of "not enough coverage" in clinics and surgical centers, there are many more risks of exposing people unnecessarily to tertiary care facilities. Worth a read.

"96 YOWM With Pneumonia." Another Times op-ed does a deep dive into the life and times of Harvard's Dr. Bernie Lown. Brigham & Women's resident Rich Joseph describes his burgeoning relationship with the remarkable cardiology pioneer who went on to found IPPNW. I feel sure this blog's readers all know this acronym. Physicians against nuclear war. Now that we have a new circus in Washington, the clock-hands have moved closer to midnight. Dr. Lown's work is ever more relevant. Interesting thing about Dr. Joseph's piece (aside from the fact that he's an MBA) is that it was kicked off when he found himself caring for the nonagenarian--none other than the "96 YOWM with pneumonia" himself--on the wards of his own fabled institution. And despite the perceived tertiary care career emphasis of both author and subject, the piece concludes, much as Dr. Emanuel did above, with a plea for more community-based development. Those interested in Lown's career would do well to download and read the PDF of an interview with him conducted some six or seven years ago by Dr. Peter Tishler of the same institution. It's a lengthy and even-handed examination of mid-twentieth century medical innovation, institutional development, and career contingency. But it's not a triumphalist whitewash. “During my professional life," Lown states, "I have seen medicine rise to an apogee of respect, sometimes amounting to adulation and then watched in distress as it began a rapid downward slide." Near the end, Lown provides a telling anecdote of a patient receiving model care: somewhere well removed from the Boston mandarinate in which he in part participated. Only through careful listening to the patient and his family did the physician reach a correct diagnosis and therapeutic plan. "That will rile up a lot of Brigham folks, some Mass General folks, and they'll picket this joint," said Lown. "I hope they do."

Wednesday, February 21, 2018

Tales from the DOG Patch: Numero Deux

A tip of the hat to Dr. Roy Poses, who did a nice job summarizing the first blast from the DOG Patch. (For those who missed it, it's a distillate of all the dander we've mustered in recent health policy debates as they veer more and more toward the utterly surreal.) Dander omnium gatherum, hurled willy-nilly at the gentle readers of HCRenewal. Ready or not, another dispatch from the DOG Patch.

Dr. Shulkin at the VA. We commented on the recent posting, also from Dr. Poses, dealing with VA Secretary David Shulkin's "apparently scandalous travel" to Europe way back in July. We've known Shulkin for a long time. He cares about good government but you'd never know that from his own OIG's hatchet job charging "serious derelictions." A lot of this is in the above linked post, as well as related articles in most newspapers. Today however we learn from John Kelly that the secretary's "job is safe." Unless, that is, "other stuff comes out." One of the better Trump appointees, Shulkin now gets to walk the tightrope while political hacks lower down in the VA try to undermine him. His crime: Seemingly dragging his heels on doing himself out of a job. Lots of folks (viz. White House insider and Wisconsin brewmaster Jake Leinenkugel) looking to privatize VA health care. Shulkin understands the great value--despite the many depredations and flaws still enormously popular with its patients--of the institution that began with the Philadelphia Naval Home around the War of 1812. These guys circling the wagons inside the White House represent the swampiest of Washington swamps. Let Shulkin be Shulkin.

Mr. Azar goes to Washington. And tips his hand. In our first DOGpatch dispatch we wondered aloud which way the new HHS Secretary would head after being sworn in. First indications are now in. He wants, in the interest of "affordable" premiums, to issue junk insurance. It sure fits into the grand scheme of things, White House-style. If you can't do in Obamacare in one swell foop, grind it down underfoot one feature at a time. So ideological. So unfair. Individual mandate already on its way out. Now comes waivers allowing cheap policies, policies that're not ACA-compliant, to go to cherry-pickers without regard to pre-existing conditions. Extending short term cruddy policies from three months to a year might benefit a few healthy young workers--maybe the ones states like Wisconsin and Indiana (wrongly) believe, via their ideological GOP governors, they'll lure back to their states. But the cost could easily become lots of the sicker folks whose premiums will become unaffordable. We see the hand of Mike Pence's Indiana favorite, Seema Verma, in all of this. Hey, if they're sick throw 'em under the bus. Your corporate donors want their cheap labor pool back. And, then, what's Azar's long game? To ingratiate himself solidly with executive branch insiders in order to do something that Trump says he wants--most temptingly, new ways to jawbone drug prices down--for his vaunted base? That's something Azar could probably pull off. Will he even try?

