More on Hospital Executives' Disproportionate Pay

Local US news media brought some more striking examples of disproportionate pay given to health care organizational leaders. 

Carolinas HealthCare System: Corporate-Style Compensation for a Public Hospital CEO

Carolinas HealthCare System declares it is "the largest health care system in the Carolinas and the third largest public system in the nation" in its membership blurb for the National Association of Public Hospitals and Health Systems.  That association describes its members thus,

Since the establishment of the first public hospital in the United States in the early 1700s, safety net hospitals and health systems have been an essential part of our nation’s health care delivery system.

In the 21st century, safety net hospitals continue their long tradition of quality and service to the community. By delivering care to America’s growing number of working uninsured families, providing world-class trauma and emergency care, preparing for and responding to the threat of terrorism, epidemics, and natural disasters, and training the next generation of doctors, nurses, and dentists—safety net health systems ensure our nation’s communities are health and strong.

The Charlotte Observer just noted how much this "safety net hospital," which declared solidarity with "working uninsured families," pays its CEO:

Carolinas HealthCare System paid its CEO $3.7 million in 2010, $287,000 more than the year before as the system lifted a pay freeze and paid bonuses for reaching annual and long-term goals.

Chief Executive Officer Michael Tarwater, 57, who has led the $6.3 billion public hospital system for nine years, received a base salary of $986,172, two bonuses totaling $2 million, and other compensation, including retirement and health benefits, of $630,346.

In 2009 his compensation package totaled $3.4 million.

So the leader of an organization that serves the poor and uninsured gets enough compensation to make him  quite rich.    

Mary Washington Healthcare: Net Income Increases, but 20% Goes to Bonuses of Top 20 Executives

According to the Fredricksburg (Virginia) Free Lance-Star, from 2008 to 2009, Mary Washington Healthcare saw its total revenues increase, but its net surplus decrease,

The company's net income was $25 million in 2008, up from $20 million in 2007.

Then

The company opened its second hospital that year [2009] and recorded revenues of more than $666 million, up from $551 million in 2008. However, net income dropped to $8 million, in part because of the opening of Stafford Hospital.

So what happened to its executive compensation?

The top employees at Mary Washington Healthcare earned more than $1.1 million in bonuses in 2009, their reward for a successful 2008.

More than two dozen key executives and employee physicians earned annual bonuses ranging from $2,000 to $246,278. The median bonus for the company was more than $28,000.

Fred Rankin, president and chief executive officer, received the largest bonus among managers: $151,430. Rankin continues to be the firm's highest-paid employee, with a 2009 salary package of $955,282.

The hospital's net income increased $5 million (25%) from 2007 to 2008.  It then dropped $17 million (66%) from 2008 to 2009.  Reflecting 2008 results, its top 20 executives received 2009 bonuses of over $1 million, an amount that exceeded 20% of the hospital's 2008 net revenue increase on which the bonuses were based.  The total compensation of these 20 people in 2009 was approximately $6.5 million (see here), which exceeded the hospital's entire increase in net revenue from 2007 to 2008.  The hospital CEO's compensation in 2009 would have consumed one-eighth of the net revenue that year.  This all suggests that the top executives of this hospital consume an inordinate part of the organization's total revenue stream.    

Hutcheson Medical Center: CEO Compensation and Deficits Rise

Here is how the Rome News-Tribune described the financial status of Hutcheson Medical Center, located in Fort Oglethorpe, Georgia:

HMC reported a profit of $766,766 in 2007 and a $7.3 million loss in 2009.

In addition,

In 2008 more than 80 Hutcheson employees lost their jobs when the hospital eliminated its emergency medical services.

And after the profitable year of 2007, the Hutcheson administration approved major renovations for the hospital’s front lobby and entered into a $35.5 million dollar bond issue to fund further renovations and pay off debt.

That bond issue is currently in default, which prohibits the next $10 million payment from being released to HMC.

Things look worse in the future:

At a meeting Thursday, Jan. 28, of the Hospital Authority Board, HMC chief financial officer Gerald Faircloth revealed that the hospital had losses of $3.3 million in the first quarter of budget year 2011 and projected total 2011 losses at around $9 million.

Faircloth, whose compensation went down by $15,000 from 2008 to 2009, also reported that HMC has an estimated 15 days of operating cash on hand.

'So the wolf is at the door,' said Bill Cohen, a trustee who represents Catoosa County on the Hospital Authority Board.

Faircloth agreed.

Wolves notwithstanding, however, the Hutcheson CEO has done very well:

In the face of Hutcheson Medical Center’s financial losses over the past several years, financial documents reveal that president and CEO Charles Stewart’s compensation package has increased more than 26 percent from 2007 to 2009.

According to Internal Revenue Service documents for the 2007 and 2009 budget years, Stewart received $337,081 and $425,745, respectively, in total compensation. The Fort Oglethorpe hospital’s budget year runs from October through September.

Stewart’s 2009 income includes a “bonus and incentive compensation” of $69,750.

So despite a major financial loss, lay-offs and service discontinuations, and a bond default, the CEO got "bonus and incentive compensation" in 2009.   At least that drew some attention:

'I’m really surprised that the board (Stewart) works for would give him such an increase,' said Walker County commissioner Bebe Heiskell, referring to the HMC board of directors that oversees the day-to-day operations of the hospital. 'For a failing hospital that’s exorbitant.'

So while the hospital's financial performance continued to decline, the total compensation provided its CEO continued to increase.

Summary

Here were three instances in which the compensation of top non-profit hospital leaders seemed out of all proportion to the hospitals' financial results, let alone their accomplishment of their missions. In the first case, the CEO of a public hospital system meant to serve poor and uninsured patients was paid enough in one year to make him an instant multi-millionaire. In the second, the bonuses alone handed out to a handful of top executives ostensibly based on a net revenue increase would have consumed one-fifth of that increase, and when net revenue declined the next year, those executives' compensation would have almost consumed that entire year's net revenue. In the third, a CEO got increasing compensation while his hospital suffered increasing losses.

As we have said before, far too often the leaders of not-for-profit health care institutions seem more interested in padding their own bottom lines than upholding the institutions' missions. They often seem entirely unaware of their duty to put those missions ahead of their own self-interest. Like the financial services sector in the era of "greed is good," health care too often seems run by "insiders hijacking established institutions for their personal benefit." True health care reform would encourage leadership of health care who understand health care and care about its mission, rather than those who see a quick way to make a small fortune.

More on Hospital Executives' Disproportionate Pay

Local US news media brought some more striking examples of disproportionate pay given to health care organizational leaders. 

Carolinas HealthCare System: Corporate-Style Compensation for a Public Hospital CEO

Carolinas HealthCare System declares it is "the largest health care system in the Carolinas and the third largest public system in the nation" in its membership blurb for the National Association of Public Hospitals and Health Systems.  That association describes its members thus,

Since the establishment of the first public hospital in the United States in the early 1700s, safety net hospitals and health systems have been an essential part of our nation’s health care delivery system.

In the 21st century, safety net hospitals continue their long tradition of quality and service to the community. By delivering care to America’s growing number of working uninsured families, providing world-class trauma and emergency care, preparing for and responding to the threat of terrorism, epidemics, and natural disasters, and training the next generation of doctors, nurses, and dentists—safety net health systems ensure our nation’s communities are health and strong.

The Charlotte Observer just noted how much this "safety net hospital," which declared solidarity with "working uninsured families," pays its CEO:

Carolinas HealthCare System paid its CEO $3.7 million in 2010, $287,000 more than the year before as the system lifted a pay freeze and paid bonuses for reaching annual and long-term goals.

Chief Executive Officer Michael Tarwater, 57, who has led the $6.3 billion public hospital system for nine years, received a base salary of $986,172, two bonuses totaling $2 million, and other compensation, including retirement and health benefits, of $630,346.

In 2009 his compensation package totaled $3.4 million.

