Thursday, January 18, 2018

Will the New Conscience and Religious Freedom Division of the US Department of Health and Human Services Help Health Care Professionals Challenge Morally Objectionable Acts - Like Bribery, Fraud and Other Criminal or Corrupt Practices?

For a long time we have argued that health care corruption is a major cause of health care dysfunction.  We have documented numerous cases in which health care professionals were exposed to or involved in actions, including fraud, bribery (also known as kickbacks), and other corrupt or criminal practices, to which they likely had moral objections.  We have also noted that in such situations, health care professionals often have little recourse, particularly in academic institutions.

The New Conscience and Religious Freedom Division of the US Department of Health and Human Services

So perhaps a new initiative of the US Department of Health and Human Services could relieve health care professionals besieged by unethical and immoral practices.  Per the Washington Post (on January 18, 2018),

The Trump administration on Thursday announced the creation of a new conscience and religious freedom division aimed at protecting doctors, nurses and other health-care workers who decline to participate in care that goes against their moral or religious convictions.

Speaking at an event featuring Republican lawmakers and religious leaders, Acting Health and Human Services Secretary Eric Hargan noted that many of the nation's hospitals, clinics and hospices are run by faith-based groups. And many have found themselves forced to provide services or referrals that violate what they believe.

'For too long, too many of these health-care practitioners have been bullied and discriminated against,' he said.

While federal officials did not immediately offer details about the new enforcement office, a Conscience and Religious Freedom section appearing Thursday on the HHS site — showing a female health-care worker in a Muslim headscarf — provides some hints. The description of the division's mandate cites abortion, sterilization and assisted suicide as examples of the types of procedures that would be covered. But the language is broad, and health experts said it appears likely to also cover a host of other scenarios, such as treating transgender patients or those seeking to transition to the opposite sex.

HHS said the protections will apply to discrimination or coercion of  'providers who refuse to perform, accommodate or assist with certain health-care services on religious or moral grounds.' They would also apply to training and research activities, according to the department.

Immoral Practices to Which Health Care Professionals Might be Exposed

On Health Care Renewal, we have focused on unethical, self-interested, conflicted and corrupt or criminal practices of the leadership of health care.  So, for example, we have seen cases in which -

- Physicians and other health care professionals were lured into financial relationships with large health care corporations which created obvious conflicts of interest, especially when they were induced to help market those corporations' products (often in the guise of "key opinion leaders,"), and often without disclosing their conflicts, making their marketing deceptive.  Health care professionals might resist such relationships, or be morally offended by their colleagues' and supervisors' acceptance of such relationships.

 - Top executives of hospitals, hospital systems, and other health care provider organizations may have perverse incentives that lead them to put short-term revenue ahead of good patient care, education or research.  Health care professionals might be morally offended by such mission hostile management, and its effect on the quality of patient care, and the integrity of education and research.

-  Leaders of government agencies may transit to or from commercial entities which might be subject to their agencies' regulations or policies.  This has been called the revolving door, and can be considered a form of health care corruption.  Health care professionals might be morally offended by the regulations or policies of agencies led by people who have come through, or will go through the revolving door.

-  Health care professionals have often been affected by outright crime, such as fraud, bribery or kickbacks, or other criminal or corrupt practices.  For example, there have been many cases in which the marketing of drugs, devices, or other health care products and services to which health care professionals are exposed has been fraudulent. There have been many cases in which health care professionals have received bribes or kickbacks to use or prescribe certain products. Health care professionals might be morally offended by fraudulent marketing, being pushed to accept bribes or kickbacks, or working with colleagues who have accepted same.

Keep in mind that many health care professionals come from mainstream Judaism, Christianity or Islam.  All accept the Old Testament as a fundamental guide.  The Bible contains many exhortations to avoid immoral behavior, most famously the Ten Commandments.

[The Ten Commandments - in an ancient synagogue in Tzfat, Israel]

Some quotes from the Old Testament about the sorts of immoral behavior listed above:

Do not pervert justice or show partiality. Do not accept a bribe, for a bribe blinds the eyes of the wise and twists the words of the innocent. [Deuteronomy 16:19]

Justice, justice shalt thou follow, that thou mayest live, and inherit the land which the LORD thy God giveth thee. [Deuteronomy 16:20]

Bread of falsehood is sweet to a man; But afterwards his mouth shall be filled with gravel. [Proverbs 20:17]

He that walketh righteously, and speaketh uprightly; He that despiseth the gain of oppressions, That shaketh his hands from holding of bribes, That stoppeth his ears from hearing of blood, And shutteth his eyes from looking upon evil; He shall dwell on high; [Isaiah 33:15 -16]

A wicked man taketh a gift [bribe] out of the bosom, To pervert the ways of justice. [Proverbs 17:23]

So for most health care professionals, the actions in health care that may be most morally repugnant would be bribery, kickbacks, fraud, and other forms of corruption or criminality going on around them.  In theory, and on paper, the new Conscience and Religious Freedom Division ought to be a powerful force to combat health care corruption.

Summary - What Were They Thinking?

Somehow, though, I am guessing that the people who came up with this new initiative were not thinking about anti-corruption efforts.

First I would note that the announcement was made by Acting Health and Human Services Secretary Eric Hargan.  We discussed Mr Hagan here. A hint: the post was entitled, "Worst Health Care Revolving Door Case So Far? - From Lobbyist to Acting Secretary of Department of Health and Human Services."  Mr Hargan is a lawyer who spent years as a lobbyist for health care corporations prior to being nominated to be acting secretary.

As we noted earlier, 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.
So I must say I am morally offended that Mr Hargan is now the Acting Secretary of DHHS.  So I really do not think he and his cronies in the department were thinking about people morally offended by fraud, bribery, kickbacks or other criminal or corrupt practices, including the revolving door, when they set up this new division.  Moreover, as the Post article stated,

The description of the division's mandate cites abortion, sterilization and assisted suicide as examples of the types of procedures that would be covered. But the language is broad, and health experts said it appears likely to also cover a host of other scenarios, such as treating transgender patients or those seeking to transition to the opposite sex.


The announcement, which comes one day before abortion opponents' annual March for Life, represents the latest move by the Trump administration to allow individuals and institutions to opt out of providing certain services or benefits based on such objections. In 2017, the administration issued new rules allowing exemptions for more employers, including for-profit businesses, from providing no-cost contraceptive coverage through their health insurance plans.


House Majority Leader Kevin McCarthy (R-Calif.), for one, said the previous administration expected health care workers 'to conform' rather than follow their religious beliefs. 'What a difference a year makes,' he added.

Roger Severino, director of the department's Office for Civil Rights, echoed that theme, saying that 'HHS has not always been the best keeper of this liberty.' Health-care workers' complaints to his office have increased in recent years, he said.

'Governments big and small have treated conscience claims with hostility instead of protection, but change is coming, and it begins here and now,' Severino said.

And Montse Alvarado, executive director of the Becket Fund for Religious Liberty, a nonprofit law firm, stressed, 'It is important to recognize that we have come to a point where a division like this would be necessary.' What happened under the previous administration, she said, resulted in 'forcing Americans to choose between their beliefs and their livelihood.'

IMHO, the people who came up with the idea of this new division completely ignored the religious and moral beliefs of a majority of Americans.

Many health care professionals have had to choose between their beliefs - that fraud, bribery, kickbacks or other corrupt practices are morally wrong - and their continued employment.  I would submit that their are more cases of health care professionals offended by such actions than their are health care professionals offended by abortions and the provision of contraception.

Furthermore, given the description of the Division's statement of conscience rights:

Conscience protections apply to health care providers who refuse to perform, accommodate, or assist with certain health care services on religious or moral grounds.

Federal statutes protect health care provider conscience rights and prohibit recipients of certain federal funds from discriminating against health care providers who refuse to participate in these services based on moral objections or religious beliefs.

It seems that it ought to provide protections to people who object to fraud, bribery, kickbacks or other corrupt practices on religious or moral grounds.  So maybe those of us who are exposed to such practices ought to see whether the division itself is real, or some new kind of fraud. 

Big Bang Theory of Health Care: Ever Since 1967

Hold on to your hat: it all comes together now. Looking at events in our nation's capital, in a strange fever dream, The Big Bang Theory just came to me. No, call it the Big Fecal-Bang Theory, as I read about how our national leadership proceeds from one inanity to the next.

But when it comes to health care, and wiping out the safety net using false premises, inanity kills. So this is worth writing. But to see how it all ties together, we have to go back over half a century.