Putting the Attack on Expertise in Perspective. A book from about a year ago, Tom Nichols's The Death of Expertise, is summarized nicely in the latest number of Harvard's alumni magazine. I mean, of course that's where you'd find it. Most of our "thought leaders," elite consultants, and favored members of the punditocracy come from elite west- and east-coast institutions. Of course the loudest plaints will come from their ranks. But Nichols is a little different. He has government experience and teaches in a variety of institutions while trying to reach the public. The book is a little repetitive but its gist can be found here, apparently unencumbered by paywall. We'll have to wade into this short book and see who and what and where Nichols points the finger. But we know all the isms already. Narcissism. Post-modernism. Managerialism. Consumerism. All rampant in clinical medicine, academic medicine and health policy. Nichols is rightly worried about the casualness and fecklessness with which people now in power approach everything from nuclear war risk to cyber-threats to the role of professionals in managing health. He's pessimistic.

Monday, February 19, 2018

The Case of the Brew Master's Plot - Was the Veterans Affairs Secretary's Travel Spending Scandalous, or Was He Framed in a Plot to Oust a Political Moderate?

"Come, Watson, come! The brew is afoot."

The Veterans Affairs Secretary's Apparently Scandalous Travel

On February 14, 2018, the Washington Post reported that the Department of Veterans Affairs (VA) Inspector General (IG) severely faulted travel arrangments made for a trip to Europe by the Department's Secretary, Dr David Shulkin.

Veterans Affairs Secretary David J. Shulkin’s chief of staff doctored an email and made false statements to create a pretext for taxpayers to cover expenses for the secretary’s wife on a 10-day trip to Europe last summer, the agency’s inspector general [IG] has found.

Vivieca Wright Simpson, VA’s third-most-senior official, altered language in an email from an aide coordinating the trip to make it appear that Shulkin was receiving an award from the Danish government, then used the award to justify paying for his wife’s travel, Inspector General Michael J. Missal said in a report released Wednesday. VA paid more than $4,300 for her airfare.

At first impression this seemed like just another travel scandal for the administration, which seemed to have made a practice of appointing top agency leaders who felt entitled to high-end travel options.  The Post article noted,

Shulkin is one of five current and former Trump administration Cabinet members under investigation by agency inspectors general over travel expenses, an issue that forced Tom Price to resign as health and human services secretary in the fall. Shulkin and other Cabinet officials have said their travel, often on private and military planes or to speak at political events, was approved by agency ethics officials.

One Republican Congressman immediately called for Dr Shulkin to resign because of "corruption," according to the Atlanta Journal Constitution.

As of February 16, 2018, VA Chief of Staff Viveca Wright Simpson did resign, according to CNN.

A Murky Brew

"the foam thickens"

On closer reading, however the details of the current case were at least somewhat murky.

The IG charged that the VA Chief of Staff, Viveca Wright Simpson, had altered an email to make it appear that Dr Shulkin would receive some sort of award at the US Embassy in Copenhagen, which would have apparently justified paying for Shulkin's wife's travel.  Yet, "In an interview with investigators, Wright Simpson said she did not recall whether she altered the email, Missal wrote."

The Secretary and his wife received tickets for events at the Wimbledon tennis tournament.  Dr Shulkin stated that the person who gave them the tickets was a friend of his wife, but the IG noted that when called, the person who gave them the tickets could not recall his wife's first name.  However, later that person provided a statement saying

The investigators unexpectedly called me on my mobile phone whilst I was driving on a very busy highway,


I felt like the investigators were twisting my words and trying to put words into my mouth.

