Princess Health and Is the adversary model the answer?. Princessiccia

Princess Health and Is the adversary model the answer?. Princessiccia

Gusty 13:13 Add Comment

In his post of Wed 18 May, Roy Poses commented on the PLoS article by former BMJ editor Richard Smith opining that medical journals have been co-opted into Big Pharma's marketing system. Coincidentally, the BMJ reports that the CEO of Merck has resigned, in a move widely seen as a response to the increasingly damaging disclosures about Merck's marketing of Vioxx (though Merck of course denies any connection).

Merck's campaign for marketing Vioxx was clearly a campaign of deliberate deception, with intensive training of detail reps in specific techniques for misleading physicians about the benefits and concealing the risks of the drug. Should we be surprised? No, not really. Consider what is at stake for any drug company marketing a new agent. Hundreds of millions of dollars have gone into its development. Even though the company itself probably hasn't paid for much if any of the actual basic science or discovery, the development of someone else's discovery to marketability costs a bloody fortune. There's no predicting whether it'll be a big seller, a market mediocrity, or a fiasco that proves dangerous but only after all the costs are incurred.

When big money is at stake, people will lie. It's human nature. Are they "bad people"? No, they're people. As the Milgrom experiment and others showed, and WWII gruesomely illustrated, the majority of people can convince themselves that literally anything - no matter how abhorent - is OK. We vastly underestimate in our usual thinking how readily people will believe what's in their interest to believe. Not just a few "bad apples", but the majority of normal people. Further, those few who are squeamish about fibbin' a bit in marketing the product are selected out at low rungs on the corporate ladder in Big Pharma. The upshot is that we just plain have to assume that Big Pharma will lie. Not because they're evil, but because they're humans in a system where extremely strong incentives exist to do so.

So what do we do? Well, we could propose that drug development be placed in the hands of neutral foundations or some similar arrangment that divorces self-interest from the product. Personally, I doubt that will work well though. The nice thing about self-interest is that it really motivates people. Only self-interest will reliably make the majority of people really work hard. Folks just naturally coast a bit if they don't have skin in the game. (You don't need to point to the economic failure of communism to illustrate that point; just check out any organization that has no competitors. Go down to the Secretary of State's office to get your driver's license paperwork, for example.)

So it's time we formally and clearly recognized that doctors and their patients vs. Big Pharma is an adversary relationship. Like prosecutors and defense attorneys, we need each other and society needs us both, but like any good defense attorney we're nuts to trust anything the prosecutor says. (The metaphor is apt, sadly, as the shocking number of falsely convicted men freed from death row or life imprisonment over the last decade demonstrates.) If we want to do the best for our patients, we need to behave adversarially toward Big Pharma. Don't socialize; assume an ulterior motive; if given a paper "proving benefit" look for how it might have been fudged or find out how many negative papers are being kept out of view; never believe industry-funded clinical trials; assume risks are being downplayed and benefits overplayed.

An adversary relationship will put a real crimp in the incomes of quite a few physicians who are used to taking drug money. It'll also raise some serious financing issues for CME, but it's time those came out on the table anyway. Patients deserve much more aggressive protection of their interests than our profession's cozy relationship with Big Pharma has provided. Time to un-cozy.

Princess Health and Is the adversary model the answer?.Princessiccia

Princess Health and Is the adversary model the answer?.Princessiccia

Gusty 13:13 Add Comment

In his post of Wed 18 May, Roy Poses commented on the PLoS article by former BMJ editor Richard Smith opining that medical journals have been co-opted into Big Pharma's marketing system. Coincidentally, the BMJ reports that the CEO of Merck has resigned, in a move widely seen as a response to the increasingly damaging disclosures about Merck's marketing of Vioxx (though Merck of course denies any connection).

Merck's campaign for marketing Vioxx was clearly a campaign of deliberate deception, with intensive training of detail reps in specific techniques for misleading physicians about the benefits and concealing the risks of the drug. Should we be surprised? No, not really. Consider what is at stake for any drug company marketing a new agent. Hundreds of millions of dollars have gone into its development. Even though the company itself probably hasn't paid for much if any of the actual basic science or discovery, the development of someone else's discovery to marketability costs a bloody fortune. There's no predicting whether it'll be a big seller, a market mediocrity, or a fiasco that proves dangerous but only after all the costs are incurred.

When big money is at stake, people will lie. It's human nature. Are they "bad people"? No, they're people. As the Milgrom experiment and others showed, and WWII gruesomely illustrated, the majority of people can convince themselves that literally anything - no matter how abhorent - is OK. We vastly underestimate in our usual thinking how readily people will believe what's in their interest to believe. Not just a few "bad apples", but the majority of normal people. Further, those few who are squeamish about fibbin' a bit in marketing the product are selected out at low rungs on the corporate ladder in Big Pharma. The upshot is that we just plain have to assume that Big Pharma will lie. Not because they're evil, but because they're humans in a system where extremely strong incentives exist to do so.