Where else can you read about the hidden connections between Hollywood, health insurance in the US of A, Really Bad Tax Cuts, Wisconsin cheese-eaters, opiate addiction and Really Bad Logic?

We will conclude with the antics over the past year of Senator Ron Johnson of Wisconsin in the annals of health care. But to pull it together we have to back to just over fifty years ago. Take a walk back to 1967.

That year two events occurred involving two major characters of the day. Hollywood!

The first was the ascent of an actor named Ronald Reagan, perhaps our first media-celebrity politician, to his first term as California governor. Some time later, eyeing higher office, he was insisting government-is-the-problem-not-the-solution. A mantra carried through ever-bigger megaphones until we arrived at the present day s-house.

California, of course, as a whole is now far less likely to throw up right wing politicians onto the national stage. (Rep. Issa is leaving it as we speak.) But our great expanse of red fly-over country still belches forth people like Paul Ryan and Ron Johnson to bollix up health care and pretty much everything else.

The second event worth recalling from 1967 is the grand Oscar-winning Mike Nichols and Buck Henry collaboration, The Graduate.  Forget about the stars. They're still in the news for all sorts of things. Remember Mr. McGuire? Until our current president trumped him with a potty-mouthed single-word viral epithet, Mr. McGuire was the single-word champ, with his fatherly diatribe to Dustin Hoffman on the future: plastics.

(The actor, Walter Brooke, who was among other things a big Thomas Jefferson enthusiast, was reportedly so enthused by his role that he remained forever wistful about his own failure to invest in plastics. Starting in 1968, though, many more did take the fictitious Mr. McGuire's advice, earning tidy sums in life imitating art.)

Show biz carrying over into the public square: Nothing New.

A decade or so later and now far from Hollywood, another family, that of today's Senator Ron Johnson saw the same writing on the wall. They launched a company in Wisconsin now called Pacur. A bit off-subject to explore just how much credit this intrepid midwestern businessman-turned-politician can take for single-handedly pumping up a company that specialized in plastic extrusions.

But by 2016-2017, Johnson had done just that in spades. And now according to multiple sources he allegedly uses the recent tax-cut legislation to win all sorts of special concessions for plastics from the GOP leadership in exchange for pushing that legislation forward. (See the cheesemen's connection with each other and the alt-right here and here.)

Simultaneously in 2016-2017, according to the reliably right wing organ Washington Examiner, Johnson was already now making a prefatory argument about Medicaid and how it might be responsible for the opiate crisis. That this took my breath away is what, in the event you're still reading, prompted the screed I'm now writing.

So first the boys from Wisconsin enact a bodacious and totally not needed nay harmful tax cut, favoring the wealthy. But long before its success was assured the cheese boys were preparing the ground for the dismantling of Medicaid. First you create a deficit by handing out tax breaks to rich friends. And donors. Then you produce the "evidence" for where the resulting deficit can be addressed, on the backs of poor patients.

That this evidence is specious is almost beside the point. It appeals to the Base, if that's still big enough (it is until November 2018 proves it isn't) to make a difference in pushing through the proverbial Drowning-of-the-Baby-in-the-Bathtub.

But the striking logic used by Johnson allows us to conclude with observations on the multiple fallacies of reasoning commonly committed by the increasingly extreme proponents of this grand new idea of repealing the twentieth century. Brings us right down to today--January 17, 2018--and the hearings Ron Johnson held on the vestiges of the Affordable Care Act and Medicaid expansion. Allegedly they were "trying to link Medicaid expansion to the opioid abuse epidemic."

The notion--now soundly disproved, if such things matter, by actual evidence--that decent health insurance gave more people access to prescription drugs, including opiates, and was therefore harmful as an unintended consequence, is as laughable as is climate change denial. But why should that stop them when "it's just common sense"? (I paraphrase.) The new line of attack on Medicaid is like so many other demagogic off-the-skids reasoning coming from extremists of every ilk.

They suffer from so many logical fallacies it's hard to know where to start. (But a good place is here, at UT El Paso.) The argument-from-pathos: "trust your gut." Too, the related biases of Confirmation and Availability, allowing for these wingers' selective use of "evidence" that only seems to bolster their view: "more people with addiction have Medicaid that those who don't."

Say what? See also: the Big Lie Technique. Over-generalization. The Post Hoc Propter Hoc Fallacy, famous ever since the Hippocratic writings. This last one is key: "Disco caused AIDS."

Or, more to the point, as a thought experiment, imagine what could be next when your parents and grandparents stand to lose some or all of their Medicare coverage. Analogous to what the boys of the GOP are doing with Medicaid--a cheap shot and easier target than Medicare.

"Evidence is now showing that addiction to death is far more common among people who have Medicare. Death is bad. Let's gut Medicare." The people don't count. What counts? Plastics!

Monday, January 15, 2018

"Hot Spot For User Entry Error": Hawaii missile alert: How one employee ‘pushed the wrong button’ and caused a wave of panic

A short post.

I believe this WaPo story vividly demonstrates issues I've seen in what Australian colleague Dr. Jon Patrick & I call "bad health IT." 

We came up with the simple-to-comprehend terminology "Good health IT/Bad health IT" in his living room in Sydney after my presentation to the Health Informatics Society of Australia in 2012 on health IT trust (, to replace my earlier terms "health IT done well" vs. "done poorly."

It was not just "one employee who pushed the wrong button."  A team of apparently incompetent IT personnel and utterly incompetent IT managers - completely devoid of any understanding of human-computer interaction - were, in essence, standing behind this this employee and guiding his hand.

The Hawaii mishap vividly demonstrates bad IT in the most critical of settings - badly conceived, designed & implemented, lacking appropriate safeguards, usually by people who do not know the domain, and often who are, dare I say, lacking common sense.

Questions that the incident raises include:
  • How [in God's name] were such critical items as "Test missile alert" and "Missile alert" (the real thing) residing in the same menu?  Who came up with such bad, terse labeling as well?  [A "hot spot" for user entry error] 
  • Why were there no reasonable safeguards? 
  • Why was it easy for anyone to make a big mistake?
  • Why was no system in place for rapid retraction?

The answers translate back to - well, I probably don't need to say it.

Hawaii missile alert: How one employee ‘pushed the wrong button’ and caused a wave of panic
Washington Post

... Around 8:05 a.m., the Hawaii emergency employee initiated the internal test, according to a timeline released by the state. From a drop-down menu on a computer program, he saw two options: "Test missile alert" and "Missile alert."

This is  a classic example of what can be called a "hot spot for user entry error."

... He was supposed to choose the former; as much of the world now knows, he chose the latter, an initiation of a real-life missile alert.

... "Based on the information we have collected so far, it appears that the government of Hawaii did not have reasonable safeguards or process controls in place to prevent the transmission of a false alert," Pai said in a statement.

... Part of what worsened the situation Saturday was that there was no system in place at the state emergency agency for correcting the error, Rapoza said...."In the past there was no cancellation button. There was no false alarm button at all,"

.... "Part of the problem was it was too easy - for anyone - to make such a big mistake," Rapoza said. "We have to make sure that we're not looking for retribution, but we should be fixing the problems in the system.

It would not be unreasonable to predict that U.S. armed forces were put on alert, perhaps even scrambling fighter planes near the Korean peninsula - moves that other countries could detect.

This "mishap" could have caused N. Korea or other hostile country to react, and led to catastrophe.

The utterly incompetent IT personnel and their utterly incompetent managers who birthed such a cornucopia of IT atrocities should be severely punished.

-- SS

Jan. 16, 2018.  Update, update.  Who's got the button?

This new WaPo story shows the "unholy" menu - a jumbled mess.

Was this designed by an expert in human-computer interaction?  I think not...


-- SS

Sunday, January 14, 2018

How To Challenge Health Care Corruption Under a Corrupt Regime?

Introduction: the Corruption of Health Care Leadership as a Major Cause of Health Care Dysfunction

For a long time we have argued that health care corruption is a major cause of health care dysfunction.  As we wrote in August, 2017, Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.

Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.

The report got little attention.  Health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,
However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects somewhere else, mainly  presumably benighted less developed countries.  At best, the corruption in developed countries that gets discussed is at low levels.  In the US, frequent examples are the "pill mills"  and various cheating of government and private insurance programs by practitioners and patients.  Lately these have gotten even more attention as they are decried as a cause of the narcotics (opioids) crisis (e.g., look here).  In contrast, the US government has been less inclined to address the activities of the leaders of the pharmaceutical companies who have pushed legal narcotics (e.g., see this post). 

However, Health Care Renewal has stressed "grand corruption," or the corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements that result in fines that small relative to their  multi-billion revenues without admitting guilt.  Almost never are top corporate managers subject to any negative consequences.

