Background - a New Species of Conflict of Interest
Since 2006, we have posted repeatedly about what was then a new species of severe conflicts of interest. This occurs when leaders of academic medical institutions or other health care non-profit organizations or non-governmental organizations (NGOs) also serve as members of boards of directors of for-profit corporations whose products and actions have major effects on health care.
Most recently, we discussed the cases of the current CEO of the National Quality Forum and past CEO of the American Board of Internal Medicine who was found to be on the board of for-profit hospital group purchasing organization Premier Inc, and had been on the board of its privately held but for-profit predecessors. We then discussed the case of the incoming president of the US Institute of Medicine and former Chancellor of Health Affairs at Duke University who was on the boards of Alnylam Pharmaceuticals, Medtronic and Pepsico. We next discussed the case of the current Dean of medicine at the University of Illinois who is on the board of Novartis.
We also recently posted about the first time these sorts of severe conflicts of interest issue have been addressed in a large circulation medical journal. A commentary in JAMA called for many such conflicts to be banned.
A Small Study of the Prevalence of a New Species of Conflict of Interest
Now JAMA has just published a research letter which examined the prevalence of board members of large, for-profit, publicly held pharmaceutical companies who also were among the leadership of academic medical centers. [Anderson TS, Dave S, Good CB et al. Academic medical center leadership on pharmaceutical company boards of directors. JAMA 2014; 311: 1353-5. Link here.]
The authors looked at public data about 2012 board membership of the 47 biggest publicly held companies based on global prescription drug sales. They tabulated those who were also leaders at (apparently only US) academic medical centers.
The most important findings were:
- 19/47 companies (40%) had at least one board member who was a leader of an academic medical center (AMC)
- 16/17 US based companies had at least one board member who was also a leader of a US AMC
- pharmaceutical company board members included 2 university presidents, 6 deans of medicine, 6 hospital or health system executives, 7 clinical department chairs or center directors
- 28 board members were also members of boards of trustees or directors of US hospitals, medical schools, or their parent universities.
Comments
We have been trying to raise awareness of this issue since 2006. Now we have some idea of the size of the problem.
Keep in mind that this study did not attempt to determine the prevalence of academic medical center leaders on boards of smaller pharmaceutical companies, privately held companies, biotechnology or device companies, or other health care and health care related companies (e.g., for-profit hospital systems, health insurance companies, for-profit contract research organizations, for-profit medical education and communication companies, large companies with major health care components, etc, etc, etc) It also did not attempt to determine the prevalence of leaders of other important health care non-profit organizations (e.g., hospitals and hospital systems, insurance companies, professional societies, patient advocacy groups, accrediting boards, etc, etc, etc) on health care or related corporate boards. It also did not address leaders of health care organizations outside of the US. So this study likely greatly underestimates the overall prevalence of and the number of people involved in what we first called a "new species of conflict of interest."
But it is a start. And publishing it in JAMA will begin to make more health care professionals, policy makers, and researchers, and more of the public at large aware of the problem.
As I said before, it is very nice to see that the issue of what we once called a new species of conflict of interest finally has made the big time. Whether it now gets any more traction remains to be seen. Unfortunately, since conflicts of interest can be so profitable for the directly affected parties, I fully expect they will continue to oppose any restrictions. The money they have made will likely be used to deploy marketing and public relations personnel and legal counsel to counter any attempts to try to make this aspect of health care more honest.
As we have said again and again, the web of conflicts of interest that is pervasive in medicine and health care is now threatening to strangle medicine and health care. Furthermore, this web is now strong enough to have effectively transformed US health care into an oligarchy or plutocracy. Health care is effectively run by a relatively small group of people, mainly professional managers plus a few (lapsed?) health care professionals, who simultaneously run or influence multiple corporations and organizations.
For patients and the public to trust health care professionals and health care organizations, they need to know that these individuals and organizations are putting patients' and the public's health ahead of private gain. Health care professionals who care for patients, those who teach about medicine and health care, clinical researchers, and those who make medical and health care policy should do so free from conflicts of interest that might inhibit their abilities to put patients and the public's health first.