So the leader of an organization that serves the poor and uninsured gets enough compensation to make him  quite rich.    

Mary Washington Healthcare: Net Income Increases, but 20% Goes to Bonuses of Top 20 Executives

According to the Fredricksburg (Virginia) Free Lance-Star, from 2008 to 2009, Mary Washington Healthcare saw its total revenues increase, but its net surplus decrease,

The company's net income was $25 million in 2008, up from $20 million in 2007.

Then

The company opened its second hospital that year [2009] and recorded revenues of more than $666 million, up from $551 million in 2008. However, net income dropped to $8 million, in part because of the opening of Stafford Hospital.

So what happened to its executive compensation?

The top employees at Mary Washington Healthcare earned more than $1.1 million in bonuses in 2009, their reward for a successful 2008.

More than two dozen key executives and employee physicians earned annual bonuses ranging from $2,000 to $246,278. The median bonus for the company was more than $28,000.

Fred Rankin, president and chief executive officer, received the largest bonus among managers: $151,430. Rankin continues to be the firm's highest-paid employee, with a 2009 salary package of $955,282.

The hospital's net income increased $5 million (25%) from 2007 to 2008.  It then dropped $17 million (66%) from 2008 to 2009.  Reflecting 2008 results, its top 20 executives received 2009 bonuses of over $1 million, an amount that exceeded 20% of the hospital's 2008 net revenue increase on which the bonuses were based.  The total compensation of these 20 people in 2009 was approximately $6.5 million (see here), which exceeded the hospital's entire increase in net revenue from 2007 to 2008.  The hospital CEO's compensation in 2009 would have consumed one-eighth of the net revenue that year.  This all suggests that the top executives of this hospital consume an inordinate part of the organization's total revenue stream.    

Hutcheson Medical Center: CEO Compensation and Deficits Rise

Here is how the Rome News-Tribune described the financial status of Hutcheson Medical Center, located in Fort Oglethorpe, Georgia:

HMC reported a profit of $766,766 in 2007 and a $7.3 million loss in 2009.

In addition,

In 2008 more than 80 Hutcheson employees lost their jobs when the hospital eliminated its emergency medical services.

And after the profitable year of 2007, the Hutcheson administration approved major renovations for the hospital’s front lobby and entered into a $35.5 million dollar bond issue to fund further renovations and pay off debt.

That bond issue is currently in default, which prohibits the next $10 million payment from being released to HMC.

Things look worse in the future:

At a meeting Thursday, Jan. 28, of the Hospital Authority Board, HMC chief financial officer Gerald Faircloth revealed that the hospital had losses of $3.3 million in the first quarter of budget year 2011 and projected total 2011 losses at around $9 million.

Faircloth, whose compensation went down by $15,000 from 2008 to 2009, also reported that HMC has an estimated 15 days of operating cash on hand.

'So the wolf is at the door,' said Bill Cohen, a trustee who represents Catoosa County on the Hospital Authority Board.

Faircloth agreed.

Wolves notwithstanding, however, the Hutcheson CEO has done very well:

In the face of Hutcheson Medical Center’s financial losses over the past several years, financial documents reveal that president and CEO Charles Stewart’s compensation package has increased more than 26 percent from 2007 to 2009.

According to Internal Revenue Service documents for the 2007 and 2009 budget years, Stewart received $337,081 and $425,745, respectively, in total compensation. The Fort Oglethorpe hospital’s budget year runs from October through September.

Stewart’s 2009 income includes a “bonus and incentive compensation” of $69,750.

So despite a major financial loss, lay-offs and service discontinuations, and a bond default, the CEO got "bonus and incentive compensation" in 2009.   At least that drew some attention:

'I’m really surprised that the board (Stewart) works for would give him such an increase,' said Walker County commissioner Bebe Heiskell, referring to the HMC board of directors that oversees the day-to-day operations of the hospital. 'For a failing hospital that’s exorbitant.'

So while the hospital's financial performance continued to decline, the total compensation provided its CEO continued to increase.

Summary

Here were three instances in which the compensation of top non-profit hospital leaders seemed out of all proportion to the hospitals' financial results, let alone their accomplishment of their missions. In the first case, the CEO of a public hospital system meant to serve poor and uninsured patients was paid enough in one year to make him an instant multi-millionaire. In the second, the bonuses alone handed out to a handful of top executives ostensibly based on a net revenue increase would have consumed one-fifth of that increase, and when net revenue declined the next year, those executives' compensation would have almost consumed that entire year's net revenue. In the third, a CEO got increasing compensation while his hospital suffered increasing losses.

As we have said before, far too often the leaders of not-for-profit health care institutions seem more interested in padding their own bottom lines than upholding the institutions' missions. They often seem entirely unaware of their duty to put those missions ahead of their own self-interest. Like the financial services sector in the era of "greed is good," health care too often seems run by "insiders hijacking established institutions for their personal benefit." True health care reform would encourage leadership of health care who understand health care and care about its mission, rather than those who see a quick way to make a small fortune.

The Hot Spotters Lower Medical Costs

Author physician, Atul Gawande has done it again with his well written article in The New Yorker magazine called, The Hot Spotters.  It deals with the fact that 5% of people with chronic illness make up over 50% of all health costs.  If we can zero in on providing better preventive care for those people, we can finally get our arms around runaway health costs.   How great that you don't even have

HITECH and Funding Cuts: The Battle Begins

At "US House of Representatives Proposes to Defund Largest Non-Consented Medical Experiment in U.S. History: HITECH" I predicted this:

... I have no financial conflicts of interest regarding HITECH or health IT to weep about. Others do, and it's not hard to predict their financial interests will push them to oppose repeal "by any means necessary."

The next few months should be an interesting time in the politics of healthcare IT.

A replacement HITECH act that's "HI" on research and caution, but not so "HIGH" on stealth, coercion and euphoria (i.e., as on mind altering substances) would be welcomed.

The battle's already begun. At "Meaningful Use incentives jeopardized by GOP bill", Jan. 28, 2011 by at Dan Bowman at FierceHealthIT.com, views exactly as I expected have begun being proffered by the industry:

... All of that [possibility of HITECH funding termination] has HIMSS Vice President for government relations Dave Roberts just a little on edge, reports Healthcare IT News.

"We're trying to tell people that this process is going on. This is only one body [of Congress]. Don't let this be a concern," he said. But "if this is a new way of thinking, that could be concerning. So I think that while this particular bill may not pass, it's something that has to be watched closely."

Patti Dodgren, CEO of Hielix--which helps to facilitate electronic health information exchanges across the U.S., shares Roberts' view. [Any possible conflicts of interest towards full-speed-ahead-damn-the-torpedoes health IT diffusion in that role, I ask? - ed.]

"Just the suggestion of repealing HITECH stimulus funds for physicians...is short-sighted at best, and threatens the very progress that is already beginning to be realized within the industry to move our healthcare system into the 20^th [yes, 20th] Century," Dodgren told FierceHealthIT. "All this bill serves to do is strengthen the cynics of health IT.

[Translation: "short sighted" and "cynic" = those more interested in taking the time to do health IT "right" and in patient rights and patient well being, than in personal gain - ed.]

We work with thousands of physicians and state government healthcare officials who have worked tirelessly over the past months to achieve the benefits that healthcare IT promises [no, Ms. Dodgren, they haven't, actually; you and they have merely encouraged a rushed, cavalier and reckless rollout (of a technology even HIMSS' former Chairman of the Board, a physician, admitted is not ready), damaging - not helping - health IT's prospects. See below - ed.], and this bill is a disservice to them and to the healthcare industry."

It may be a "disservice" to those who stand to profit from the health IT industry, but it's a great service to the healthcare industry and to the patients it serves.

I didn't really need to look, as experience at HC Renewal has proven time and again about the healthcare pundits, but the credentials of someone making such claims about health IT are not impressive IMO.