While we at Health Care Renewal have written about this for years, we saw little improvement.  However, in the past few years we began to feel a little more encouraged.  For example, we had long complained that US law enforcement had not been devoting enough effort going after the corruption of the leadership of large health care organizations, thus effectively allowing these leaders' impunity. However, the US Department of Justice during the Obama administration made some modest attempts to decrease such impunity.  One such measure was the formation of a Health Care Corporate Strike Force.

As reported by,

the strike force was created in the fall of 2015, with five dedicated lawyers working on about a dozen of the most complex corporate fraud cases in the health care space.

Andrew Weissmann, the then-chief of the DOJ’s fraud section, told a health care conference in April 2016 that the section was placing 'a heightened emphasis' on corporate health care fraud investigations. He pointed to the recently established Corporate Fraud Strike Force that he said would focus resources in investigation and prosecution of larger corporate health care law violations, as opposed to smaller groups or individuals.

Unfortunately, that strike force was downsized by the Trump administration as we noted in July, 2017.  Perhaps that could have been viewed as just a minor setback.

Yet as the year wore on, it became obvious that the corruption was becoming an even bigger problem.  In fact, it was becoming even more systemic, and worse, it appeared that the administration itself was fundamentally corrupt.

The Systemic Corruption of the Trump Regime

In December, 2017, the Los Angeles Times published a list by Adam Johnson of the "top 10 under-coverd news stories of 2017."  His third entry was:

3. President Trump's unprecedented non-Russia corruption

Time will tell the extent of President Trump’s connection to Russian officials and how it may or may not have influenced his campaign but — regardless — Trump has led the most nakedly corrupt administration in modern American history, enriching himself, his family and his friends and hiring a Cabinet of political cronies and billionaires. Many journalists have done great work revealing this corruption, but these stories have not turned into full-blown scandals, let alone harmed the president.

The article used as a source a website, entitled "Tracking Trump's Conflicts of Interest" published by the Sunlight Foundation.  It includes a spreadsheet of literally hundreds of conflicts.

In January, 2017, Washingon Monthly published two related articles on President Trump's conflicts of interest and corruption.  The first was "Commander-in-Thief," which categorized Mr Trump's conflicted and corrupt behavior.  The second, "A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

Commander-In-Thief opened with this explanation,

official Washington has tolerated an entire other class of corrupt and potentially unconstitutional behavior being carried out in plain sight, as Trump uses the presidency to enrich himself and his family. He has installed immediate relatives at the helm of the Trump Organization, continued to accept payments from foreign governments and private interests, and lavishly billed the government for using his own properties—all without guaranteeing that he will prioritize his duties as president over his own bottom line.

No president ever entered office with the type of immense personal fortune and ongoing business interests that Trump has. Trump’s vast business empire spans more than 500 companies in twenty-five countries and has earned him an estimated net worth of $3.1 billion. Traditionally, on taking office, presidents have placed their assets in a “blind trust” whose trustee is legally barred from telling the beneficiary about the trust’s holdings. Jimmy Carter famously placed the family peanut business into a blind trust in 1977. Ronald Reagan, George H. W. Bush, Bill Clinton, and George W. Bush all followed suit.

Trump’s trust agreement is a little different. For one thing, it’s not blind—Trump’s children have admitted to providing their father with regular business updates. For another, the agreement allows him to withdraw profits and assets from the trust at any time. That means Trump has a direct and ongoing financial interest in any policy decision that could affect his businesses.

Much of this has happened in broad daylight. The mainstream media has covered Trump’s conflicts doggedly. But the steady drip-drip-drip of evidence hasn’t captured the public’s attention like Russia has, or motivated any serious response by the government—no investigations are under way, either in Congress or the executive branch. This despite the fact that the infractions raise the same terrifying possibility as Trump’s possible collusion with Russia: the sacrificing of American interests in the service of the president’s personal gain.

[the Trump Chicago, an example of Mr Trump's vast business empire]

The article noted that at the time of publication,

The only active effort to investigate Trump’s profiteering is happening through civil lawsuits in New York, D.C., and Maryland federal courts. The plaintiffs challenging Trump’s behavior include the watchdog group Citizens for Responsibility and Ethics in Washington (CREW); some 200 Democrats in Congress, led by Connecticut Senator Richard Blumenthal; attorneys general in Washington, D.C., and Maryland; and hotel and restaurant owners who compete with Trump. They all argue that Trump is in blatant violation of a provision in the Constitution meant to ensure that the president can’t exploit his office for profit.

Note that since those articles were written, Democrats in the House of Representatives have called for a serious investigation by the House Oversight Committee of how the Trump Organization is exploiting his presidency for financial gain, although the likelihood that their political opponents would condone such an investigation seems small (look here).

The article posited that Mr Trump's corrupt activities fit into three categories.

Corruption Type 1: Foreign Emoluments

Mr Trump appears to be benefiting from payments or the equivalent from foreign governments, an apparent violation of the Foreign Emoluments Clause of the US Constitution.

Foreign interference in our political system was of grave concern to the framers of the Constitution. They knew that when a federal officeholder receives gifts, money, or other benefits from foreign governments, his judgment is compromised and his loyalties are divided. So they wrote a strict rule into the text of the Constitution, the Foreign Emoluments Clause, which provides that federal officeholders may not 'accept of any present, emolument, office, or title, of any kind whatever, from any king, prince, or foreign state' without Congress’s approval.

Unlike with bribery statutes, a violation of the Foreign Emoluments Clause doesn’t require proof that an official gave something in return. It’s designed to protect against not just quid pro quo corruption, but also the mere appearance of improper influence on government officials.

Note that the Constitution also provides that

Before he enter on the Execution of his Office, he shall take the following Oath or Affirmation: — 'I do solemnly swear (or affirm) that I will faithfully execute the Office of President of the United States, and will to the best of my Ability, preserve, protect and defend the Constitution of the United States.'

So any presidential violation of the Foreign Emoluments clause is also an example of what we have previously called mission-hostile management.

The Foreign Emoluments clause is basically a prohibition of a particular kind of conflict of interest, payments to the President by foreign leaders or states. However, many examples of violations of this clause by Mr Trump also suggest corruption. "Commander-in-Thief" describes

foreign governments’ lavish spending at Trump’s hotel and restaurants, particularly at the Trump International Hotel just steps away from the White House, in some cases at the prodding of Trump’s agents. After the election, the Trump International hosted more than 100 foreign diplomats for a tour, sending them home with goody bags and brochures in an attempt to encourage their patronage. Former Mexican diplomat Arturo Sarukhan has said that the State Department urged diplomats to stay at the Trump International while on official visits.

Delegations from at least eight countries have obliged. In September, Malaysian Prime Minister Najib Razak and other members of his administration were seen hobnobbing in meeting rooms at the hotel, bringing in what is estimated to be hundreds of thousands of dollars in revenue. Saudi Arabia has spent more than a quarter of a million dollars—$190,000 on lodging, $78,000 on catering, and $1,600 on parking—at the hotel in connection with its lobbying against legislation that would allow American citizens to sue foreign governments over terrorist attacks.

And the Kuwaiti embassy suddenly changed the venue for its National Day celebration last February from the Four Seasons to the Trump International, paying an estimated $40,000 to $60,000. A source with knowledge of the conversations between the hotel and the embassy told ThinkProgress that Trump Organization members had pressured the Kuwaiti ambassador to cancel the embassy’s 'save the date' reservation at the Four Seasons, where it had held the event in the past. Perhaps it’s purely a coincidence that neither Saudi Arabia nor Kuwait were among the Muslim-majority nations singled out by Trump’s travel ban.

[Trump International Hotel, Washington, DC]

Recall the Transparency International definition of corruption, abuse of entrusted power for private gain.  That the Trump Organization, owned mainly by Mr Trump, and likely still run according to his wishes by his children, actively promoted foreign governments pay for overpriced hospitality services which would directly profit Mr Trump.  Given that Mr Trump is supposed to lead foreign policy in the interests of all US citizens and according to the US Constitution, this seems to be a gross example of abuse of entrusted power, and is obviously for private gain.

"Commander-in-Chief" listed various other examples of violations of the Foreign Emoluments clause.  Moreover, the companion article, "A Year in Trump Corruption," listed pages of examples of the more prominent known violations, starting with the case of the 100 foreign diplomats above, and ending with

Oct. 31, 2017: Mexico’s former U.S. ambassador Arturo Sarukhan tweets that the State Department is encouraging diplomats to stay at the Trump International Hotel during official visits.