The IG concluded that the awarding of tickets was improper, Ms. Gosling gave a gift of the Wimbledon tickets, valued at thousands of dollars on the secondary commercial market, because of Secretary Shulkin’s official position.” However, "Shulkin’s attorneys said the secretary was not prohibited from accepting the tickets, because Gosling neither does nor seeks to do business with VA."

The IG also contended that a VA staffer was excessively helpful in making travel arrangements for Dr Shulkin's wife, and that some travel expenses were poorly documented.


In his formal response to Missal, Shulkin wrote that VA staffers suggested his wife’s travel be paid for by the agency. He called the inspector general’s portrayal of the trip 'entirely inaccurate' and said it 'reeks of an agenda.'

'It is outrageous that you would portray my wife and me as attempting to take advantage of the government,' he wrote.

Of course, a high government official in trouble for this sort of thing might make that sort of response.

But wait, there is more, including substantial evidence about that "agenda."

A Political Plot?

Political Appointees Scheme to Oust Dr Shulkin

One day later, a New York Times story suggested it was all a lot more complicated.  The background is that

Dr. Shulkin was an unexpected but popular choice for secretary. After the 2016 election, Mr. Trump considered several critics of the department as possible nominees to head the agency. But to the relief of most veterans’ organizations, he chose Dr. Shulkin, a moderate who headed the agency’s health care system under President Barack Obama.

Dr Shulkin also is a fan of having the VA continue to directly provide care to most of its veteran clients/ patients. Note that,

The department currently operates its own health system, with more than 1,200 hospitals and clinics across the country where about nine million veterans receive treatment at little or no cost to them.


Some conservatives, including some advisers to the White House, [who] favor gradually dismantling that system and allowing veterans to choose to receive taxpayer-subsidized care from private doctors instead.

Veterans’ groups have overwhelmingly opposed that idea. But Mr. Trump promised during his election campaign that 'vets will have the right to go to a V.A. facility or the right to see a private doctor or clinic of their choice — whatever is fastest or best for the vet.'
Note that those who favor privatizing or out-sourcing VA health care functions have apparently provided no evidence from clinical or health services research that doing so would provide benefits to veterans that outweigh their harms.  Nonetheless, it appears that some VA officials who were political appointees of the Trump administration did not think Dr Shulkin was doing enough to privatize VA sevices.

In December, according to congressional staff members, political appointees in the department quietly bypassed the secretary to advance legislation that would open the way for more privately provided health care for veterans. The bill was introduced by Senator Jerry Moran, Republican of Kansas, who has received substantial campaign donations from the Koch brothers.

Meanwhile, the NYT reported that a campaign began to remove Dr Shulkin.

An email sent in December by Jake Leinenkugel, the White House senior adviser on veterans affairs, expressed frustration with Dr. Shulkin and listed ways to topple the leadership of his department once key legislation was passed.

The email was addressed to Camilo Sandoval, a former data manager for the Trump campaign who was given a political post at the department. In it, Mr. Leinenkugel, a former brewery executive, wrote that although he initially had a positive impression of the secretary, they had fallen out over staffing and policy issues.

The tactics proposed for this sort of an in-house coup were:

Mr. Leinenkugel, who has an office in the department, proposed 'solutions' in the email, including using a continuing investigation of the secretary’s travel to remove Dr. Shulkin’s chief of staff, Vivieca Wright Simpson; replacing the deputy secretary, Thomas G. Bowman, with Mr. Leinenkugel; and replacing Dr. Shulkin with a 'strong political candidate.'

Re that "strong political candidate":

Mr. Leinenkugel’s suggested replacement for Dr. Shulkin would be likely to spark controversy: Michael J. Kussman, a former under secretary who has been associated with Concerned Veterans of America, a group funded largely by the billionaire conservative activists Charles G. Koch and David H. Koch that advocates shifting spending on veterans’ health care to the private sector.