From an online bio, Ms. Dodgren holds the illustrious "CPHIMS" certification that I wrote about at my April 2008 post "Is the HIMSS Certified Professional in Healthcare Information and Management Systems stamp substantive, or just alphabet soup?". After 8 years as Director Budgeting & Financial Systems at (now-defunct) Digital Equipment Corp. (DEC) and 4 years as Senior Business Analyst at Dun & Bradstreet, she has been a "change management professional" for twenty years who "co-founded a management consulting practice which specializes in the application of change management principles to health information technology." I note no medical (or medical informatics) training or experience.

My reply to these people is as follows, as posted in a FierceHealthIT comment:

By S Silverstein MD | Posted 7:09pm | January 30, 2011

Patti Dodgren and Dave Roberts seem to favor continuation of a risky and even harmful national medical experiment that does not even have the fundamental decency to seek patient informed consent.

See http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html for examples of some of the risks.

The former Board Chair of HIMSS, Barry Chaiken, MD, MPH, FHIMSS said it best in July 2010:

http://histalk2.com/2010/07/19/histalk-interviews-barry-chaiken/

... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better.

Let the industry learn the responsible way, not on patients' and physicians' blood, sweat and tears through way-too-early national initiatives that will only add to the $14 trillion national debt (http://www.usdebtclock.org/), and throw some of the money into industry pockets.

Franky, as a physician with no financial conflict-of-interest axes to grind, I am increasingly disgusted with the cavalier, money-grubbing attitudes of the health IT industry and its pundits. Their attitudes and behaviors represent a poster study of healthcare industry at its worst.

This latter fact is not lost on me as I speak with government representatives seeking to improve medical drug/device watchdog legislation, and to attorneys looking to protect patients from harm or gain recompense for those already injured as a result of faulty IT.

-- SS

HITECH and Funding Cuts: The Battle Begins

At "US House of Representatives Proposes to Defund Largest Non-Consented Medical Experiment in U.S. History: HITECH" I predicted this:

... I have no financial conflicts of interest regarding HITECH or health IT to weep about. Others do, and it's not hard to predict their financial interests will push them to oppose repeal "by any means necessary."

The next few months should be an interesting time in the politics of healthcare IT.

A replacement HITECH act that's "HI" on research and caution, but not so "HIGH" on stealth, coercion and euphoria (i.e., as on mind altering substances) would be welcomed.

The battle's already begun. At "Meaningful Use incentives jeopardized by GOP bill", Jan. 28, 2011 by at Dan Bowman at FierceHealthIT.com, views exactly as I expected have begun being proffered by the industry:

... All of that [possibility of HITECH funding termination] has HIMSS Vice President for government relations Dave Roberts just a little on edge, reports Healthcare IT News.

"We're trying to tell people that this process is going on. This is only one body [of Congress]. Don't let this be a concern," he said. But "if this is a new way of thinking, that could be concerning. So I think that while this particular bill may not pass, it's something that has to be watched closely."

Patti Dodgren, CEO of Hielix--which helps to facilitate electronic health information exchanges across the U.S., shares Roberts' view. [Any possible conflicts of interest towards full-speed-ahead-damn-the-torpedoes health IT diffusion in that role, I ask? - ed.]

"Just the suggestion of repealing HITECH stimulus funds for physicians...is short-sighted at best, and threatens the very progress that is already beginning to be realized within the industry to move our healthcare system into the 20^th [yes, 20th] Century," Dodgren told FierceHealthIT. "All this bill serves to do is strengthen the cynics of health IT.

[Translation: "short sighted" and "cynic" = those more interested in taking the time to do health IT "right" and in patient rights and patient well being, than in personal gain - ed.]

We work with thousands of physicians and state government healthcare officials who have worked tirelessly over the past months to achieve the benefits that healthcare IT promises [no, Ms. Dodgren, they haven't, actually; you and they have merely encouraged a rushed, cavalier and reckless rollout (of a technology even HIMSS' former Chairman of the Board, a physician, admitted is not ready), damaging - not helping - health IT's prospects. See below - ed.], and this bill is a disservice to them and to the healthcare industry."

It may be a "disservice" to those who stand to profit from the health IT industry, but it's a great service to the healthcare industry and to the patients it serves.

I didn't really need to look, as experience at HC Renewal has proven time and again about the healthcare pundits, but the credentials of someone making such claims about health IT are not impressive IMO.

From an online bio, Ms. Dodgren holds the illustrious "CPHIMS" certification that I wrote about at my April 2008 post "Is the HIMSS Certified Professional in Healthcare Information and Management Systems stamp substantive, or just alphabet soup?". After 8 years as Director Budgeting & Financial Systems at (now-defunct) Digital Equipment Corp. (DEC) and 4 years as Senior Business Analyst at Dun & Bradstreet, she has been a "change management professional" for twenty years who "co-founded a management consulting practice which specializes in the application of change management principles to health information technology." I note no medical (or medical informatics) training or experience.

My reply to these people is as follows, as posted in a FierceHealthIT comment:

By S Silverstein MD | Posted 7:09pm | January 30, 2011

Patti Dodgren and Dave Roberts seem to favor continuation of a risky and even harmful national medical experiment that does not even have the fundamental decency to seek patient informed consent.

See http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html for examples of some of the risks.

The former Board Chair of HIMSS, Barry Chaiken, MD, MPH, FHIMSS said it best in July 2010:

http://histalk2.com/2010/07/19/histalk-interviews-barry-chaiken/

... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better.

Let the industry learn the responsible way, not on patients' and physicians' blood, sweat and tears through way-too-early national initiatives that will only add to the $14 trillion national debt (http://www.usdebtclock.org/), and throw some of the money into industry pockets.

Franky, as a physician with no financial conflict-of-interest axes to grind, I am increasingly disgusted with the cavalier, money-grubbing attitudes of the health IT industry and its pundits. Their attitudes and behaviors represent a poster study of healthcare industry at its worst.

This latter fact is not lost on me as I speak with government representatives seeking to improve medical drug/device watchdog legislation, and to attorneys looking to protect patients from harm or gain recompense for those already injured as a result of faulty IT.

-- SS

US House of Representatives Proposes to Defund Largest Non-Consented Medical Experiment in U.S. History: HITECH

In a new bill in the House of Representatives, the ‘‘Spending Reduction Act of 2011’’ (link - PDF), it is proposed to cut unobligated funds of, among others, division A of the "American Recovery and Reinvestment Act of 2009":

Spending Reduction Act of 2011

... TITLE III—RESCISSION OF UNOBLIGATED STIMULUS FUNDS AND REPEAL OF CERTAIN STIMULUS PROVISIONS

SEC. 301. RESCISSION OF UNOBLIGATED STIMULUS FUNDS.

Effective on the date of the enactment of this Act, there are rescinded all unobligated balances of the discretionary appropriations made available by division A of the American Recovery and Reinvestment Act of 2009 (Public Law 111–5).

SEC. 302. REPEAL OF CERTAIN STIMULUS PROVISIONS.

Effective on the date of the enactment of this Act, subtitles B and C of title II and titles III through VII of division B of the American Recovery and Reinvestment Act of 2009 (Public Law 111–5) are repealed, and the provisions of law amended or repealed by such provisions of division B are restored or revived as if such provisions of division B had not been enacted.

Division A of the ARRA Act of 2009 (link to PDF) includes this:

SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘American Recovery and Reinvestment Act of 2009’’.

SEC. 2. TABLE OF CONTENTS.

... The table of contents for this Act is as follows:

DIVISION A—APPROPRIATIONS PROVISIONS

... TITLE XIII—HEALTH INFORMATION TECHNOLOGY

Title XIII of the ARRA along with title IV of division B is better known as HITECH:

SEC. 13001. SHORT TITLE; TABLE OF CONTENTS OF TITLE.