Corruption Type 2: Domestic Emoluments

Mr Trump appears to be directly benefiting from payments made by the US government, in violation of the Domestic Emoluments Clause.  Per "Commander-in-Thief," 

The framers weren’t just worried about foreign influences. They intended the Domestic Emoluments Clause to ensure that Congress, other parts of the federal government, and the states 'can neither weaken [the president’s] fortitude by operating on his necessities, nor corrupt his integrity by appealing to his avarice,' as Alexander Hamilton wrote in the Federalist Papers. It entitles the president to receive a salary (currently $400,000 a year) and benefits fixed by Congress, but prohibits him from taking any other profits from the public—whether from the federal government or from any of the states.

Trump violates this provision, many constitutional scholars have argued, when state or federal entities patronize his properties and spend taxpayer money.

Again, this provision also prohibits a certain kind of conflict of interest, that produced were a president to personally profit from activities of the US or state governments.

One sort of example the article provided was

Trump doesn’t just rely on others to put money into his businesses—he patronizes them himself with stunning frequency, having spent more than 100 days at them, nearly a third of his presidency, while in office. Unlike any previous president, Trump’s vacation properties are for-profit enterprises, meaning each visit funnels public money to Trump’s business, mainly in the form of exorbitant security costs. Secret Service has blown through its budget due to Trump’s frequent travel expenses, requesting an additional $60 million to protect the first family in March. Trump’s detail reportedly paid Mar-a-Lago, Trump’s luxury club in Palm Beach, Florida, at least $63,000 between February and April, and has spent at least $144,975 on golf cart rentals at Trump properties in New Jersey, Virginia, and Palm Beach as of November. And last spring, the Defense Department signed a $2.39 million eighteen-month lease for space in Trump Tower for a military office meant to provide various presidential services, including access to nuclear launch codes.

In this example, Mr Trump's personal decisions, for example to vacation at one of his own properties, automatically entail major expenses by the government he is supposed to lead.  These these USG government expenses thus become revenues for none other than Mr Trump.  Again, it seems easy to argue that such decisions are abuse of entrusted power for private gain.

Again, the companion article listed multiple other examples, beginning with

Nov. 14, 2016: Six days after the election, Trump receives all-but final approval from the National Park Service for a $32 million historic preservation tax credit for the Trump International Hotel.

And ending with:

Nov. 15, 2017: USA Today reports that, thanks to Trump’s refusal to divest from his businesses, the federal government has assigned at least 10 Justice Department lawyers and paralegals, at salaries ranging between $133,000 to $185,000 in public money, to defend Trump in four lawsuits alleging violations of the Emoluments Clause.

Corruption Type 3: Slimy, but Probably Legal

Mr Trump has also taken advantage of his office to increase revenues to the Trump Organization, which he owns.  Per "Commander-in-Thief,"

Many presidents have been independently wealthy, but none before Trump entered the White House with a massive on-going business empire—or brazenly used the office to drive up that empire’s value.

Some examples given were

Almost immediately following his inauguration, the annual membership rate at Mar-a-Lago, which Trump has dubbed his 'Winter White House,' doubled, from $100,000 to $200,000, reflecting Trump’s eagerness to capitalize on the market value of access to the leader of the free world. In February, Mar-a-Lago management sold a tennis shirt featuring a '45' on the sleeve in reference to Trump, the forty-fifth president. By April, rates at the Trump International Hotel had jumped to at least $660 per night, an increase in hundreds from before his election. And in November, the president plugged his New Jersey golf course during a foreign policy speech in Seoul.

The companion article again listed numerous examples, starting with the increase in the Mar-a-Lago membership rate, and after examples involving Mr Trump's Trump International Hotel in Washington, DC, and various other Trump resort and hotel properties, ending with:

Dec. 31, 2017: Trump ends 2017 the way he started it: with a private gala at Mar-a-Lago. This time, tickets are up to $600 for club members and $750 for guests.

Again, given that these cases involved the president trading on his office and the advantages of gaining personal access to him to increase revenues at the hospitality properties he owns, it seems easy to argue that they involved abuse of entrusted power for private gain.


In the rare instances in which health care corruption has been discussed publicly, one sometimes sees ideas about addressing corruption affecting various health care organizations.  For example, in October, 2016, Transparency International announced its Pharmaceuticals & Healthcare Programme, based in the UK. It would

target global, national and local interventions. Ongoing research and the lessons drawn from regional and national projects will be used to influence global policy to produce structural change within the health sector; promote global best practice standards to strengthen transparency and accountability; and support national and local interventions and solutions.

That is all well and good, and will hopefully lead to some improvements globally.  But such recommendations are based on tacit assumptions, particularly that well-intentioned governments will at least consider such changes in policy.

We in the US are now in a different situation. In an interview published by Vox, historian Robert Dallek said,

Often you see a lot of corruption result from a lack of oversight, but I think this administration is quite different in that Trump really sets the tone for all this. He encourages it, really. The fish rots from the head, and the stench of this administration starts at the very top.

IMHO, when the fish is rotting from the head, it makes little sense to try to clean up minor problems halfway towards the tail.  It would be silly to expect that the Trump regime would want to "produce structural change within the health sector; promote global best practice standards to strengthen transparency and accountability; and support n ational and local interventions and solutions" all to reduce corruption in health care.  Why would a corrupt regime led by a president who is actively benefiting from corruption act to reduce corruption?

The only way we can now address health care corruption is to excise the corruption at the heart of our government.

Friday, January 05, 2018

Ill-Informed, Incompetent* Health Care Leadership: the Case of President Trump's Interview in the New York Times

[* - see discussion of definitions below]

On December 28, 2017, the New York Times published an impromptu interview by reporter Michael S Schmidt with President Donald J Trump at one of Mr Trump's private golf clubs.  Excerpts from the transcript appeared here.  An analysis of 24 points made by the president appeared in the Washington Post.  A number of commenators later weighed in on the interview.

The interview touched on some major issues in health policy relevant to Health Care Renewal.  I will first present in full the transcript of relevant part of the interview by health care topic.  Then I will present comments from the Washington Post article, and then by some of the commenators.

That all sounds rather mundane, but even this stolid method of presentation cannot conceal how things quickly ran off the rails.

Relevant Interview Excerpts

President Trump's Health Care Policy Expertise

I know more about the big bills. … [Inaudible.] … Than any president that’s ever been in office. Whether it’s health care and taxes.

I know the details of health care better than most, better than most. And if I didn’t, I couldn’t have talked all these people into doing ultimately only to be rejected.

Association Health Plans, and Sales of Health Plans Across State Lines

Also, beyond the individual mandate, but also [inaudible] associations. You understand what the associations are. …

[Cross talk.]

TRUMP: So now I have associations, I have private insurance companies coming and will sell private health care plans to people through associations. That’s gonna be millions and millions of people. People have no idea how big that is. And by the way, and for that, we’ve ended across state lines. So we have competition. You know for that I’m allowed to [inaudible] state lines. So that’s all done.

Now here’s the good news. We’ve created associations, millions of people are joining associations. Millions. That were formerly in Obamacare or didn’t have insurance. Or didn’t have health care. Millions of people. That’s gonna be a big bill, you watch. It could be as high as 50 percent of the people. You watch. So that’s a big thing. And the individual mandate. So now you have associations, and people don’t even talk about the associations. That could be half the people are going to be joining up. … With private [inaudible]. So now you have associations and the individual mandate.

The Affordable Care Act (ACA, "Obamacare") and Its Mandate

But now that the individual mandate is officially killed, people have no idea how big a deal that was. It’s the most unpopular part of Obamacare. But now, Obamacare is essentially. … You know, you saw this. … It’s basically dead over a period of time.

The Washington Post Article on Trump's Claims

 The article began:

We combed through the transcript and here’s a quick roundup of the false, misleading or dubious claims that he made, at a rate of one every 75 seconds.

President Trump's Health Care Policy Expertise

Lawmakers who dealt with Trump on taxes and especially health care privately told reporters they were shocked how little he knew about these issues.

Association Health Plans, and Sales of Health Plans Across State Lines

Trump is referring to an executive order, mentioned above, but it has no force in law on its own and no one has yet joined these associations. The rules spelling out how the executive order would work have not been issued yet, so Trump is simply making up his 'millions' number.

Trump signed an executive order encouraging the formation of health plans across state lines. But there is still a law in place that exempts insurance companies from aspects of federal antitrust law and ensures that individual states remained the primary regulators of insurance.