Health care professionals ought to make it their highest priority to ensure that the organizations for which they work, or with which they interact also put patients' and the public's health ahead of private gain, especially the private gain of the organizations' leaders and their cronies.
ADDENDUM (3 April, 2014) - see also comments by Paul Levy on the Not Running a Hospital blog, on the 1BoringOldMan blog, and by Ed Silverman (welcome back!) on the WSJ Corporate Intelligence blog.
Showing posts with label academic medical centers. Show all posts
Showing posts with label academic medical centers. Show all posts
Thursday, April 3, 2014
Thursday, March 20, 2014
Better Late than Never - JAMA Article Advocates Banning Academic Medical Leaders from Serving on Many Health Care Corporate Boards
Will wonders never cease? Eight years after we started posting about this issue, it has made it into a large circulation medical journal, albeit not completely
A JAMA Commentary Decries Leaders of Academic Medical Centers Serving on Boards of Organizations with Conflicting Priorities
A recent JAMA commentary(1) noted the importance of conflicts of interest affecting top leaders of academic medicine,
(The article oddly omitted discussing conflicts of interest affecting the boards of trustees of such institutions, who are charged with their stewardship.)
Anyway, the authors' rationale was that,
So,
The authors stressed that the most intense conflicts are generated by service on the boards of directors of "organizations with interests that overlap those of the academic health system." Presumably they would have included among such organizations health care corporations that sell goods or services that might be used within academic medical centers, and/or be the subject of teaching or research by faculty at these centers, although the article did not make that explicit.
The authors suggested such conflicts are not infrequent, noting a survey by Campbell et al of department chairs in academic medical institutions that showed a majority had some sort of relationships with industry, although they did not specify what these relationships were. In fact, the Campbell article did report that 11% of department chairs admitted to being on the board of directors of companies that had activities that related to the chairs' academic or administrative responsibilities.(2)
Finally, the authors called for banning most such conflicts
Note however that they did offer some loopholes.
Despite the omissions and loopholes, this is a very significant article. It is the first challenge to such severe conflicts of interest affecting academic medicine to appear as an article in a major medical journal, at least to my knowledge.
You Heard It Here First
However, on Health Care Renewal we have been attempting to challenge such conflicts for at least eight years. In 2006 we first discussed a newly discovered species of conflict of interest in health care, in which leaders of medical or health care organizations were simultaneously serving on boards of directors of health care corporations.
We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive. It ostensibly requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] Of course, after the global financial collapse of 2008 made us sadder and a little wiser, we realized that many board members actually seem to have unyielding loyalty to their cronies among top management. However, in any case, the stated or actual interests of a member of the board of a health care corporation, like a pharmaceutical company or medical device company, could be very different and at odds with the mission of an academic medical institution or a non-profit ostensibly dedicated to improving health care quality.
Vivid Cases Would Strengthen the Argument
It is odd that the JAMA article included very little evidence about the occurrence of such conflicts of interest. It really is not hard to find. Since 2006, we have discussed numerous cases of such conflicts of interest.
The case that first attracted our attention was that of Marye Anne Fox, the then Chancellor of the University of California - San Diego, a major campus of the state university that includes a medical school. January, 2006 media reports noted that Chancellor Fox was simultaneously servingon 10 corporate boards, including those of two health care corporations, Boston Scientific, a medical device company, and Pharmaceutical Product Development Inc (PPDI), a for-profit contract research organization. At the time, I wrote,
Nonetheless, beyond local media, the case got little attention at the time. What attention it did get focused on the magnitude of Chancellor Fox's commitments to outside organizations, not the conflicts they apparently caused (look here). Chancellor Fox apparently retired from the PPDI board in 2008 (look here) but did not retire from the Boston Scientific Board until 2011 (look here).
Since then, we found many more striking cases.