(a) SHORT TITLE.—This title (and title IV of division B) may be cited as the ‘‘Health Information Technology for Economic and Clinical Health Act’’ or the ‘‘HITECH Act’’.

It looks like HITECH is one of a number of spending extravaganzas now on the proposed chopping block.

I can't be too sorry about this for these reasons:

• This country cannot afford HITECH at this time. We are broke, with some calling the economic crisis of 2008 worse than the crisis of 1929, and the national deficit ballooning far out of control. The money would be far better spent at this time on care of those who cannot afford it.
  

• HITECH appeared as if out of nowhere, with little to no input time from stakeholders. This suggests lobbying by those with conflicts of interest to push this bill onto the public, affecting their medical care without informed consent (see my March 2009 post "Draft Patient Rights Statement and Informed Consent on Use of HIT"). The bill includes persuasion along with economic coercion for non-adopting organizations and physicians. ("Adoption" = adherence to government-set standards of "meaningful use" of poorly usable technology.) I disapprove of the stealth process by which HITECH appeared. This is the U.S., not the old USSR.

• Mass social experiments involving major systemic changes to our healthcare delivery system, with exceptional claims being made about IT, need to be backed by exceptional evidence. That evidence is lacking. (March 2011 addendum: the evidence might actually be in the negative direction. See my post "An Updated Reading List on Health IT.")
  

• The technology is not ready. It is dangerous in unqualified hands, which most every medical center and physician office is in 2011 (i.e., an IT backwater). The field of health IT was somehow transformed from an experimental field into the 'savior of medicine' without the proof of value and safety that would ordinarily be required to move an experimental technology from lab to national rollout. Per the Washington Post, this process appears to have been a highly politicized one, favoring the corporate elites. The Washington Post’s 2009 article on the influential HIT vendor lobby “The Machinery Behind Healthcare Reform” is at this link.

While this House Bill is just the initial battle in the repeal of this and other mass expenditures, I would not weep for the HITECH act's passing. It would allow the restoration of health IT back to an unrushed and careful endeavor. It would also give time to work out the significant issues causing health IT difficulty (such as raised in 2009 by our National Research Council) before we embark on national diffusion.

In other words, its passing would reduce risk and help restore an essential level of sanity and due diligence to the healthcare IT sector, now afflicted by irrational exuberance bordering on delirium. We would avoid the largest non-consented medical experiment in US history, which as I have repeatedly written I feel would be disastrous with current levels of understanding of this technology and how to design, deploy and manage it. (My relative's 2010 HIT-related injuries only strengthened my convictions in this regard.)

Of course, I have no financial conflicts of interest regarding HITECH or health IT to weep about. Others do, and it's not hard to predict their financial interests will push them to oppose repeal "by any means necessary."

The next few months should be an interesting time in the politics of healthcare IT.

A replacement HITECH act that's "HI" on research and caution, but not so "HIGH" on stealth, coercion and euphoria (i.e., as on mind altering substances) would be welcomed.

-- SS

US House of Representatives Proposes to Defund Largest Non-Consented Medical Experiment in U.S. History: HITECH

In a new bill in the House of Representatives, the ‘‘Spending Reduction Act of 2011’’ (link - PDF), it is proposed to cut unobligated funds of, among others, division A of the "American Recovery and Reinvestment Act of 2009":

Spending Reduction Act of 2011

... TITLE III—RESCISSION OF UNOBLIGATED STIMULUS FUNDS AND REPEAL OF CERTAIN STIMULUS PROVISIONS

SEC. 301. RESCISSION OF UNOBLIGATED STIMULUS FUNDS.

Effective on the date of the enactment of this Act, there are rescinded all unobligated balances of the discretionary appropriations made available by division A of the American Recovery and Reinvestment Act of 2009 (Public Law 111–5).

SEC. 302. REPEAL OF CERTAIN STIMULUS PROVISIONS.

Effective on the date of the enactment of this Act, subtitles B and C of title II and titles III through VII of division B of the American Recovery and Reinvestment Act of 2009 (Public Law 111–5) are repealed, and the provisions of law amended or repealed by such provisions of division B are restored or revived as if such provisions of division B had not been enacted.

Division A of the ARRA Act of 2009 (link to PDF) includes this:

SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘American Recovery and Reinvestment Act of 2009’’.

SEC. 2. TABLE OF CONTENTS.

... The table of contents for this Act is as follows:

DIVISION A—APPROPRIATIONS PROVISIONS

... TITLE XIII—HEALTH INFORMATION TECHNOLOGY

Title XIII of the ARRA along with title IV of division B is better known as HITECH:

SEC. 13001. SHORT TITLE; TABLE OF CONTENTS OF TITLE.

(a) SHORT TITLE.—This title (and title IV of division B) may be cited as the ‘‘Health Information Technology for Economic and Clinical Health Act’’ or the ‘‘HITECH Act’’.

It looks like HITECH is one of a number of spending extravaganzas now on the proposed chopping block.

I can't be too sorry about this for these reasons:

• This country cannot afford HITECH at this time. We are broke, with some calling the economic crisis of 2008 worse than the crisis of 1929, and the national deficit ballooning far out of control. The money would be far better spent at this time on care of those who cannot afford it.
  

• HITECH appeared as if out of nowhere, with little to no input time from stakeholders. This suggests lobbying by those with conflicts of interest to push this bill onto the public, affecting their medical care without informed consent (see my March 2009 post "Draft Patient Rights Statement and Informed Consent on Use of HIT"). The bill includes persuasion along with economic coercion for non-adopting organizations and physicians. ("Adoption" = adherence to government-set standards of "meaningful use" of poorly usable technology.) I disapprove of the stealth process by which HITECH appeared. This is the U.S., not the old USSR.

• Mass social experiments involving major systemic changes to our healthcare delivery system, with exceptional claims being made about IT, need to be backed by exceptional evidence. That evidence is lacking. (March 2011 addendum: the evidence might actually be in the negative direction. See my post "An Updated Reading List on Health IT.")
  

• The technology is not ready. It is dangerous in unqualified hands, which most every medical center and physician office is in 2011 (i.e., an IT backwater). The field of health IT was somehow transformed from an experimental field into the 'savior of medicine' without the proof of value and safety that would ordinarily be required to move an experimental technology from lab to national rollout. Per the Washington Post, this process appears to have been a highly politicized one, favoring the corporate elites. The Washington Post’s 2009 article on the influential HIT vendor lobby “The Machinery Behind Healthcare Reform” is at this link.

While this House Bill is just the initial battle in the repeal of this and other mass expenditures, I would not weep for the HITECH act's passing. It would allow the restoration of health IT back to an unrushed and careful endeavor. It would also give time to work out the significant issues causing health IT difficulty (such as raised in 2009 by our National Research Council) before we embark on national diffusion.

In other words, its passing would reduce risk and help restore an essential level of sanity and due diligence to the healthcare IT sector, now afflicted by irrational exuberance bordering on delirium. We would avoid the largest non-consented medical experiment in US history, which as I have repeatedly written I feel would be disastrous with current levels of understanding of this technology and how to design, deploy and manage it. (My relative's 2010 HIT-related injuries only strengthened my convictions in this regard.)

Of course, I have no financial conflicts of interest regarding HITECH or health IT to weep about. Others do, and it's not hard to predict their financial interests will push them to oppose repeal "by any means necessary."

The next few months should be an interesting time in the politics of healthcare IT.

A replacement HITECH act that's "HI" on research and caution, but not so "HIGH" on stealth, coercion and euphoria (i.e., as on mind altering substances) would be welcomed.