The Affordable Care Act (ACA, "Obamacare") and Its Mandate

While the individual mandate was an important incentive for Americans to seek health insurance, it was only one part of a far-reaching law that remains intact. The repeal does not take effect until 2019, and enrollment in Obamacare has remained strong. The Congressional Budget Office says the marketplaces are expected to remain stable for years.

Commenators' Take on Trump's Statements

Ezra Kelin wrote a commentary for Vox published December 29.  Yuval Levin wrote a commentary for the National Review published the same day

President Trump's Health Care Policy Expertise

Klein wrote:

In psychology, there’s an idea known as the Dunning-Kruger effect. It refers to research by David Dunning and Justin Kruger that found the least competent people often believe they are the most competent because they 'lack the very expertise needed to recognize how badly they’re doing.' This dynamic helps explain comments like the one Trump makes here.

Association Health Plans, and Sales of Health Plans Across State Lines

Klein wrote:

I can, with some effort, untangle what Trump might have been trying to say here, but it’s so incoherent, so suffused with half-related ideas and personal obsessions (why did Trump feel the need to bring up McCain’s vote?), that it’s hard to say for sure.


At best, Trump is saying something that is comprehensible but incorrect. He signed an executive order making it easier to form association health plans, which are health plans formed by groups of small businesses, and making it easier for those plans to skirt Obamacare’s insurance regulations and to contain small businesses from multiple states.

As of now, and Trump doesn’t seem to realize this, it’s just an executive order — the rules defining and implementing it have not been written, so it is not yet happening, and we don’t know how it will work in practice, much less how many people may eventually sign up. Nor does the order get rid of the prohibition on selling insurance across state lines for most people — it’s only for this one kind of plan which can include members in multiple states, and which will only serve a tiny minority of the health insurance market.

Levin wrote:

My best guess is that at some point President Trump was briefed by his staff about the executive order he signed in October that, among other things, instructed his administration to expand the scope of association health plans. The word salad we find here is what remained of that briefing (or maybe of a conversation with a knowledgeable AHP supporter, like Rand Paul) after it was minced and digested by the president’s mind into a mess of little unconnected proofs of his own acumen and prowess. Trump appears to believe that millions of people are joining such plans, but in fact his order has yet even to be translated into a proposed rule, so that it has had no practical effect so far. He describes his order (I take it) as 'a big bill'—and this from the man who earlier in the same interview said  'I know more about the big bills. … [Inaudible.] … Than any president that’s ever been in office'. But maybe he just meant a big deal. He suggests that half of some presumably significant group of people will join such plans, and that in combination with the zeroing out of the individual mandate these plans will somehow drive Democrats to make a deal on health care.

The Affordable Care Act (ACA, "Obamacare") and Its Mandate

Neither commenator specifically addressed this issue

General Comments on Trump's Approach to Health Care

Both commentators were very concerned about Trump's approach beyond any questions of truthfullness of claims or arguments about whether proposed policies would be good for the country.

Klein wrote:

Whatever Trump is saying, it does not reveal much familiarity with health policy, or even with the status and limits of his own actions. And yet Trump believes himself, on policy, to be the most informed president in American history. As the Dunning-Kruger effect suggests, he doesn’t know how much he doesn’t know, and that, combined with his natural tendency toward narcissism, has left him dangerously overconfident in his own knowledge base.

Even worse:

This is the president of the United States speaking to the New York Times. His comments are, by turns, incoherent, incorrect, conspiratorial, delusional, self-aggrandizing, and underinformed. This is not a partisan judgment — indeed, the interview is rarely coherent or specific enough to classify the points Trump makes on a recognizable left-right spectrum.


I am not a medical professional, and I will not pretend to know what is truly happening here. It’s become a common conversation topic in Washington to muse on whether the president is suffering from some form of cognitive decline or psychological malady. I don’t think those hypotheses are necessary or meaningful. Whatever the cause, it is plainly obvious from Trump’s words that this is not a man fit to be president, that he is not well or capable in some fundamental way. That is an uncomfortable thing to say, and so many prefer not to say it, but Trump does not occupy a job where such deficiencies can be safely ignored.

Levin wrote:

After reading this, it is advisable to take a moment to wonder at the absurdity of life, to offer a quiet prayer of thanks for the fact that any of us is still alive, and then to pursue—yet again, and surely not for the last time—that recurring question of our era: What in the world is the president talking about?


I have no doubt these claims began as duly grounded and modest statements of fact in some policy discussion. But they have ended up as worse than nonsense—worse, I say, because the only function they are left to perform is to affirm the president’s belief in things that aren’t true.

This is a narrow example of a broader pattern, of course. It doesn’t matter all that much if the president doesn’t really know anything about Association Health Plans. He’s got bigger problems to worry about. But it’s hard to deny that he seems to approach those bigger problems in the same general way, and that the broader pattern is therefore itself a very big problem, given the nature and demands of the modern presidency.


We have frequently criticized the leadership of big health care organizations as ill-informed, incompetent, ignorant of or even hostile to the values of health care professionals, deceptive, self-interested, conflicted or even corrupt. The President of the United States is the country's most important health care leader, since all government agencies that deal with health, health care, health care policy, etc report to him.  Unfortunately, we have previously discussed examples of how the president appeared to be an ill-informed or incompetent health care leader, for example here

So it would be easy to just say that his responses in his recent interview as discussed above just corroborate this opinion. 

However, in his latest interview with a reporter from the New York Times, it was not that the President of the United States deferred on issues of health policy to health policy experts.  It was not that he was evasive, or exaggerated.  It was not that he advocated policies that were controversial.  It was not even that what he said was untrue.

As per the title of Levin's commentary, it was that the President created a word salad.  What he said often made no sense.

This goes way beyond ill-informed or incompetent leadership as we have used these terms previously.   When we have discussed incompetence, it was in the sense of ordinary English usage.  For example, per, incompetent means "lacking qualification or ability; incapable." 

We have seen many leaders of big health care organizations who did not seem to have adequate qualifications or abilities to run such organizations, even though they might be perfectly intelligent, well-educated, generally capable people.  Such leadership often seemed to be a consequence of the doctrine of managerialism promoted in business schools that people trained in management should lead every type of human organization and endeavor.  Management by people from the disciplines most relevant to the mission and nature of particular organizations should be eschewed.  So managers, not physicians or other health care professionals, should lead health care organizations.  Following that theme, managers, or those like them, rather than health care professionals and health policy experts should lead health policy. 

However, managers who run health care organizations, or make policy, have an unfortunate tendency to be ill-informed (as well as unsympathetic if not hostile to health care professionals' value and the health care mission, and subject to perverse incentives that often put short-term revenue ahead of the health of patients and the population.)

In one sense, President Trump is the ultimate embodiment of managerialism.  He is a life long businessman, whose highest academic training resulted in an MBA from the Wharton School, with no demonstrated knowledge of or experience in public policy, the law, or the US Constitution.  Yet for years he has felt free to make pronouncements about any subject which caught his eye. 

Yet as we first noted here, the problem goes beyond the ignorance about health care of the managerialist health care manager.  How he thinks about health care at times seems incoherent, confused, or demented.  Questions about the President's competence, in terms of his ability to sustain rational thought, have become a national concern (e.g., look here and here.)  An approach to this has got to be devised at the highest levels of US government, but independent of Mr Trump.

Meanwhile, in the hope that the country can recover from this, maybe the case of President Trump's word salad will remind us that we have to rethink who should become leaders of health care organizations.

Monday, January 01, 2018

A Remedy for Corruption

Do I really have a remedy for corruption? I wish I did. But, I have lately found an effective balm for the sickening discouragement that it is easy to feel when confronted day after day with another instance of the medical industry’s price-gouging corruption, purposeful distortions, and callous disregard of patient  welfare. That remedy is a new podcast from Australia: Ray Moynihan’s The Recommended Dose. 

If you don’t already recognize Moynihan’s name, he’s an author of Selling Sickness and he’s had a persistent interest in overdiagnosis and medicalization. He describes the podcast as “interviews promoting healthy questioning in medicine” and most, though not all, of the interviewees are medical professionals somehow associated with evidence-based medicine and/or Cochrane. Many interviewees have practiced in unfamiliar countries and settings; hearing about problems and issues there is broadening for a U.S. listener.

So far there are eight episodes, and not a dud in the lot. Moynihan interviews the people as human beings, not just as experts, so you get a real feeling for their lives and motivations, including background, interests, and motivations. He doesn’t hesitate to go a bit afield, as in Episode 7 where he interviews a novelist! His conversation with Sarah Moss covered literature and themes related to medicine very enjoyably.

