Health care corruption: the doctors’ dilemma

Roy M. Poses MD
President, the Foundation for Integrity and Responsibility in
Medicine (FIRM)
http://www.firmfound.org/
Associate Clinical Professor of Medicine
Brown University
– Institute of Medicine’s Crossing the Quality Chasm: “quality problems are everywhere, affecting many patients.” – Medicare fee cuts leading to physicians dropping • There are new calls for health care reform • Supposed “Aura of inevitability” about health care – Health care professionals are also increasingly unhappy – Increased sense we are not getting our money’s worth • Asked physicians open-ended questions about their concerns about what is going wrong with health care • Compiled and described their major themes in “A Cautionary Tale: The Dysfunction of American Health Care” • Examples sought in health care literature and media – Tips from physicians, crude search attempts and ongoing – Little yield from medical and health care literature • Little systematic research yet reported Poses RM. Eur J Int Med 2003; 14: 123.
• Physicians felt that their core values are
externally threatened
• They cited numerous local examples of concentration and abuse of power
– Health care is increasingly dominated by large organizations whose goals may not be aligned with physicians’ professional values – Such organizations may be led by the ill- informed, the unethical, or even the criminal • Most physicians could cite local examples of • Most thought their examples were unique, and that they were particularly unfortunate to work in proximity to it • Most had not heard of examples from outside their • Most did not recognize concentration and abuse of The Allegheny Health Education and Research • From Allegheny General Hospital in Pittsburgh (1968) to largest health care system in Pennsylvania (1997) • CEO was Sherif Abdelhak, called a “visionary,” “genius,” gave John D. Cooper Lecture at AAMC (1996), published in Academic Medicine • By 1995, Abdelhak earned $1.2 M, 3 times the median for a health • In 1997, although Abdelhak was still publicly announcing expansion • In 1998, Abdelhak fired, AHERF declared Chapter 11 bankruptcy, $1.2 billion in debt, second largest bankruptcy in US at that time • Allegheny University of Health Sciences downsized, multiple hospitals closed, multiple lay-offs, multiple lawsuits filed • After plea bargain, Abdelhak sentenced to 11-23 months for raiding The Allegheny Health Education and Research – “colossal disaster that could have been avoided” – “obscene,” “an atrocity,” “repugnant” – Abdelhak was “an evil person” who “never took responsibility for bringing the system down” The Allegheny Health Education and Research Foundation (AHERF) Case: National Responses Tepid responses of national organizations: – CEO of American Association of Medical Colleges: “unprecedented for a medical school to be caught up in this type of bankruptcy” – Liaison Committee for Medical Education: would help place students if AUHS bankrupt– Joint Commission on Accreditation of Healthcare Organizations: Hahnemann Hospital – Physicians’ organizations, like AMA, ACP, AAFP, etc - ?– Academic boards, like ACGME, ABIM, federal agencies, etc - ? One article in Health Affairs, covered only through mid-1999, but not outcome of most legal proceedings [1] Nothing in any large-circulation journal (including news sections) Nothing in Academic Medicine since Abdelhak’s paper First article that mentioned Abdelhak’s conviction: Poses in Euro J Int Med in 2003[2] 1. Burns LR. Health Affairs 2000; 19: 7. 2. Poses RM. Eur J Int Med – Hermann Hospital’s managers convicted of theft– Seven convicted for embezzling >$20 M from Cooper Hospital/UMC – AMA endorsed Sunbeam, AMA endorsed alteplase for cash – NIH leaders got six-figure consulting fees from pharma– Hospital CEOs fired for ethical lapses: Fletcher Allen (convicted of conspiracy), Bellevue, Jacobi, Staten Island University (EVP), Roger Williams (convicted of conspiracy and mail fraud) UC- Irvine, Caritas Christi – UMDNJ President, board members, other leaders resign, now operating under • Have American physicians (or health care researchers, or health
policy makers) ever heard of them?
• The “recent unpleasantness” - most cases have only been discussed locally, and only in news media • Academia and medical/ health care/ health policy literature, medical organizations mostly silent • Until recently, doctors sometimes complained • Therefore, no recognition of more wide-spread and • Those who are ignorant of history are bound to • Pervasive “conflicts of interest” • Health care institutions revered since days when they were small, relatively thread-bare, mission oriented • The cult of the “imperial CEO” leads to – The institution and the leaders are one • In academic medicine, the dogma is that “conflicts of interest” are inevitable, and should be “disclosed” and “managed,” but not eliminated • Many such “conflicts of interest” fit Transparency International’s definition of corruption: – Abuse of entrusted power for private gain
• Medical academics are entrusted to seek and • For a medical academic to help promote a commercial product or service in his or her guise as an academic can be abuse of entrusted power • For an academic to do so while personally being paid or otherwise rewarded by the commercial provider of the product or service can be – Abuse of entrusted power for private gain
– Often speak or write under academic auspices in ways that promote the companies’ products – May fail to disclose the nature, size, and intensity of their relationships to the companies, and only in fine print physicians as “key opinion leaders” to market product • Low level, most common – small gifts, meals, trips to students, house-staff, faculty from industry • Mid level, common – speaking fees, consulting fees, etc to faculty “thought-leaders” • High level, less common – service on for-profit health care corporations’ boards of directors (plus fees and stock options) for senior faculty, medical school and university leaders • Almost half of faculty reported conflicts • More than one-third of academic leaders • 7/10 members of conflicts of interest • Gave talks, wrote articles, and lead government research grant on mifespristone as treatment of depression • Simultaneously sat on board of directors and scientific advisory board of, and held 3 million shares of company that sought to get approval to market mifepristone as treatment of depression • Failed to reveal the nature and intensity of his financial relationships with the company in published articles that were positive about the drug – Article only said study was “supported by a grant” from the company, and that the chair of psychiatry had “a financial interest in” it.
• Parke-Davis’ strategy for marketing gabapentin – Recruited physicians who could influence colleagues – Recruited “thought leaders,” “key influencers,” and “movers and shakers” (department chairs, vice-chairs, directors of academic programs or divisions) – Speakers bureaus were meant to “identify and train – Recruited academics as authors of articles to be Steinman MA et al. Ann Intern Med 2006; 145: 284 – Staff and leaders of health care or medical not-for- profit organizations and non-governmental organizations (NGOs) – Staff and leaders of health care or medical government • People with conflicts of interest “often find
giving clear advice (or opinions) particularly
difficult.”
– Joe Collier, “The Price of Independence” • Many in academics, not-for-profits/ NGOs, government have “conflicts of interest” • Many more work with or for someone with • In this context, conflict aversion, political correctness, and fear of retaliation may produce silence • Unethical behavior, corruption, criminality may be common in health care in developed countries • The issue is largely unstudied; but many practitioners are • The issue may remain hidden, without echoes, “anechoic” – Outdated reverence– L’hospital c’est moi– Pervasive “conflicts of interest”– Political correctness and the like • Until the issue is widely discussed, we are unlikely to

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