Note that Mr Leinenkugel apparently has no training, experience, or expertise in medicine, health care, or public health.  Rather he is a former executive of a family owned brewery that had been sold off to MillerCoors (look here).  Mr Leinenkugel did serve as a Marine for six years, but in the Phillipines, and Korea, apparently not seeing combat (look hereand here).  As the executive and presumably part owner of a substantial brewery, it seems doubtful that he ever had to personally seek care at a VA facility.

Furthermore, Mr Leinenkugel was working with Camilo Sandoval, a former data operations manager for the Trump campaign, with no known health care or public health background, or military experience (look here).

Dr Shulkin Fights Back and the Influence of More Political Operatives Revealed

Dr Shulkin suggested that the alleged plotter might not have been acting to promote the best interests of veterans, saying
he was investigating a number of political appointees in his department for misconduct and possible removal. On Thursday, he spoke directly to the White House chief of staff, John F. Kelly, about concerns that political appointees were trying to undermine his agency, according to department officials.

'If there are people here who don’t want the V.A. to succeed, I want them out,' Dr. Shulkin said in the interview.

Whether Dr Shulkin will prevail is a big question.Turmoil at the department seems to be growing.  Last week the Washington Post quoted unnamed White House officials who said Mr. Bowman, the deputy secretary, would soon be fired as a “warning shot” to “knock Shulkin down a peg or two” for not pushing harder for privatization.

Also, per the NY Times,

In another sign of division, John Ullyot, a former top Trump campaign official who now runs the press office, told staff members in an email on Wednesday that reporters’ requests for comment should not be forwarded to the secretary or deputy secretary; instead, he would be referring them all to the White House.

The move forced Dr. Shulkin to do much of his communication with the media over the travel investigation on his personal cellphone.

Then, per CNN on February 16, Viveca Wright Simpson, VA Chief of Staff, had resigned, and in response Dr Shulkin stated,

'This was a personal decision,' Shulkin said, adding that Wright Simpson called him on Friday morning to inform him. 'She just didn't feel that it was the right thing for her and her family to continue in that type of environment.'

Furthermore, her replacement, Peter O'Rourke, appears to be something of a political appointee,

the VA announced that Peter O'Rourke would replace Wright Simpson as chief of staff, effective immediately. O'Rourke currently serves as executive director for VA's Office of Accountability and Whistleblower Protection. O'Rourke's job will be 'ensuring that the department works closely with the White House going forward,' according to a statement from VA Press Secretary Curt Cashour.

O'Rourke is a Navy and Air Force veteran and previously worked for Trump's presidential campaign, according to his LinkedIn profile.

Furthermore,also on Feb 16, Pro Publica in conjunction with Politico published a long article on the background to the political dispute about privatizing or out-sourcing VA clinical functions.  It turns out that this is been going on for a while, and that the privatization/ out-sourcing agenda is mainly being pushed by the Concerned Veterans for America (CVA), a group backed by the Koch brothers.

The Pro Publica article provided more information about the roster of de facto political commissars attached by White House operatives to the VA.  One was Darin Selnick, a retired Air Force Captain, who had a career as a business consultant, and led "faith-based" initiatives at the VA under President George Bush, according to his LinkedIn profile. I can find no evidence he has any training,  experience or expertise in health care or health policy.

Trump picked Darin Selnick for the 'landing team'that would supervise the transition at the VA. Selnick had directed CVA’s policy task force, which in 2015 recommended splitting the VA’s payer and provider functions and spinning off the latter into a government nonprofit corporation.


He joined the VA as a 'senior advisor to the secretary.' Though he reported to Shulkin, he quickly began developing his own policy proposals and conducted his own dealings with lawmakers, according to people with knowledge of the situation. In mid-2017 Shulkin pushed him out — sort of.

Selnick left the VA offices and took up roost in the White House’s Domestic Policy Council. There he started hosting VA-related policy meetings without informing Shulkin, according to people briefed on the meetings.