So what do we do? Well, we could propose that drug development be placed in the hands of neutral foundations or some similar arrangment that divorces self-interest from the product. Personally, I doubt that will work well though. The nice thing about self-interest is that it really motivates people. Only self-interest will reliably make the majority of people really work hard. Folks just naturally coast a bit if they don't have skin in the game. (You don't need to point to the economic failure of communism to illustrate that point; just check out any organization that has no competitors. Go down to the Secretary of State's office to get your driver's license paperwork, for example.)

So it's time we formally and clearly recognized that doctors and their patients vs. Big Pharma is an adversary relationship. Like prosecutors and defense attorneys, we need each other and society needs us both, but like any good defense attorney we're nuts to trust anything the prosecutor says. (The metaphor is apt, sadly, as the shocking number of falsely convicted men freed from death row or life imprisonment over the last decade demonstrates.) If we want to do the best for our patients, we need to behave adversarially toward Big Pharma. Don't socialize; assume an ulterior motive; if given a paper "proving benefit" look for how it might have been fudged or find out how many negative papers are being kept out of view; never believe industry-funded clinical trials; assume risks are being downplayed and benefits overplayed.

An adversary relationship will put a real crimp in the incomes of quite a few physicians who are used to taking drug money. It'll also raise some serious financing issues for CME, but it's time those came out on the table anyway. Patients deserve much more aggressive protection of their interests than our profession's cozy relationship with Big Pharma has provided. Time to un-cozy.

Princess Health and The "Misconduct" of a Leader with "Gravitas,". Princessiccia

Princess Health and The "Misconduct" of a Leader with "Gravitas,". Princessiccia

Mismanagement Staten Island University Hospital

Gusty 11:05 Add Comment

A follow-up on the story of Staten Island (NY) University Hospital's settlement of charges that it had defrauded the state Medicaid program....

According to the NY Times, it turns out that Joseph Pisani, the former Executive Vice President of State Island University Hospital, who was accused of involvement in the scheme to defraud Medicaid, had taken a position as Senior Vice President for financial planning and forecasting at troubled Westchester (NY) Medical Center in 2003, at a salary of $275,000. In 2004 he was promoted to Executive Vice President and Chief Administrative Officer, with a salary of $480,000. At the time, employees and union officials said this salary was excessive given the perilous financial condition of the institution. (The Journal News reported that the hospital has lost $200 million since 2002, and is projected to lose $60 million in 2005.) However, the Chair (in 2004) of the Westchester County Health Care Corporation defended Pisani's salary thus,

• "To get out of this thing, you need good troops, and Joe is really C.E.O material. He has that kind of gravitas and can think outside the box and can think of creative solutions."

Yesterday, when the story of the fraud settlement at Staten Island University Hospital, and Pisani's involvement in it was revealed, Westchester Medical Center fired him. Staten Island University Hospital had announced its regrets over its leaders' "misconduct."
OK, here comes my rant. How many times have we heard about the brilliance of health care leaders (often proclaimed by other health care leaders)? How many times have we heard about their intelligence, their vision, their ability to think outside the box? How many times have we heard about how their brilliant plans will improve care, lower costs, etc., etc.? And how many times do these predictions turn out to be wrong?
My favorite example of the over-hyping of health care leadership: In 1995, Sherif Abdelhak gave the prestigious Cooper Lecture at the American Association of Medical Colleges meeting, later published in the prestigious journal, Academic Medicine. In it he proclaimed how through his brilliant leadership, the Allegheny Health Education and Research Foundation was moving into the brave new world of large-scale integrated health care systems. (Remember, they were all the rage in the 1990's.) In 1997, the ACP Observer reported that Abdelhak was considered a "visionary." By 1998, AHERF was bankrupt, the second largest bankruptcy in the US at that time. Abdelhak was convicted of misappropriating charitable funds, and went to jail. (See my summary of the case here starting on page 5.)
So maybe the next time we hear that some top health care leader is "visionary," has "gravitas," or the ability to "think outside the box" of another, a high degree of skepticism is in order. Maybe we should look for leaders who display some modesty, humility, and realism, for a change.

Princess Health and The "Misconduct" of a Leader with "Gravitas,".Princessiccia

Princess Health and The "Misconduct" of a Leader with "Gravitas,".Princessiccia

Mismanagement Staten Island University Hospital

Gusty 11:05 Add Comment

A follow-up on the story of Staten Island (NY) University Hospital's settlement of charges that it had defrauded the state Medicaid program....

According to the NY Times, it turns out that Joseph Pisani, the former Executive Vice President of State Island University Hospital, who was accused of involvement in the scheme to defraud Medicaid, had taken a position as Senior Vice President for financial planning and forecasting at troubled Westchester (NY) Medical Center in 2003, at a salary of $275,000. In 2004 he was promoted to Executive Vice President and Chief Administrative Officer, with a salary of $480,000. At the time, employees and union officials said this salary was excessive given the perilous financial condition of the institution. (The Journal News reported that the hospital has lost $200 million since 2002, and is projected to lose $60 million in 2005.) However, the Chair (in 2004) of the Westchester County Health Care Corporation defended Pisani's salary thus,

• "To get out of this thing, you need good troops, and Joe is really C.E.O material. He has that kind of gravitas and can think outside the box and can think of creative solutions."