Other episodes I particularly enjoyed were: 
  • Episode 2. Psychiatrist Allen Frances discusses mental health, including his role in the DSM and how he regrets the direction later editions have taken. On another topic, he thinks diagnosing Trump remotely with some psychiatric disorder is unenlightening; it’s more the US public, he says, that is insane than Trump.
  • Episode 4. South African Jimmy Volmink recounts how Cochrane was contacted by the government to look into the evidence for using antiretrovirals for prevention of mother-to-newborn HIV transmission; government officials stressed they were particularly interested in harms of these toxic chemicals. A big project resulted, concluding that side effects were comparatively minor, and the treatment tremendously effective. Decision makers (who had clamored for the study) then proceeded to disregard the results. That was an interesting insight into an environment where the pressures were to make treatments look less effective than they are rather than more effective than they are, as is generally the case in the U.S. setting. Volmink comments that people are “very keen to use evidence when it supports what they already want to do.” (Fortunately the study was still of great use when the Treatment Action Campaign took the government to court.)
  • Episode 6. Indian psychiatrist Prathap Tharyan discusses being on a team to assist people after a tsunami and what evidence shows people need after disasters (spoiler: it’s not mass debriefing/counselling for everyone). It concludes by a recording of Tharyan’s singing Leonard Cohen’s Alleluia; I feared it would be embarrassing, but it was sublime.
  • Episode 8. An optimistic interview with Julian Elliot, who is working on access to evidence including in low-income countries. His reflections on working on HIV treatment in Cambodia were interesting. But the highlight of the episode for me was when Moynihan reflected that there are two elements in science, innovation and evaluation. The public, Moynihan says, appreciates medical innovation, but not evaluation, important though it is. (What a factor that is in the many “medical reversals” Vinay Prasad and Adam Cifu write so eloquently about!) 
I have to compliment Moynihan on his excellent diction. I usually find Australians really hard work to listen to. Although Moynihan’s accent is strong, he speaks so clearly that it’s a pleasure to listen to him and not difficult for this American to understand what he’s saying at all.  Such beautiful clarity is a fantastic asset in making accessible the meat of the podcasts.

The Recommended Dose vividly showcases some of the many people who make medicine and life still wonderful and beautiful (in parts); and who live with intelligence, determination, courage, and humor despite obstacles.  That’s an excellent medicine for the heart and mind, and I recommend it without reservation.

Thursday, December 14, 2017

Transparency International US Corruption Barometer: Striking Increases in Public Perceptions of Government Corruption in the US, Especially in the White House

Introduction: Transparency International's 2017 Global Corruption Barometer US Results

Last month, Transparency International (TI) released the results of its 2017 US Corruption Barometer, a global survey of peoples' perceptions of the degree to which their national institutions are corrupt.  We discussed the results from the US, based on data collected in late 2016, which showed that

the US had results suggesting it has important problems with corruption.  More than one-third of US respondents thought that most executive branch leaders, legislators, and business executives are involved in corruption,  Just less than one-third thought that most government officials are involved in corruption.  More than one-half of US respondents thought that the government is handling the fight against corruption badly.  More than one-third thought that corruption had gotten worse in the previous year.  More than 20% thought it is not socially acceptable to report corruption.

Furthermore, the US had the worst results, compared to the other four developed countries, in four categories, and did not have the best results in any.

Unfortunately, since this data was collected no later than January, 2017, it did not reflect events during the Trump presidency.  There are reasons to think that things are now worse.

Since Trump's inauguration we have frequently posted about apparent conflicts of interest and corruption affecting health and health care policy and regulation under that regime. (Our most recent post was here. Older ones are included here.)

In particular, the Trump regime chose many people for health care leadership positions who would have to transit the revolving door from health care corporations to these new jobs.  In them they would be able to affect policies or regulations which could influence these same corporations.  The most striking recent example was the nomination of the former top US executive of global pharmaceutical company Eli Lilly to be Secretary of the Department of Health and Human Services, (look here.)

But the Global Corruption Barometer survey was done too early to be affected by these phenomena.  .

Transparency International's New 2017 US Corruption Barometer

However, this week Transparency International released results of a new 2017 US version of the Corruption Barometer.  It was based on data collected during the Trump regime, from October to November, 2017.  (The news release is here, and the full report is here.)   Its results were striking, and did corroborate our case based observations.

From the press release, here are the key results:

- 44 per cent of Americans believe that corruption is pervasive in the White House, up from 36 per cent in 2016.

- 58 per cent of people say the level of corruption has risen in the past twelve months, up from 34 per cent who said the same in January 2016.

- Almost 7 out of 10 people believe the government is failing to fight corruption, up from half in 2016.

- 55 per cent gave fear of retaliation as the main reason not to report corruption, up from 31 per cent in 2016.

- Close to a third of African-Americans surveyed see the police as highly corrupt, compared to a fifth across the survey overall.

- 74 per cent said ordinary people can make a difference in the fight against corruption, up 4 percentage points from 2016.

Note that:

In both 2016 and 2017, the Office of the President, members of Congress and government officials were seen as the most corrupt. In 2017, the White House overtook Congress.

Local government fared better than federal institutions, indicating that people place more trust in their representatives closer to home. Judges are seen as the least corrupt of the nine groups we asked about.

In constrast, the proportion of people who believe business executives are seriously involved with corruption was stable at 32%.


the survey revealed a worrying increase in those who say that the main reason people do not report corruption is because they are afraid of the consequences, up from 31 per cent in 2016 to 55 per cent in 2017. Sixteen per cent said the main reason people do not report corruption is because nothing will be done.

Here is a graphic from the report that shows the proportions of respondents who thought most or all of those who worked in particular institutuions were involved in corruption:

Here is a graphic form the report showing how well respondents thought the government is fighting corruption (2016 vs 2017):

Media Response

Unlike the 2017 Global Corruption Barometer report, the new US report got some media attention, at least there were reports by the Washington Post, Newsweek and NPR.

It was striking that all focused on how the public's opinion about Trump administration corruption was corroborated by an extensive series of cases, including those in health care that we discussed, but also many more.  The most extensive summary of cases was in Newsweek. 

Since before he took office, Trump and his family’s personal conflicts of interest, and his agencies’ revolving doors, have been widely reported on in the media and heavily criticized by ethics lawyers and government watchdogs.

While the president handed off day-to-day oversight of his company to his sons Eric and Donald Jr., his hotels and golf courses have become vehicles for lobbyists and foreign dignitaries to curry favor with the administration, and, in the case of the golf courses, actually meet and play with the golf-loving president.

Shortly before his election last year, the Trump campaign trotted out a new slogan and a five-point plan for ethics reform that featured new lobbying restrictions. The plan was called 'drain the swamp.'

But a year later, he had stocked his agencies with lobbyists for industries that were regulated by the agencies, and his administration has been rocked by almost daily legal and investigatory bombshells related to corruption. Trump is being sued in Maryland and Washington, D.C., for violating the 'emoluments clause' of the U.S. Constitution by running his Trump International Hotel in Washington, D.C.; Paul Manafort, the second Trump campaign manager, has been indicted on money-laundering charges; Trump’s first national security adviser, Michael Flynn, has pleaded guilty to lying to the FBI in an investigation that also uncovered secret lobbying work for the Turkish government; and his son-in-law, Jared Kushner, failed to disclose $1 billion in loans tied to his real estate company, and has repeatedly had to revise his financial-disclosure forms to add items he 'forgot.'

At least six Trump Cabinet secretaries are being investigated for or asked about exorbitant travel expenses, including using government planes for private business, security details or business dealings.

Cabinet members, including Veterans Affairs Secretary David Shulkin and Interior Secretary Ryan Zinke, have used travel to combine business with pleasure and fundraising. Shulkin took in a Wimbledon tennis game on business, and Treasury Secretary Steven Mnuchin reportedly spent at least $800,000 on nonwork travel, including a viewing of the August 21 solar eclipse. He also requested a jet for his honeymoon, and to take his wife to the Fort Knox gold reserve.

The president’s hiring of his daughter Ivanka and son-in-law are at odds with the federal anti-nepotism law, which states that 'a public official may not appoint, employ, promote, advance, or advocate for appointment, employment, promotion, or advancement, in or to a civilian position in the agency in which he is serving or over which he exercises jurisdiction or control any individual who is a relative of the public official.' His Justice Department gave him an exemption, however.

I would also note that the Sunlight Foundation has found that President Trump has over 600 conflicts of interest, and that his family has over 1100 (look here).