Another was Dr Shulkin's own press secretary, Curt Cashour.  According to his LinkedIn profile, he previously worked for Republican Scott Walker's campaign for governor of Wisconsin, is not a veteran, and has no health care or health policy training, experience or expertise. Cashour also was a former staffer of Representative Jeff Miller:

Jeff Miller, then the chairman of the House veterans committee. Miller, who retired from Congress in January 2017, was a close ally of CVA and a scathing critic of Obama’s VA.

Miller became one of the first congressmen to endorse Trump, in April 2016. He did so a few weeks after attending a meeting of the campaign’s national security advisers. (That meeting, and the photo Trump tweeted of it, would become famous because of the presence of George Papadopoulos, who is cooperating with investigators after pleading guilty to lying about Russian contacts. Miller is wearing the light gray jacket in the front right. Now a lobbyist with the law firm McDermott Will & Emery, he didn’t reply to requests for comment.)

At one time, Dr Shulkin directed Cashour to

update its motto, to be inclusive of servicewomen. (Adapted from Abraham Lincoln’s second inaugural address, the original reads, 'To care for him who shall have borne the battle and for his widow, and his orphan.' The new version would read: 'To care for those who shall have borne the battle and their families and survivors.')

Cashour told The Washington Post the motto wouldn’t change. A few days later, the secretary’s strategic plan went out using the updated, gender-neutral motto. Cashour then denied the change a second time, telling the Post that was 'not VA’s position.' A new document with the Lincoln quote restored subsequently appeared on the VA’s website. Shulkin was stunned at being disobeyed by his own spokesman, two people briefed on the incident said. (Cashour denied defying the VA secretary. “The premise of your inquiry is false,” he told ProPublica. Cashour said Shulkin never approved the letter regarding the updated motto and authorized the restoration of the original one.)

So, to summarize, Dr Shulkin, a previous appointee of President Obama, who was appointed to head the Department of Veterans Affairs by President Trump, with the unanimous approval of the Senate, was under seige because he did not support proposals to privatize or out-source many of the VA's clinical functions.   The main functions of the VA involve providing health care to Veterans.   Out-sourcing/ privatization was mainly supported by a Koch backed organization, the CVA, apparently for ideological reasons, but not apparently based on evidence that it would provide benefits to veterans that would outweigh its harms.  Much of the seige work was accomplished by Trump administration political appointees, none of whom had training, experience or expertise in health care or health policy. 

Summary and Discussion

Dr David Shulkin, a holdover appointee of President Obama who was nominated to be Secretary of Veterans Affairs by President Trump, was alleged by the VA Inspector General to have committed various ethical violations involving a trip to Europe the Secretary took with his wife.  This appeared to be just the latest in a string of travel-related scandals by top officials of the Trump administration.

When this was first reported, I was inclined to see Dr Shulkin as an entitled, and conflicted  former health care executive who ran afoul of the government's strict ethical standards.  (Dr Shulkin's official VA biography lists his previous positions, including "chief executive roles at Morristown Medical Center, and the Atlantic Health System Accountable Care Organization. He also served as President and CEO of Beth Israel Medical Center in New York City." His 2016 federal financial disclosure, according to Open Secrets, listed assets of $9,342,201 to $24,966,000.  Also, he had served on advisory boards and boards of directors of numerous commercial health care firms, and held stock options from some of these positions.)

Note that the NY Times editorial page just supported that position, lumping his case with that of other Trump cabinet members with "dubious ethics."

But on review, his travel improprieties did not seem as serious as those of some other administration figures (for example, now ex-Secretary of Health and Human Services Dr  Tom Price, had flown multiple times on private aircraft costing the government hundreds of thousands of dollars, per Politico.)