- A month later, there was the case of the president of the University of Miami, a board member of for-profit health insurance company UnitedHealth, whose lowest paid employees were on strike to protest their lack of health insurance, among other issues.
- It turned out the UnitedHealth board in particular seemed to be a refuge for multiple academic leaders, at least one of whom seemed partly responsible for allowing the then UnitedHealth CEO to collect many backdated stock options (look here)..
- Then there was the 2008 case of the conflict of interest involving an anti-health company. After Virginia Commonwealth University was criticized for taking money from giant tobacco company Philip Morris for medical research, it turned out that the then president of the university, Eugene Trani, was on the board of another tobacco company, Universal Corp (see post here).
- Then, in 2009, some attributed the problems at George Washington University's medical school that caused it to be put on probation to the conflict of interest of its provost and vice president for health affairs, John F Williams, who also sat on the board of Universal Health Services, which owned the university hospital (look here).
We posted about a number of other colorful cases since then (look here)
Although this evidence is admittedly case based and therefore anecdotal, it could be used to highlight the importance of the problem and develop support for its solution.
A Welcome Addition to Previous Recommendations about Countering Conflicts of Interest
For whatever reason, this issue somehow seemed to escape the attention of many of those who have written about conflicts of interest in health care. Even those who advocated taking a harder line on conflicts of interest have generally avoided this issue.
Brennan et al made recommendations about reducing conflicts of interest in 2006, but focused on students and faculty, not top leaders and executives (see post here).(3) The 2009 Institute of Medicine report set relatively tough standards for managing conflicts of interest affecting clinical research and teaching, which unfortunately since have largely been ignored. It did call for senior institutional officials to disclose their conflicts of interest, and for institutional boards of trustees to form conflicts of interest committees that would exclude conflicted individuals, but otherwise did not address conflicts of interest affecting academic leaders or institutional trustees. The 2013 Pew Charitable Trusts Conflicts-of-Interest Policies for Academic Medical Centers suggested restrictions on conflicts affecting faculty, trainees, and students, but again did not mention senior institutional leaders or boards of trustees.
Conclusion
So it is very nice to see that the issue of what we once called a new species of conflict of interest finally has made the big time. Whether it now gets any traction remains to be seen. Unfortunately, since conflicts of interest can be so profitable for the directly affected parties, I fully expect they will continue to oppose any restrictions. The money they have made will likely be used to deploy marketing and public relations personnel and legal counsel to counter any attempts to try to make this aspect of health care more honest.
As we have said again and again, the web of conflicts of interest that is pervasive in medicine and health care is now threatening to strangle medicine and health care. For patients and the public to trust health care professionals and health care organizations, they need to know that these individuals and organizations are putting patients' and the public's health ahead of private gain. Health care professionals who care for patients, those who teach about medicine and health care, clinical researchers, and those who make medical and health care policy should do so free from conflicts of interest that might inhibit their abilities to put patients and the public's health first.
References
1. Pisano ED, Golden RN,Schweitzer L. Conflict of interest policies for academic health system leaders who work with outside corporations. JAMA 2014;311(11):1111-1112. doi:10.1001/jama.2014.788 Link here.
2. Campbell EG, Weissman JS, Ehringhaus S et al. Institutional academic-industry relationships. JAMA 2007;298(15):1779-1786. doi:10.1001/jama.298.15.1779. Link here.
3, Brennan TA, Rothman DJ, Blank L et al. Health industry practices that create conflicts of interest. a policy proposal for academic medical centers. JAMA 2006;295(4):429-433. doi:10.1001/jama.295.4.429 Link here.
A JAMA Commentary Decries Leaders of Academic Medical Centers Serving on Boards of Organizations with Conflicting Priorities
A recent JAMA commentary(1) noted the importance of conflicts of interest affecting top leaders of academic medicine,
Conflict of interest is particularly relevant for those in the upper echelons of academic health system leadership—presidents, vice presidents, provosts, deans, chief executive officers, and the senior administrators who report to them.