We have previously insisted that health care corruption is an important cause of US health care dysfunction, and that any efforts to truly reform health care require addressing health care corruption.  For example, here we said,

if we really want to reform health care, in the little time we may have before our health care bubble bursts, we will need to take strong action against health care corruption.  Such action will really disturb the insiders within large health care organizations who have gotten rich from their organizations' misbehavior, and thus taking such action will require some courage.

But in the US, since the beginning of the Trump regime, health care corruption appears to be getting worse, in the context of severely worsening corruption in the executive branch of government.

Transparency International modestly suggested its results indicate

our elected leaders in Washington have much more work to do to win back the trust of citizens
They did have concrete recommendations (detailed in the full report):

1. Transparency in political spending:

Make all spending on politics genuinely transparent, with:

- real-time information accessible in online, machine-readable form to the public

- transparency on political spending by publicly traded companies

- transparency to the public on every level of influence, from political ad campaigns, to lobbying, to bundled campaign contributions.

2. Prevention of revolving doors:

Stop the unchecked exchange of personnel among corporations, lobbyists and our elected and high-level government officials.

3. Establishing who owns what:

End the use of anonymous shell companies, which can be a source of conflict of interest and/or vehicles for illicit activity.

4. Strengthening the ethics infrastructure:

Reinforce the independence and oversight capabilities of the Office of Government Ethics.

5. Protection of whistleblowers:

Improve and implement laws and regulations to protect the whistleblowers who expose corruption and other misconduct by the government and its contractors.

6. Providing basic access to information:

Increase access to information about the government, as a means to empower the public to fight corruption.

IMHO these provide a good framework for immediate action.  However, it seems highly unlikely that given its record, the current regime would be interested in any of them.  But I live in hope.

Sunday, December 10, 2017

Heads They Win, Tails We Lose - Non-Profit Hospital Executives Paid Generously After They Were Shown the Door

On Health Care Renewal, we have been decrying American health care dysfunction since 2004.  For years, the US consistently has had the most expensive health care system of any developed country.  For that exhorbitant price, it provides at best medicocre access to and quality of care.  The latest (2017) international comparison of health systems produced by the Commonwealth Fund shows that the US spends about 16% of its gross domestic product (GDP) on health care, compared to less than 12% spent by 10 other countries.  The US ranked no better than fifth on performance rankings measuring care process, access, administrative efficiency, equity, and health care outcomes.  It had the worst access, equity and health outcomes.

Even given that some of the measures used are debatable, these are dismal results.  No wonder US physicians are demoralized and burnt-out, as we first noted in our 2003 article. [Poses RM.   A cautionary tale: the dysfunction of American health care. Eur J Intern Med 14 (2003) 123–130. Link here.] 

Health care dysfunction is commonly discussed in the US, especially since health care reform became a legislative priority during the Obama administration.  The resulting Affordable Care Act (ACA, "Obamacare") resulted in some improvement in access to health insurance, but problems with access, quality and cost remain.

It is hard to understand how such a dysfunctional system continues without considering who benefits from it. One group who greatly benefit is health care organizational managers.  We have frequently discussed their luxurious and ever increasing pay.  Furthermore, often their pay seems wildly disproportionate to their accomplishments.  For example, in June, 2017 we profiled the CEO of safety-net hospital who made over $1 million a year from an institution charged with caring for the poor.  His institution demonstrated no great achievements in clinical care or improving patient outcomes.  Meanwhile it was alleged that he tried to increase revenue via unethical means, and was even cozy with organized crime.  

Such executive compensation is rarely challenged, but when it is, the responses are formulaic.  Justifications are made by public relations flacks who are accountable to these executives, or the executives' cronies on their boards of trustees.  As I wrote in 2015,  and in May, 2016,  It seems nearly every attempt made to defend the outsize compensation given hospital and health system executives involves the same arguments, thus suggesting they were authored as public relations talking points. Additional examples appear here, here here, here, here, and here, here and here

They talking points are:
- We have to pay competitive rates
- We have to pay enough to retain at least competent executives, given how hard it is to be an executive
- Our executives are not merely competitive, but brilliant (and have to be to do such a difficult job).

As we discussed recently, these talking points are easily debunked.  Additionally, rarely do those who mouth them in support of a particular leader show evidence that they apply to that leader. Could so many highly paid executives be so brilliant?

Instead we now we present cases from the second part of 2017 in which non-profit hospital executives were given lavish compensation just after they were forced out of their jobs.In alphabetical order by the states in which the hospitals are located...

Florida: Broward Health Vice President Got $214,008 After Allegations of Improper Payments Lead to Resignation

As reported by the Broward County (FL) Sun-Sentinel first on August 7, 2017,

Doris Peek resigned July 20 as senior vice president of Broward Health, which runs five hospitals and various clinics, after a law firm hired by Broward Health accused her of improperly directing nearly $1.7 million to a company owned by a prominent Republican consultant. At the time of the report, Broward Health released a statement saying that it took the report 'very seriously' and that 'every individual at Broward Health is held accountable in order to uphold established legal and ethical standards.'

Peek’s severance agreement, released by Broward Health in response to a public records request from the Sun-Sentinel, states that she will receive $214,008, most of which represents six months’ severance and the rest accrued leave.

Under the agreement, signed by Broward Health interim chief executive officer Beverly Capasso, Peek may cooperate with any government investigators or regulators looking into Broward Health, a taxpayer-supported system legally known as the North Broward Hospital District. But she promised to not take Broward Health to court and 'not engage in any activity either oral or written which disparage or adversely affect Broward Health.'

Such non-disparagement clauses are common in severance agreements, although they have been criticized for allowing employers to cover up problems.

The hospital administration gave no clear reason for the generosity of the agreement.  

Asked why Broward Health would agree to such a payment, considering the highly critical contents of the report, Broward Health’s public relations agency, EvClay Public Relations, released this statement: 'It is the policy of Broward Health to not discuss severance agreements.' Pressed on the reason for this, the agency provided this statement: 'We respect the privacy of our employees.'

Given the placement of the non-disparagement clause in the agreement it is worth considering that the interim CEO, Ms Beverly Capasso, who approved the contract, was also under a cloud at the time it was written. The Sun Sentinel had previously reported,

The new chief executive of Broward’s largest public hospital system holds a master’s degree in health administration from a defunct university that has been identified by federal investigators as a diploma mill.

Beverly Capasso, who was just awarded a $650,000 annual salary to run Broward Health, received the degree from Kennedy-Western University, a mail and online institution based in California and Wyoming that closed in 2009 after failing to gain accreditation. Her resume invokes the degree at the very top, giving her name as 'Bev Capasso RN, BSN MHA.'

Furthermore, soon after the severance agreement was announced, the Sun-Sentinel reported more resignations among Broward Health management,

Two more top Broward Health executives quit this week, deepening the leadership turmoil at the taxpayer-supported hospital system.

Dionne Wong, senior vice president for human resources, and Mark Sprada, interim chief executive of Broward Health Medical Center in Fort Lauderdale, both resigned. 

And in the months since, other major management problems became apparent.

The resignations come after Broward Health’s credit rating was lowered last month by S&P Global Ratings, which cited weak financial results and the leadership turmoil at the troubled system, legally known as the North Broward Hospital District.

After that, the hospital system was also alleged to have given a no-bid contract to 21st Century Oncology, allegedly with the involvement of Florida governor Rick Scott (News-Press, September 25); and  has been under grand jury investigation for violations of the open meeting law (Sun-Sentinel, September 26).

Ms Peek was allegedly involved in improper contracting.  While Ms Peek may not have been responsible for all the additional trouble and turmoil at the hospital system, she surely participated in it.  On the other hand, there is no obvious offsetting evidence of the brilliance of her management.    Why reward her with such a generous severance package?

Georgia: South Georgia Medical Center CEO Will Get More than $2M After Allegations of Violations of Open Meeting Law Lead to Termination

As reported by the Valdosta (GA) Daily Times, July 6, 2017,

The former South Georgia Medical Center CEO will be paid more than $2 million over the next three years, for doing nothing.

Raymond Snead was ousted as CEO in March, but he’ll stay on the payrolls for a while, according to his termination letter.

The April 19, 2017 letter, effectively firing Snead, called the ouster a 'termination without cause.'

The hospital will continue to pay Snead $650,000 per year — his base annual salary — for the next three years, the letter says. He’ll also get a $2,000 car allowance each month during that period.

The local Hospital Authority, which governs the hospital, also gave Snead and his wife the option to receive health benefits for the three years. He took the offer, said Sam Allen, Hospital Authority chairman.

However, it appears that this executive also had not previously covered himself in glory, certainly not sufficient to justify this level of post-employment compensation.