Yesterday, when the story of the fraud settlement at Staten Island University Hospital, and Pisani's involvement in it was revealed, Westchester Medical Center fired him. Staten Island University Hospital had announced its regrets over its leaders' "misconduct."
OK, here comes my rant. How many times have we heard about the brilliance of health care leaders (often proclaimed by other health care leaders)? How many times have we heard about their intelligence, their vision, their ability to think outside the box? How many times have we heard about how their brilliant plans will improve care, lower costs, etc., etc.? And how many times do these predictions turn out to be wrong?
My favorite example of the over-hyping of health care leadership: In 1995, Sherif Abdelhak gave the prestigious Cooper Lecture at the American Association of Medical Colleges meeting, later published in the prestigious journal, Academic Medicine. In it he proclaimed how through his brilliant leadership, the Allegheny Health Education and Research Foundation was moving into the brave new world of large-scale integrated health care systems. (Remember, they were all the rage in the 1990's.) In 1997, the ACP Observer reported that Abdelhak was considered a "visionary." By 1998, AHERF was bankrupt, the second largest bankruptcy in the US at that time. Abdelhak was convicted of misappropriating charitable funds, and went to jail. (See my summary of the case here starting on page 5.)
So maybe the next time we hear that some top health care leader is "visionary," has "gravitas," or the ability to "think outside the box" of another, a high degree of skepticism is in order. Maybe we should look for leaders who display some modesty, humility, and realism, for a change.

Princess Health and Jacobi's Missing Test Results. Princessiccia

Princess Health and Jacobi's Missing Test Results. Princessiccia

Jacobi Hospital Mismanagement

Gusty 12:55 Add Comment

Another problem in New York. The Times reports how Jacobi Hospital, part of the city's Health and Hospitals Corporation, failed to notify hundreds of women of their Pap test results, including some with abnormal results.
Apparently, supposedly to reduce bureaucracy, a single clerk was given the job of scheduling all Pap tests, and notifying all patients of their results. Apparently no one was monitoring the clerks work, so it took a long time for anyone to notice that the notifications of 307 women with abnormal results never got out.
Hospital management seems at a loss to explain why all this happened.
The hospital's executive director (a quaint term in this day and age) has been suspended.
What was left unsaid is whether any physicians were notified of their patient's abnormal results.

Princess Health and Jacobi's Missing Test Results.Princessiccia

Princess Health and Jacobi's Missing Test Results.Princessiccia

Jacobi Hospital Mismanagement

Gusty 12:55 Add Comment

Another problem in New York. The Times reports how Jacobi Hospital, part of the city's Health and Hospitals Corporation, failed to notify hundreds of women of their Pap test results, including some with abnormal results.
Apparently, supposedly to reduce bureaucracy, a single clerk was given the job of scheduling all Pap tests, and notifying all patients of their results. Apparently no one was monitoring the clerks work, so it took a long time for anyone to notice that the notifications of 307 women with abnormal results never got out.
Hospital management seems at a loss to explain why all this happened.
The hospital's executive director (a quaint term in this day and age) has been suspended.
What was left unsaid is whether any physicians were notified of their patient's abnormal results.

Princess Health and Kling on the EMR. Princessiccia

Princess Health and Kling on the EMR. Princessiccia

electronic medical records

Gusty 12:37 Add Comment

A nice discussion by Arnold Kling on Tech Central Station on pitfalls to expect on the road to electronic medical records (EMRs)....
His reminds us that computer systems must be viewed in the organizational context in which they will be employed, and the health care context is a particularly complex one. He then points out two specific problems.
One is that in the current health care system, no one really owns the whole of a patient's medical record. Yet it is hard to understand how an EMR would work if no one is responsible for any given patient's record. Apparently, the Gingrich proposal includes the formation of regional health information networks. Yet if these have no power, their formation will not solve the lack of ownership problem. On the other hand, if they have the power to own the records, they risk becoming "a new and potentially intrusive entrant into the health care system."
Kling suggests instead that primary care physicians should become accountable for each patient's health care (gasp). Of course, right now primary care and generalist physicians are an embattled species, and there is little support right now for improving our lot.
The other, perhaps better known problem is the requirement for a large number of interfaces to support a large number of types of transactions done by a large number of different actors. Kling contrasted this situation with, for example, electronic banking in which the number of different kinds of actors and different kinds of transactions is small.
I don't think Kling has actually described all the important pitfalls. The elephant in this room remains the poorly understood structure of medical and health care data. Simply storing data as text and images would be clumsy, and sacrifices the ability of computers to truly process data. But we may not yet know how to store health care data other than as word processing and image files.
My fear remains that the EMR is just the latest business fad to captivate health care leaders who don't really understand the health care context. Remember mergia mania? And when physicians are forced to cope with clumsy systems that don't really work well in the clinical context, the health care leaders will be onto their next fad. We'll see.