Furthermore, subsequent reports raise doubts about whether Dr Shulkin committed any improprieties, and suggested rather that he was targeted for removal because he was insufficiently "political," presumably meaning insufficiently beholden to President Trump, and unenthsiastic about dismantling the VA health system and handing its work over to the commercialized health care private sector.  Furthermore, considerable opposition to Dr Shulkin came from within his own department, apparently organized by political appointees devoted to Trump, and an ideological agenda of privatization and out-sourcing, who seemed to be acting like old-style Stalinist political commissars.

Note that USA Today just reported that three big veterans' groups weighed in with their support for Dr Shulkin, suggesting that his travel misdeeds were minor, and his efforts to improve care for veterans major.

But what really happens remains something of a mystery.  Perhaps a modern day Sherlock Holmes would help?

In any case, the events do not reflect well on the Trump regime management of the Department of Veterans Affairs.  Either it placed an entitled, and possibly previously conflicted physician in charge, who was then cavalier about government ethics rules; or worse, it put in charge a perhaps politically clumsy physician who was nonetheless dedicated to the welfare of veterans, but then undermined him when he proved to be insufficiently politically loyal, and perhaps not interested enough in promoting private commercial health care interests ahead of veterans' care. 

Nothing in this story suggests that the Trump regime really cares that much about veterans, other than as means to political ends and to economic benefits to corporate cronies.  Note that privatizing VA clinical functions would provide a huge new patient population to private, including for-profit hospital systems, many of which may not be equipped to deal with the needs of veterans who need rehabilitation for complex and severe injuries, or suffering from the extreme psychological effects of the battlefield.  Privatizing would also presumably provide a physician pool suddenly free from tight VA restrictions on conflicts of interest, who would suddenly become vulnerable to drug, device, biotechnology and other companies bearing money.

Speaking of true health care reform in the time of Trump seems almost silly, but true health care reform requires putting patients' and the public's health ahead of private greed and lust for political power.

Thursday, February 15, 2018

Welcome to the DOG Patch: first in a series?

Lately my dander is up so often and so copiously, over what's happening in health care and the world at large, I'm exhausted. Covered with nasty dander. Cowering under the sheets. Others seem to share this dysphoria. But I found if not a cure, at least a palliative. There's so much dander I can scrape it off with a great big shovel and toss as much as I can your way. Here's my first Dander Omnium Gatherum, or DOG, from the Cetona DOG Patch. Remember, these stories are all DOGs.