-- SS

First Trimester Abortions Don't Cause Psychologic Problems

The New England Journal of Medicine published a new study that shows there is no increased psychologic impact for women who have early abortions.  The researchers from Denmark looked at almost 85,000 women who had first trimester abortions over a 13 year period and compared them with women who gave birth to live babies.  They found that there was no increase in women who sought psychiatric

"Making Their Numbers" - Examples of the Perverse Effect of Incentives Based on Short-Term Financial Targets in Health Care

Last week, we discussed how the large incentives for pharmaceutical executives to meet short term financial targets (that is, "making their numbers") may be an important cause of their firms' decreasing capacity to fulfill their most basic mission, manufacturing pure, unadulterated medicines. 

In the news recently were two examples of how other health care leaders are incentivized to meet short-term financial targets.

University of California

The first, and bigger example appeared in the San Francisco Chronicle. First, note that the University of California system is currently in dire shape:

Finances are so dire at the University of California that it might have to turn away qualified students,....

Also,

UC President Mark Yudof told the regents that UC will need to close a $1 billion budget gap next year. He said layoffs and course reductions are inevitable, and that he expects to have to turn away 20,000 to 30,000 qualified students over the next decade because the university won't have the money to educate them.

However, that did not stop the university from giving bonuses to a variety of employees, including larger bonuses for higher-ranking managers

UC has still found a way to reward hundreds of employees with more than $4 million in incentive pay and raises.

At the regents meeting Thursday in San Diego, UC officials reported giving rewards of $150 to $41,205 to nearly 1,500 UCSF employees who met performance targets, raising the pay of some campus executives to above market rate, and providing 10 percent raises of about $20,000 a year to three executives at their Oakland headquarters.


The executives, who have various financial responsibilities for the UC system, will earn between $216,370 and $247,500 in base pay.

'Whether a budget crisis or not, the university still has to be able to pay competitive salaries and incentives consistent with industry standards,' said Steve Montiel, a spokesman for the university. 'The university has no problem paying incentives to be competitive.'

Note that the bonuses were apparently mainly based on short-term financial goals,

[UCSF spokeswoman Amy] Pyle said the rewards were issued because those employees met targets for saving money and streamlining procedures - but that the incentive program for that group has now been suspended because of the budget crisis.

Note that despite the fact that the University has long-term financial woes, the biggest bonuses went to finance executives whose short-term performance obviously did not have much effect on these long-term problems:

One of them, Grace Crickette, UC's chief risk officer, 'has saved the university over $100 million by driving down the cost of workers' compensation, negotiating much more advantageous terms with our insurance company,' Taylor said. The raises 'are a small price to pay for people working at the highest level.'

That rationale failed to convince representatives of UC's lowest-paid workers.

'The lowest-paid workers do a lot to save money too, and we've actually told them how. But our workers are being hit' with higher costs for their own benefits, said Lakesha Harrison, president of the American Federation of State, County and Municipal Employees, which represents custodians, groundskeepers, patient-care workers and other employees earning less than $40,000.

Also,

At UC Berkeley, for example, the new vice chancellor for administration and finance will earn a base salary of $375,000 - 9 percent higher than the salary midpoint of $344,000 earned by colleagues at other universities, UC officials reported.

At UCLA, the chief financial officer of the hospital system will receive a 10.5 percent raise, bringing his salary to $420,000 from $380,000 as a hedge against the possibility that he would go somewhere else. The campus called it a 'pre-emptive retention salary adjustment.'

So while the University of California has long-term financial woes, so severe that they will likely require major curtailment of fulfillment of its major academic mission, its leadership had no problem handing out bonuses for meeting short-term financial goals whose achievement obviously did not forestall the current problems. The biggest bonuses went to financial managers, rationalized by their supposed performance "at the highest level," or their need to prevent them from going "somewhere else." However, obviously the long-term FINANCIAL performance of the University is its current biggest problem, suggesting that overall these financial managers are not doing so well. Thus, the way the University handed out bonuses for people "making their numbers" seemed completely at odds with the University's inability to make its numbers in the long-run. Of course, the bonuses also seemed entirely unrelated to the University's ability, or lack thereof to fulfill its mission.

Erlanger Health System

The Erlanger Health System is "an academic medical center associated with the UT College of Medicine Chattanooga." The Chattanooga (TN) Times Free Press reported:

Erlanger Health System executives took home bigger bonuses in December compared with the awards paid out the year before, despite recording lower profits.

In December, 123 management-level Erlanger employees split $1.9 million in bonus payments, $200,000 more than the total awarded in bonuses in fiscal year 2009.

President and CEO Jim Brexler received a $192,395 bonus in December on top of his base salary of $550,000.

The payments were based on the hospital's performance in fiscal year 2010, which ended in June of last year. The hospital's operating profit of $8.58 million, and other performance measurements that year, met pre-established criteria approved by the hospital's board of trustees.

The irony is that by the time the bonuses for fiscal year 2010 were awarded, it was already known that this year's finances are not so good:

Fiscal year to date, Erlanger has earned a $1.3 million profit, compared with a budgeted $6 million profit, according to financial statements released at the hospital's Budget and Finance Committee Monday.

Of course, one rationale for the bonuses is that Erlanger's executives are above average, just like, it seems, finance executives at the University of California (as noted above), and maybe all other health care organizational leaders:

'It takes a real expertise to deal in health care. ... Just to make any positive operating margin is great,' said Kim White, an Erlanger trustee and chairwoman of Erlanger's Management and Board Evaluation Committee, which sets the criteria that determines whether bonus pay will be awarded and how much.

'It's tough for people who don't have jobs to look at bonuses, but we look at this as a piece of their total compensation package.'

Of course managers and executives may have "real expertise," as noted above, or be in charge of some initiatives that saves money (as noted above in the case of a UC executive.)  However, there may be many other people who work for the organization with "real expertise," some of whose expertise may be more directly related to the organization's primary mission.  Also, as the union leader noted above, even low-paid workers may have ideas for saving money.  However, the big bonuses or raises given to reward only the managers' expertise, or prevent only the managers from finding other jobs, show the exceptional treatment given to health care managers and executives, perhaps because they tend to answer to governing bodies (boards of trustees or directors) run by other managers and executives.

Summary

There is increasing evidence that bonuses given to employees of health care organizations, particularly high-level managers and executives, are predominantly tied to short-term financial goals, e.g., "making their numbers." In my humble opinion, these are important perverse incentives, driving people to actions that disregard, or may even subvert the organizations' fundamental missions.

While it is desirable for all health care organizations to be run in a business-like manner, and for not-for-profit health care organizations to have competent financial management, these are means to an end. The mission of health care organizations is health care.

The main priority of non-profit organizations (or NGOs) should be to uphold their missions, not to make surpluses. Avoiding deficits, or making surpluses are means to uphold the mission, but ought to be subservient to the mission.

While for-profit health care corporations are meant to make a profit, in the long run their profitability should depend on whether the health care products they make or services they provide are fit for purpose, that is, further health care of individual patients or populations. Putting short-term financial goals ahead of making quality products (e.g., making pure and unadulterated medicines as noted in our previous post) will ultimately be bad for patients, for public health, and for the long-term financial health of the corporation.

Therefore, I submit that incentives for employees should be based on how their work upholds the primary mission. It may not be unreasonable to have some incentives based on long-term financial goals for financial executives of health care organizations. However, even those should be explicitly tied to mission fulfillment.

However, as health care leaders seemed to have learned from leaders of financial services firms, the emphasis on incentives based on short-term financial goals seems to only be increasing. Failure to address these increasingly perverse incentives will only lead to increasing health care dysfunction.

"Making Their Numbers" - Examples of the Perverse Effect of Incentives Based on Short-Term Financial Targets in Health Care

Last week, we discussed how the large incentives for pharmaceutical executives to meet short term financial targets (that is, "making their numbers") may be an important cause of their firms' decreasing capacity to fulfill their most basic mission, manufacturing pure, unadulterated medicines. 

In the news recently were two examples of how other health care leaders are incentivized to meet short-term financial targets.

University of California

The first, and bigger example appeared in the San Francisco Chronicle. First, note that the University of California system is currently in dire shape:

Finances are so dire at the University of California that it might have to turn away qualified students,....