Snead became CEO in September 2015, and the hospital had been under fire for poor management practices under his watch.

There also was a major issue with an apparent subordinate of Snead's on his watch.

Snead’s ouster came on the heels of the resignation of hospital attorney Walter New.

New, along with the entire Hospital Authority, got into trouble in 2016 when the group held a closed meeting without the public’s knowledge, which is a violation of Georgia law.

Furthermore, City Councilman Robert Yost

has called repeatedly for the resignations of Hospital Authority members, saying their mismanagement has caused the hospital great harm. 'They have run the ER into the ground. They have run off doctors, nurses and regular employees, some who have worked there for 25 to 30 years,” he said at the June 22 City Council meeting.

'They have intimidated employees and treated them like dirt. When it is time to reappoint the City of Valdosta’s representatives on this authority, I say let’s make sure they are all reappointed.'

'… (They) have again made very bad business decisions on our behalf and they should all be fired.'

Again, it seems that Snead's management was the opposite of brilliant, yet he was allowed to walk away with a multi-million dollar severance package. 

North Carolina: Nash UNC Health Center CEO Will Get More than $1M After Concerns about Revenue Losses and Patient Safety Lead to Retirement

As reported by the Rocky Mount (NC) Telegram, July 16, 2017, Larry Chewning the CEO of Nash UNC Health Care retired

with around $1 million since he has an ironclad two-year rolling contract, according to multiple sources familiar with the situation but not authorized to speak publicly on the matter.

Chewning didn't deny the amount he is receiving....

However, it turns out that he did not actually retire, but,

was asked to step down late last month by the local hospital board but was allowed to announce he was retiring.

The hospital was hardly transparent about the facts of the case, which were futher confused by (perhaps deliberately) complicated corporate relationships:

Inquiries into Chewning's salary and severance package led the Telegram on a goose chase involving lawyers, public relations spokesmen and uninformed officials.

Beginning with Chewning, there has been a series of refusals to disclose the salary of the top executive at a publicly-owned hospital in a state-owned network of hospitals. Drilling down, it was discovered that all the CEOs in the UNC system except for the UNC Medical Center in Chapel Hill are employed by Rex Hospital, a privately-owned hospital in Raleigh.

'I am legally precluded from disclosing any information from my employment agreement with Rex Hospital,' Chewning said, including the contact information for Don Esposito, Rex Hospital's general counsel.

Esposito referred the Telegram to Alan Wolf, the media relations manager for UNC Health Care and UNC REX Healthcare.

'We comply with all legal requirements, but it's not our practice to disclose salary information, for competitive and privacy reasons,' Wolf said. 'Mr. Chewning is employed by Rex Hospital Inc., which is not a North Carolina governmental entity and therefore is not subject to Chapter 132, the Public Records Act.'
How public hospitals can have CEOs who are employees of a separate, private hospital system was not explained.

Even local government officials were kept in the dark.

Nash County officials said they understood that's they way it had to be, but none of them knew the CEO was being paid through Rex, which makes their salaries private.


At least one member of the local hospital board said they don't understand how the process works and isn't sure how the hospital will get a new CEO. 'As part of the management agreement, UNC Health Care provides Nash with a CEO,' Wolf said. 'Having a centralized management team gives UNC Health Care more control over decisions and operations at its affiliated hospitals.'

But the hospital CEOs "provided" by state institution UNC all are employed by Rex?

Perhaps all this secrecy just added to the cognitive dissonance created when considering how Chewning's lucrative retirement package might have been related to events that lead up to Chewning's retirement:

Chewning's exit comes after the hospital has been losing money and in the wake of a negative patient safety report. Chewning will remain with the hospital while his replacement is sought, according to his retirement announcement.

So Chewning's management was hardly brilliant.  Yet those responsible for hospital governance were not only happy to let the CEO walk away with a munificent retirement package, they also did their best to obscure the facts of the matter

Ohio: Ohio State University Werner Medical Center CEO Receiving More than $1M Per Year as Senior Consultant After Complaints by Physicians Lead to Resignation

According to the Columbus (OH) Dispatch, August 16, 2017, after Dr Sheldon Retchin, the CEO of Ohio State University Wexner Medical Center resigned in May, but

from his resignation, which was announced on May 10, through June 30, Retchin was still paid the CEO and executive vice president salary and benefits for performing 'transitional duties,...

That base salary was $1.1 million.

[To make full disclosure, note that I was a colleague of Dr Retchin's when we were both young  faculty members in the Department of Internal Medicine at the Medical College of Virginia from 1987 - 1994.]


a contract obtained by the The Dispatch on Tuesday shows that, since July 1, Retchin has been serving as senior advisor to the president for health policy at a base salary of $500,000 annually.  The university is also making a $600,000 annual contribution to a retirement plan for Retchin, who will hold the position for two years.

So his total compensation would be at least $1.1 million a year for two years post-retirement.  Also,

the new contract says he will be paid a 35 percent performance bonus.

The rationale for this new position per university spokesman Chris Davey was that

Retchin will make important contributions to Ohio State.

'Sheldon Retchin is a nationally known leader in health-care policy,' Davey said. 'During his two-year administrative appointment, he will advise the university concerning the critical issues of health-care reform, Medicaid policy and data-driven improvements to health outcomes.'

Left unsaid is that $1.1 million a year seems like greatly inflated compensation for a health policy adviser.

Also left unsaid were the circumstances surrounding Dr Retchin's departure.

Complaints against Rechin surfaced after a May 1 letter signed by 25 leading physicians criticized his leadership.  That was followed by a letter from five doctors representing the senior leadership of the medical center's Neurological Institute.  Another group of 14 physicians, who head clinical departments at the medical center, had engaged in discussions with top university l eaders.

Upon Retchin's resignation, the university issued a statement in which it said that allegations raised in the letters were untrue.  That prompted another critical letter from leaders in the College of Medicine's Department of Internal Medicine.

A report from a local television station's news department provided further details about why the physicians declared no confidence in Dr Retchin

Dozens of doctors and professors have written letters expressing 'no confidence' in the CEO of Ohio State's Wexner Medical Center.

10TV has obtained three letters from three different groups of doctors and staff members, including department chairs and senior leadership.

They all described problems with management and morale that they said are damaging care and endangering patients and issued a 'Vote of No Confidence' in CEO Sheldon Retchin and his leadership team.

They accused Retchin of a 'management style that is inconsistent with the University's values of excellence, integrity, transparency and trust' and of fostering a culture where physicians have been described as 'lazy' and the program called 'a complete mess.'

It has led to what they call a 'dramatic impact on morale' and 'an increasing number of faculty resignations.'

They said the consequences reach beyond the walls of the Wexner citing an ongoing shortage of doctors which in their words, 'endanger(s) patient safety and lowers the quality of care,' adding to the stress of remaining faculty.


In the first letter, 25 staffers who signed it said they represent many more employees, but limited the number signing out of concern for retaliation.

They complained of threats against faculty leaders who don't 'get on board' with the plans of medical center leadership.

From the information publicly available, I cannot tell whether the complaints about patient safety and quality of care are valid.  Certainly, however, Dr Retchin's management was questionable.  Creating this degree of anger among the physician staff of an academic medical center hardly seems the mark of brilliant leadership.  Yet Dr Retchin, like the other executives above, seems to have been generously rewarded after he was forced out.


The plutocratic compensation given leaders of non-profit hospitals is usually justified by the need to competitively pay exceptionally brilliant leaders.  Yet even leaders whose records seem to be the opposite of brilliance often end up handsomely rewarded.  Thes are examples of perverse incentives.

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

Exalted pay of hospital managers occurred after managers largely supplanted health care professionals as leaders of health care organizations.  This is part of a societal wave of "managerialism."  Most organizations are now run by generic managers, rather than people familiar with the particulars of the organizations' work.  The best current example is the election of a business executive with an MBA to the Presidency of the United States.

Rather than putting patient care first, paying managers sufficiently to make them rich now seems to be the leading goal of hospitals. I postulate that managerialism is a major reason the US health care system costs much more than that of any other developed country, while providing mediocre access and health care quality.

Improving the situation might first require changing regulation of executive compensation practices in hospitals, improving its oversight, and making hospital boards of trustees more accountable.  But that would be just a few small steps in the right direction

True health care reform might require something more revolutionary, the reversal of the managers' coup d'etat, returning leadership of health care to health care professionals who actually care about patients and put their and the public's health first, ahead of their personal gain.  Of course, that might not be possible without a societal revolution to separate managers from the levers of power in government, industry, and non-profit organizations.