  • Litmus Test for New HHS Secretary. The new sheriff at Health & Human Services, Alex Azar, has barely had a chance to wipe his feet in front of the now ironically-named Hubert Humphrey Building in DC. And already the attorney and former Eli Lilly big shot gets his big shot at letting us know whether he'll go up against his fellow plutocrats when it comes to the Affordable Care Act. WaPo has a good story on how, in Idaho, Azar's fellow rich white guy, multi-million dollar livestock owner and red state governor Butch Otter, is considering a truly insidious gem of a way to gut sick folks' access to health care in the Gem State. Allow insurors to sell ACA-noncompliant policies, which, if the sheriff doesn't come to town and say not on my watch, allows risk pools to be invidiously divided. Which of course drives up sick folks' premiums to untenable levels. What's it going to be, Alex?
  • Opioid Addiction Industry: the Gift that Keeps On Giving. Hard to be snarky when so many people are dying including my own patients. But I'll try anyway. Actually, this is a slightly more hopeful comment than my recent ones on the depredations inflicted by this industry, especially Purdue Pharma and its founders from the Sackler family. Can you guess the cost to society of this crisis? Oh, about a trillion dollars in the past decade and a half. I'd not seen it quantified heretofore, but Altarum has given it a go here. In any case, pressured by who knows who--for sure not HCRenewal, but maybe some inordinately publicity-shy latter generation Sackler family members--Purdue just announced they'd no longer promote OxyContin to providers. Oh, wait. Could it have anything to do with the fact that doctors are sick of them? Or, even more likely, that earlier this week Senator Claire McCaskill (D-MO) released a report on the back-door support this industry's been slipping to advocacy groups. A telling quote: "'The question was: Do we make these people suffer, or do we work with this company that has a terrible name?' said U.S. Pain founder Paul Gileno, explaining why his organization sought the money." Read McCaskill's report here.
  • The Soul of the Texas GOP. What's it got to do with health policy and HCRenewal? Antivax, folks, antivax. In Houston--not exactly the most rabidly extreme, left or right, among Texas cities--a PAC and Facebook (surprise surprise) offshoot called "Texans for Vaccine Choice" is mounting a challenge to Republican Sarah Davis, re-election candidate for the state legislature. (This is in the heart of Texas medicine: Baylor, M. D. Anderson, etc. Seems an awful lot of ultraconservatives go to Harvard Law then come back to Texas. This challenger edited an in-house law review featuring Ted Cruz and Neil Gorsuch.) Seems Davis committed the mortal sin of opposing a proposal to prevent physicians from vaccinating foster children. I guess this is normalized. In Texas we already knew there's a rift between business moderates and ideologues. And anti-vaccination is rampant nationwide, backed by celebrities. Rugged individualism, and resistance to empathic concern for one's neighbors, has brought us antivax, the gun death epidemic, and so so much more. It's all about choice, folks. Texas GOP seems to be divided on this matter, actually, so again, Watch This Space.
  • California Probes Aetna Medical Director. Funnily enough, I can easily see how and why this happens. But it don't make it right. The insurance commissioner in the Golden State is investigating Aetna after one of its medical directors (who's now moved on) admitted to CNN that he never looked at any of the patient files he was adjudicating for health care approvals. (Aetna, of course, denies.) How could this happen, you ask? Guy (under direction from non-physician bosses) sits there and judges patients' futures without a glance at their records? If you ever sat on hold for an hour waiting for one of this guy's lieutenants, typically nurses or even lower-rung than that, you wouldn't ask. Then you argue for an hour with the nurse. Sometimes (s)he sees the light and coaches you in how to game the system--which didn't really need to be gamed in the first place--but you end up outraged at the arbitrariness. Then this guy, in the present instance family physician Jay Ken Iinuma MD, pushes out the denial letter to your patient. You appeal. Eventually, if you had your act together in the first place, on behalf of your patient, you win. The inefficiency of it of course is just the point. I appeal. Many don't. Aetna makes out. And our system costs double anyone else's.
  • Tech Industry: the Impossible Dream. It's fun to tilt at windmills a la Don Quixote. Tech entrepreneurs--I know a lot of them--come up with a lot of great ideas. Most are DOGs. But a few are pretty neat. Here's one just maybe in the latter group. Year before last, in the Research Triangle of North Carolina, some IBMers came up with a patient-centered navigation tool whereby sick folks could look up symptoms and see their options. The company is already defunct. “'The short answer is nobody really used [it],' according to Ateev Mehrotra from Harvard. 'For a variety of reasons, they just forgot about it. This is what I would say in my defense: I still think it’s a good idea.'” But this one's a little bit complicated. Mehrotra, who spends a fair amount of time investigating such tools, had previously authored a BMJ article showing that a whole bunch of these tools, net net, are right about half the time at best. A Kaiser article on the matter noted that "[h]alf the sites had the right diagnosis among their top three results, and 58 percent listed it in their top 20 suggestions." Jury's out on this one. On top of which, the only tech applications, thanks to ACA and HITECH, that've really made it in the health care marketplace are EHRs (see InformaticsMD's many great pieces in this blog) and--actually a little better--patient portals. For now, they may just be crowding everything else out.
  • When are Ted Cruz and Diane Feinstein on the Same Team? Rarely. But WaPo now reports an instance of "real change to drug pricing being ignored by Congress." The so-called CREATES act is procompetitive in the generic space. It's supported by the ultraconservative FreedomWorks caucus, AHIP, and AHA. So why not pass it? It got left out of the recent deficit-swelling spendthrift legislation that broke the back of the threatened Can you spell Big Pharma? What's there to be said. The drug lobby and the gun lobby together practically run this country. Is it a democratic country? Do patients, who're also voters, count? Or do lobbyists' contributions to the characters writing the legislation? Oh, wait.... Why do I even pose that as a question?
  • Postmodernism Yet Again. Dr. Poses, your editor, has written eloquently and often in this blog about the baleful effect of pomo thinking on modern science and medicine, especially in the scientific and medical education spaces. This writer has stayed away from the topic, mostly because they believe the postmodern "turn" since the 1970s has been confined largely to the realms of architecture and the academy. (Lots of the academy.) But the topic is suddenly very much in the news again of late, mainly because of the truthiness--or lack thereof--on the part of so many political actors. A recent NY Times piece by Thomas Edsall, entitled "Is President Trump a Stealth Postmodernist or Just a Liar?", is especially juicy. Edsall has a truly admirable Rolodex of people to whom he can reach out and ask the question embodied in his title. If "truth is not found but made," than who among us can be righter than the next guy--say our president? Some on Edsall's Rolodex made the point that pomo just made it a lot harder to rely glibly on western "grand narratives." That much we can concede, for sure. But the truth (whoops) is: we're left in a state of ambiguity. A decade or so ago historian Charles Rosenberg, in a superb essay based on his book Our Present Complaint, said this of the "inconveniently subjective object, the patient [creating] the characteristic split screen that faces today’s clinician": we're left with "a feeling of paradox, the juxtaposition of a powerful faith in scientific medicine with a widespread discontent at the circumstances in which it is made available. It is a set of attitudes and expectations postmodern as well as quintessentially modern." But maybe the last word should go to New Republic columnist Jeet Heer, who quotes Fredric Jameson in characterizing pomo as the "transformation of the ‘real’ into so many pseudoevents." In other words, the fractionation of our political and cultural understandings of policy and society. As Roger Cohen recently wrote, the fact that politicians and lobbyists have so successfully divided us into warring tribes, where everything and everyone is self-serving and convinced of its own reality, there's the real danger. And many traditional institutions, outside of those still harboring Received Truth, have abdicated their former bridging roles along with in loco parentis.
Cetona looks forward to hearing your responses to any of these emanations from the DOG Patch.