Also,

UC President Mark Yudof told the regents that UC will need to close a $1 billion budget gap next year. He said layoffs and course reductions are inevitable, and that he expects to have to turn away 20,000 to 30,000 qualified students over the next decade because the university won't have the money to educate them.

However, that did not stop the university from giving bonuses to a variety of employees, including larger bonuses for higher-ranking managers

UC has still found a way to reward hundreds of employees with more than $4 million in incentive pay and raises.

At the regents meeting Thursday in San Diego, UC officials reported giving rewards of $150 to $41,205 to nearly 1,500 UCSF employees who met performance targets, raising the pay of some campus executives to above market rate, and providing 10 percent raises of about $20,000 a year to three executives at their Oakland headquarters.


The executives, who have various financial responsibilities for the UC system, will earn between $216,370 and $247,500 in base pay.

'Whether a budget crisis or not, the university still has to be able to pay competitive salaries and incentives consistent with industry standards,' said Steve Montiel, a spokesman for the university. 'The university has no problem paying incentives to be competitive.'

Note that the bonuses were apparently mainly based on short-term financial goals,

[UCSF spokeswoman Amy] Pyle said the rewards were issued because those employees met targets for saving money and streamlining procedures - but that the incentive program for that group has now been suspended because of the budget crisis.

Note that despite the fact that the University has long-term financial woes, the biggest bonuses went to finance executives whose short-term performance obviously did not have much effect on these long-term problems:

One of them, Grace Crickette, UC's chief risk officer, 'has saved the university over $100 million by driving down the cost of workers' compensation, negotiating much more advantageous terms with our insurance company,' Taylor said. The raises 'are a small price to pay for people working at the highest level.'

That rationale failed to convince representatives of UC's lowest-paid workers.

'The lowest-paid workers do a lot to save money too, and we've actually told them how. But our workers are being hit' with higher costs for their own benefits, said Lakesha Harrison, president of the American Federation of State, County and Municipal Employees, which represents custodians, groundskeepers, patient-care workers and other employees earning less than $40,000.

Also,

At UC Berkeley, for example, the new vice chancellor for administration and finance will earn a base salary of $375,000 - 9 percent higher than the salary midpoint of $344,000 earned by colleagues at other universities, UC officials reported.

At UCLA, the chief financial officer of the hospital system will receive a 10.5 percent raise, bringing his salary to $420,000 from $380,000 as a hedge against the possibility that he would go somewhere else. The campus called it a 'pre-emptive retention salary adjustment.'

So while the University of California has long-term financial woes, so severe that they will likely require major curtailment of fulfillment of its major academic mission, its leadership had no problem handing out bonuses for meeting short-term financial goals whose achievement obviously did not forestall the current problems. The biggest bonuses went to financial managers, rationalized by their supposed performance "at the highest level," or their need to prevent them from going "somewhere else." However, obviously the long-term FINANCIAL performance of the University is its current biggest problem, suggesting that overall these financial managers are not doing so well. Thus, the way the University handed out bonuses for people "making their numbers" seemed completely at odds with the University's inability to make its numbers in the long-run. Of course, the bonuses also seemed entirely unrelated to the University's ability, or lack thereof to fulfill its mission.

Erlanger Health System

The Erlanger Health System is "an academic medical center associated with the UT College of Medicine Chattanooga." The Chattanooga (TN) Times Free Press reported:

Erlanger Health System executives took home bigger bonuses in December compared with the awards paid out the year before, despite recording lower profits.

In December, 123 management-level Erlanger employees split $1.9 million in bonus payments, $200,000 more than the total awarded in bonuses in fiscal year 2009.

President and CEO Jim Brexler received a $192,395 bonus in December on top of his base salary of $550,000.

The payments were based on the hospital's performance in fiscal year 2010, which ended in June of last year. The hospital's operating profit of $8.58 million, and other performance measurements that year, met pre-established criteria approved by the hospital's board of trustees.

The irony is that by the time the bonuses for fiscal year 2010 were awarded, it was already known that this year's finances are not so good:

Fiscal year to date, Erlanger has earned a $1.3 million profit, compared with a budgeted $6 million profit, according to financial statements released at the hospital's Budget and Finance Committee Monday.

Of course, one rationale for the bonuses is that Erlanger's executives are above average, just like, it seems, finance executives at the University of California (as noted above), and maybe all other health care organizational leaders:

'It takes a real expertise to deal in health care. ... Just to make any positive operating margin is great,' said Kim White, an Erlanger trustee and chairwoman of Erlanger's Management and Board Evaluation Committee, which sets the criteria that determines whether bonus pay will be awarded and how much.

'It's tough for people who don't have jobs to look at bonuses, but we look at this as a piece of their total compensation package.'

Of course managers and executives may have "real expertise," as noted above, or be in charge of some initiatives that saves money (as noted above in the case of a UC executive.)  However, there may be many other people who work for the organization with "real expertise," some of whose expertise may be more directly related to the organization's primary mission.  Also, as the union leader noted above, even low-paid workers may have ideas for saving money.  However, the big bonuses or raises given to reward only the managers' expertise, or prevent only the managers from finding other jobs, show the exceptional treatment given to health care managers and executives, perhaps because they tend to answer to governing bodies (boards of trustees or directors) run by other managers and executives.

Summary

There is increasing evidence that bonuses given to employees of health care organizations, particularly high-level managers and executives, are predominantly tied to short-term financial goals, e.g., "making their numbers." In my humble opinion, these are important perverse incentives, driving people to actions that disregard, or may even subvert the organizations' fundamental missions.

While it is desirable for all health care organizations to be run in a business-like manner, and for not-for-profit health care organizations to have competent financial management, these are means to an end. The mission of health care organizations is health care.

The main priority of non-profit organizations (or NGOs) should be to uphold their missions, not to make surpluses. Avoiding deficits, or making surpluses are means to uphold the mission, but ought to be subservient to the mission.

While for-profit health care corporations are meant to make a profit, in the long run their profitability should depend on whether the health care products they make or services they provide are fit for purpose, that is, further health care of individual patients or populations. Putting short-term financial goals ahead of making quality products (e.g., making pure and unadulterated medicines as noted in our previous post) will ultimately be bad for patients, for public health, and for the long-term financial health of the corporation.

Therefore, I submit that incentives for employees should be based on how their work upholds the primary mission. It may not be unreasonable to have some incentives based on long-term financial goals for financial executives of health care organizations. However, even those should be explicitly tied to mission fulfillment.

However, as health care leaders seemed to have learned from leaders of financial services firms, the emphasis on incentives based on short-term financial goals seems to only be increasing. Failure to address these increasingly perverse incentives will only lead to increasing health care dysfunction.

Big Door Keeps On Turning - Bi-Directional Interchanges Among Government and Corporate Health Care Leadership

Recently we noted some complex examples of the health care "revolving door," cases of health care corporate leaders who came from government heading back into government.  The first was reported by Politico:

California Rep. Mary Bono Mack has hired PhRMA’s former chief spokesman as a senior adviser, adding another Republican lawmaker to the list of those who have recruited staff members with K Street ties.

Ken Johnson will serve as a senior policy and communications adviser to Bono Mack, chairwoman of a House Energy and Commerce subcommittee. Johnson has deep ties to the committee, having worked for former Republican Rep. Billy Tauzin when he headed the Energy and Commerce Committee.

When PhRMA hired Tauzin months after the Louisiana congressman helped pass the industry-supported Medicare drug benefit, Johnson followed. So it was not surprising that Johnson did not stay on with PhRMA last year after Tauzin stepped down.

In 2009, Tauzin made more than $4.5 million and Johnson pulled in more than $500,000, according to tax records.

Note that Mr Johnson went from an influential government position to a position representing the pharmaceutical industry, and then back to government
In the same vein and in the same article was:

House Speaker John Boehner hired the medical device industry’s chief lobbyist as his policy director.

Meanwhile, the Minneapolis Star-Tribune noted:

Minnesota health executive Lois Quam has signed to lead the multibillion dollar Global Health Initiative at the U.S. State Department.

A State Department spokesman confirmed Wednesday that Quam will be executive director of the initiative.

In 2009, President Barack Obama committed $63 billion over six years to the program aimed at helping developing nations fight disease, improve nutrition and provide more aid for prenatal and postnatal care.

Quam, of St. Paul, is a former UnitedHealth Group executive who co-founded a health consulting firm last year. She is married to Matt Entenza, a former state lawmaker who ran unsuccessfully for governor in 2010.

The appointment reunites Quam with Secretary of State Hillary Clinton. Quam was a senior adviser to Clinton's health care task force in the 1990s.

Note that Ms Quam went from government leadership (in the Clinton administration's abortive attempt at health care reform via an elaborate version of managed care), to corporate leadership (in one of the largest commercial managed care organizations, some of whose exploits are discussed here), then back to government (now leading global health.  As an aside, UnitedHealth has been developing its global presence for years, e.g., see this post about its forays into the UK.)

We last discussed the "revolving door," that is, the easy interchange among leadership in government and health care corporations here.  The brief news items above shows how the door spins continuously, resulting not only in former government leaders ending up in influential, and well-recompensed positions in the health care industry, but also in industry leaders ending up in influential government positions.  In two cases above, people who started out in influential government positions transitioned to health care corporate positions, and then back to government. 

As we noted earlier, the continually revolving door is a sign of the increasingly corporatist nature of the US.  Government and the biggest corporations now seem to see themselves as natural allies, partially because their leadership increasingly forms a cozy combined group.  The big problem, of course, is such an alliance leaves out everybody else, from small business, to individual professionals, to the people at large. 

As I noted earlier, if we want health care to put the needs of individual patients first, we ought to consider ways to make both government and corporate health care leaders more responsive to the people rather than to their combined self-interest. 

Big Door Keeps On Turning - Bi-Directional Interchanges Among Government and Corporate Health Care Leadership

Recently we noted some complex examples of the health care "revolving door," cases of health care corporate leaders who came from government heading back into government.  The first was reported by Politico:

California Rep. Mary Bono Mack has hired PhRMA’s former chief spokesman as a senior adviser, adding another Republican lawmaker to the list of those who have recruited staff members with K Street ties.

Ken Johnson will serve as a senior policy and communications adviser to Bono Mack, chairwoman of a House Energy and Commerce subcommittee. Johnson has deep ties to the committee, having worked for former Republican Rep. Billy Tauzin when he headed the Energy and Commerce Committee.

When PhRMA hired Tauzin months after the Louisiana congressman helped pass the industry-supported Medicare drug benefit, Johnson followed. So it was not surprising that Johnson did not stay on with PhRMA last year after Tauzin stepped down.

In 2009, Tauzin made more than $4.5 million and Johnson pulled in more than $500,000, according to tax records.

Note that Mr Johnson went from an influential government position to a position representing the pharmaceutical industry, and then back to government
In the same vein and in the same article was:

House Speaker John Boehner hired the medical device industry’s chief lobbyist as his policy director.

Meanwhile, the Minneapolis Star-Tribune noted:

Minnesota health executive Lois Quam has signed to lead the multibillion dollar Global Health Initiative at the U.S. State Department.

A State Department spokesman confirmed Wednesday that Quam will be executive director of the initiative.

In 2009, President Barack Obama committed $63 billion over six years to the program aimed at helping developing nations fight disease, improve nutrition and provide more aid for prenatal and postnatal care.

Quam, of St. Paul, is a former UnitedHealth Group executive who co-founded a health consulting firm last year. She is married to Matt Entenza, a former state lawmaker who ran unsuccessfully for governor in 2010.

The appointment reunites Quam with Secretary of State Hillary Clinton. Quam was a senior adviser to Clinton's health care task force in the 1990s.

Note that Ms Quam went from government leadership (in the Clinton administration's abortive attempt at health care reform via an elaborate version of managed care), to corporate leadership (in one of the largest commercial managed care organizations, some of whose exploits are discussed here), then back to government (now leading global health.  As an aside, UnitedHealth has been developing its global presence for years, e.g., see this post about its forays into the UK.)

We last discussed the "revolving door," that is, the easy interchange among leadership in government and health care corporations here.  The brief news items above shows how the door spins continuously, resulting not only in former government leaders ending up in influential, and well-recompensed positions in the health care industry, but also in industry leaders ending up in influential government positions.  In two cases above, people who started out in influential government positions transitioned to health care corporate positions, and then back to government. 

As we noted earlier, the continually revolving door is a sign of the increasingly corporatist nature of the US.  Government and the biggest corporations now seem to see themselves as natural allies, partially because their leadership increasingly forms a cozy combined group.  The big problem, of course, is such an alliance leaves out everybody else, from small business, to individual professionals, to the people at large. 

As I noted earlier, if we want health care to put the needs of individual patients first, we ought to consider ways to make both government and corporate health care leaders more responsive to the people rather than to their combined self-interest. 

BLOGSCAN - By Feb. all ER physicians at DePaul Health Center (MO) will be using scribes

At my Sept. 2010 post "The Ultimate Workaround To Mission Hostile Health IT: Humans (a.k.a. Scribes)" I had written that:

The EMR is a technology that was supposed to improve clinical medicine (revolutionize it, some say). It was supposed to facilitate clinical medicine. It was not supposed to slow physicians and others down to the point of impairing their ability to practice medicine. However, the rosy predictions are not proving to be the case. Instead, we have the ultimate workaround to the health IT mission hostile user experience: [the medical scribe].

On the HisTALK blog today, apparently one medical center agrees:

By February, all ER physicians at DePaul Health Center (MO) will be using scribes for electronic medical documentation. Administrators hope to improve staff productivity as well as patient satisfaction. Apparently patients were “annoyed” that doctors were sharing their attention with a computer.

In the cited article "Scribes are finding their place in emergency rooms" by Michele Munz, St. Louis Post-dispatch.com, Jan. 25, 2011:

"[With a scribe] I can just completely focus on and deal with the patient," [ED physician] Lebo said.

The emergency department at DePaul Health Center in Bridgeton, which sees about 60,000 patients a year, is the first to use scribes in the St. Louis area. By February, all the hospital's emergency physicians will have a scribe tapping away at a laptop or tablet computer while they work. Across the nation, about 200 hospital emergency departments have started using scribes, most within the last two years, according to the three major companies providing scribes.

Several points worthy of note:

• The cost of scribes will be an issue affecting the supposed ROI of EHR's, and are necessitated by the fact that the EHR and its mission hostile nature get in the way of physicians. (See Dr. Doug Perednia's analysis at this link.)
  

• Scribes are a workaround to the mission hostile user experience.

• You should not have to work around something that is not in the way.

• That a technology touted as of extreme benefit now is seen to need an "isolation layer" between enduser and subject of the system's benefits is another example of how health IT remains an experiment.

-- SS

BLOGSCAN - By Feb. all ER physicians at DePaul Health Center (MO) will be using scribes

At my Sept. 2010 post "The Ultimate Workaround To Mission Hostile Health IT: Humans (a.k.a. Scribes)" I had written that:

The EMR is a technology that was supposed to improve clinical medicine (revolutionize it, some say). It was supposed to facilitate clinical medicine. It was not supposed to slow physicians and others down to the point of impairing their ability to practice medicine. However, the rosy predictions are not proving to be the case. Instead, we have the ultimate workaround to the health IT mission hostile user experience: [the medical scribe].