Wednesday, February 07, 2018

New article in J. of General Internal Medicine calls for simplifying EHRs

At my January 31, 2018 Healthcare Renewal blog post "The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging" at, I opined that the downgrading of the clinician-facing components of EHRs was essential and inevitable. A new editorial in the Journal of General Internal Medicine makes similar points: ​Electronic Health Records: a "Quadruple Win," a "Quadruple Failure," or Simply Time for a Reboot?
Journal of General Internal Medicine
Michael Hochman

"Perhaps most importantly, there must be a dramatic and thoughtful simplification of EHR documentation templates: it should not take over 200 mouse clicks and more than 700 key strokes to complete one ambulatory encounter."


And this statement, seen frequently at this site, also appears:

"Put simply, EHRs must be redesigned around the needs of clinicians and patients rather than billers and administrators."

The article also makes many other points about the technology I've been writing about for decades, such as the now-obvious grossly exaggerated claims about benefits and cost savings, and others:

... many of the predictions about the benefits of EHRs have yet to materialize to the extent predicted. Though EHRs have facilitated some substantial improvements—the ability for clinicians to access charts from any wired location, electronic transmission of prescriptions, and enhanced tracking of population health measures, to name just a few—they have also resulted in numerous unintended consequences. Noteworthy concerns include egregious medical errors resulting from design glitches, charting templates filled extensively with meaningless boilerplate, the common practice of pasting old notes that makes it difficult to know which documentation is “real,” “alert fatigue” due to excessive EHR warnings (note that some warnings are essential, such as on critical actions with possibly serious consequences, e.g., on confusing screens that can be described as "hot spots for user input error" - ed.), and even reduced communication among clinical team members.

Note that you saw the idea about EHR simplification on Healthcare Renewal first.

-- SS