On the HisTALK blog today, apparently one medical center agrees:

By February, all ER physicians at DePaul Health Center (MO) will be using scribes for electronic medical documentation. Administrators hope to improve staff productivity as well as patient satisfaction. Apparently patients were “annoyed” that doctors were sharing their attention with a computer.

In the cited article "Scribes are finding their place in emergency rooms" by Michele Munz, St. Louis Post-dispatch.com, Jan. 25, 2011:

"[With a scribe] I can just completely focus on and deal with the patient," [ED physician] Lebo said.

The emergency department at DePaul Health Center in Bridgeton, which sees about 60,000 patients a year, is the first to use scribes in the St. Louis area. By February, all the hospital's emergency physicians will have a scribe tapping away at a laptop or tablet computer while they work. Across the nation, about 200 hospital emergency departments have started using scribes, most within the last two years, according to the three major companies providing scribes.

Several points worthy of note:

• The cost of scribes will be an issue affecting the supposed ROI of EHR's, and are necessitated by the fact that the EHR and its mission hostile nature get in the way of physicians. (See Dr. Doug Perednia's analysis at this link.)
  

• Scribes are a workaround to the mission hostile user experience.

• You should not have to work around something that is not in the way.

• That a technology touted as of extreme benefit now is seen to need an "isolation layer" between enduser and subject of the system's benefits is another example of how health IT remains an experiment.

-- SS

EverythingHealth Anniversary

Thanks to faithful reader, KM for this graphic and reminding me that I've been a blogger for 4 years!  Almost 1,000,000 visitors have been to EverythingHealth from every part of the world.  I have met other wonderful and creative health bloggers and developed cyber-friendships and learned so much from other health bloggers. I never run out of material or ideas because life and science and

Older Physicians and Safety

One third of all physicians in the United States are older than 65.  A 2006 study found that mortality rates among patients in complicated operations were higher when the physician was 60 or older.  The New York Times  recently ran an article  about the need for safeguards to protect patients from physicians who suffer from cognitive decline as they age and it is sparking debate about older

Orderless in Seattle: Software "glitch" shuts down Swedish Medical Center's medical-records system

A commenter yesterday commented that after 25 years in practice, they had one lost [paper] chart (as opposed to an IT systems crash, where every chart is lost temporarily).

As coincidence would have it, there's this story in the news:

Software glitch shuts down Swedish medical-records system
Tuesday, January 25, 2011
By Carol M. Ostrom
Seattle Times health reporter

Related

A four-hour shutdown of Swedish Medical Center's centralized electronic medical-records system Monday morning was caused by a glitch in another company's software, said Swedish chief information officer Janice Newell.

There's that word "glitch" again that I see so frequently in the health IT sector when a system suffers a major crash that could harm patients. Why do we not call it a "glitch" when a doctor amputates the wrong body part, or kills someone?

The system, made by Epic Systems, a Wisconsin-based electronic medical-records vendor, turned itself off because it noticed an error in the add-on software, Newell said, and Swedish was forced to go to its highest level of backup operation.

Turned itself off? Back we go to the old Unix adage that "either you're in control of your information system, or it's in control of you."

To prove that point, note that "the highest level of backup operation" had a bit of a problem:

That allowed medical providers to see patient records but not to add or change information, such as medication orders.

I'm sure sick and unstable patients such as in the ICU's, as well as their physicians and nurses, appreciated this minor "glitch." Look, Ma, no orders!

(Do events like this ever happen in the middle of a Joint Commission inspection?)

The "glitch" didn't just affect a few charts:

The outage affected all of Swedish's campuses, including First Hill, Cherry Hill, Ballard and its Issaquah emergency facility, as well as Swedish's clinics and affiliated groups such as the Polyclinic.

I cannot imagine a paper-based "glitch" that could affect so many, so suddenly, other than a wide-scale catastrophe.

During the outage, new information was put on paper records [that 5,000 year old, obsolete papyrus-based technology that's simply ruining healthcare, according to the IT pundits - ed.] and transferred into patient records in the Epic system after the system went back up in the afternoon. [By whom? Busy doctors? - ed.] Epic, Newell said, is "really good at fail-safe activity," and if it detects something awry that could corrupt data, it shuts itself off, which it did Monday at about 10 a.m.

Which means that interfaced systems need to undergo the highest levels of scrutiny in real world use, if they can in effect shut down an entire enterprise clinical system.

I note the identity of the "other company's software" that brought the whole system to a grinding halt was not identified, nor was the nature of the "other vendor's" software "glitch" itself. Was the problem truly caused by "another vendor" via a bug in their product, via a faulty upgrade, or an internal staff error related to the "other vendor's" software?

It seems we now have yet another defense for HIT "glitches" other than "blame the users": it's not OUR fault; blame the other vendors.

Newell said the shutdown likely affected about 600 providers, 2,500 staffers and perhaps up to 2,000 patients, but no safety problems were reported.

As I've noted at this blog before, it is peculiar how such "glitches" never seem to produce safety problems, or even acknowledgments of increased risk.

Staff members were notified of the shutdown via error messages, e-mails, intranet, a hospital overhead paging system and personal pagers.

"Warning! Warning! EHR and CPOE down! Grab your pencils!" Just what busy doctors and nurses want to hear when they arrive for a harrowing day of patient care.

I wonder if the alert was expressed in a manner not understandable to patients, i.e., "Code 1100011" (99 in binary!) or something similar as in a medical emergency.

Newell said she was "99.9 percent sure" other hospitals have had similar shutdowns [that's certainly reassuring about health IT - ed.], because software, hardware and even power systems are not perfect. [That's why we have resilience engineering, redundancy, etc. - ed.]

"Anybody who hasn't had this happen has not been up on an electronic medical record very long," Newell said. "I would bet a year's pay on that."

A logical fallacy to justify some action or situation can take the form of an appeal to common practice. Is what I am seeing here what might be called an appeal to common malpractice?

Or is the fallacy simply a manifestation of the adage "misery loves company?"

Newell said this is not the first shutdown of Epic, which was fully installed in Swedish facilities in 2009 after a nearly two-year process. But it was the longest-running one, she acknowledged.

Gevalt.

Swedish is exploring creating "more sophisticated levels of backup" with other hospitals, Newell said, locating a giant server in a different geographic area to protect against various disasters such as earthquakes or floods.

Maybe they should have done that after the aforementioned other "glitches."

I repeat the adage:

"Either you're in control of your information system, or it's in control of you."

Indeed, if the information system is mission-critical, and you cannot control it, you literally have no business disrupting clinicians en masse and putting patients at risk by letting it control you.

Finally, on the topic of 'cybernetic extremophiles', I note that we have several Mars Rovers and very distant space probes such as Voyager 1 whose onboard computers (in the case of Voyager, built long ago with much less advanced technology than today's IT) have been working flawlessly in environments far more hostile than a hospital data center, and long beyond their stated life expectancies.

The Voyager 1 spacecraft is a 722-kilogram (1,592 lb) robotic space probe launched by NASA on September 5, 1977 to study the outer Solar System and eventually interstellar space. Operating for 33 years, 4 months, and 22 days, the spacecraft receives routine commands and transmits data back to the Deep Space Network. Currently in extended mission, the spacecraft is tasked with locating and studying the boundaries of the Solar System, including the Kuiper belt, the heliosphere and interstellar space. The primary mission ended November 20, 1980, after encountering the Jovian system in 1979 and the Saturnian system in 1980.^[2] It was the first probe to provide detailed images of the two largest planets and their moons.

As of January 23, 2011, Voyager 1 was about 115.963 AU (17.242 billion km, or 10.8 billion miles) or about 0.00183 of a light-year from the Sun. Radio signals traveling at the speed of light between Voyager 1 and Earth take more than 16 hours to cross the distance between the two.

While these are exceptional case examples of resilience in IT systems far less complex than hospital IT, I believe healthcare can do better in terms of computer "glitches" affecting mission critical systems that are a bit closer than 10 billion miles away.

-- SS