(The article oddly omitted discussing conflicts of interest affecting the boards of trustees of such institutions, who are charged with their stewardship.)
Anyway, the authors' rationale was that,
Unlike most faculty and staff, senior institutional officials are involved in financial and business decisions, including purchasing, resource allocation, and development of corporate partnerships, and have fiduciary responsibility to the entire institution. In addition, it is critical that the public, students, employees, and faculty maintain confidence in the integrity of institutional leaders. Leaders have a responsibility to set an example for others in their institution, especially for those training to be health care professionals.
Independence and integrity of judgment are core precepts of professionalism. Every employee, faculty member, and student in an academic health system should feel confident that their leaders are making decisions based on the best interests of the institution and not driven by biases secondary to financial connections to outside corporate entities.
So,
Having a fiduciary responsibility to 2 separate entities is at best a very difficult situation. Will the leader direct business inappropriately to the outside company on whose board he or she sits? Will the leader inappropriately use information about the institution he or she leads to influence decisions by the outside corporation? It is difficult to separate these types of activities and decisions. In addition, there are administrative costs associated with the management of this level of conflict, and such relationships might have a 'chilling effect' on other companies that could do business with the academic health system. Beyond service on fiduciary boards, undertaking any paid role (consulting, participation on advisory boards, etc) with an outside entity with interests that overlap those of the leader’s institution raises the same issues.
The authors stressed that the most intense conflicts are generated by service on the boards of directors of "organizations with interests that overlap those of the academic health system." Presumably they would have included among such organizations health care corporations that sell goods or services that might be used within academic medical centers, and/or be the subject of teaching or research by faculty at these centers, although the article did not make that explicit.
The authors suggested such conflicts are not infrequent, noting a survey by Campbell et al of department chairs in academic medical institutions that showed a majority had some sort of relationships with industry, although they did not specify what these relationships were. In fact, the Campbell article did report that 11% of department chairs admitted to being on the board of directors of companies that had activities that related to the chairs' academic or administrative responsibilities.(2)
Finally, the authors called for banning most such conflicts
the fiduciary responsibilities of presidents, provosts, vice presidents, deans, chief executive officers, and those who report to them should preclude a paid relationship with an outside entity in related and relevant areas,...
Note however that they did offer some loopholes.
unless a case can be made that there is a compelling institutional interest in the leader’s service in such a role, or if the role with the outside organization is outside the scope of the leader’s role at the academic health system.
Despite the omissions and loopholes, this is a very significant article. It is the first challenge to such severe conflicts of interest affecting academic medicine to appear as an article in a major medical journal, at least to my knowledge.
You Heard It Here First
However, on Health Care Renewal we have been attempting to challenge such conflicts for at least eight years. In 2006 we first discussed a newly discovered species of conflict of interest in health care, in which leaders of medical or health care organizations were simultaneously serving on boards of directors of health care corporations.
We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive. It ostensibly requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] Of course, after the global financial collapse of 2008 made us sadder and a little wiser, we realized that many board members actually seem to have unyielding loyalty to their cronies among top management. However, in any case, the stated or actual interests of a member of the board of a health care corporation, like a pharmaceutical company or medical device company, could be very different and at odds with the mission of an academic medical institution or a non-profit ostensibly dedicated to improving health care quality.
Vivid Cases Would Strengthen the Argument
It is odd that the JAMA article included very little evidence about the occurrence of such conflicts of interest. It really is not hard to find. Since 2006, we have discussed numerous cases of such conflicts of interest.
The case that first attracted our attention was that of Marye Anne Fox, the then Chancellor of the University of California - San Diego, a major campus of the state university that includes a medical school. January, 2006 media reports noted that Chancellor Fox was simultaneously servingon 10 corporate boards, including those of two health care corporations, Boston Scientific, a medical device company, and Pharmaceutical Product Development Inc (PPDI), a for-profit contract research organization. At the time, I wrote,
having ultimate leadership responsibilities for a medical school and medical center, while also having ultimate fiduciary responsibilities for the management of a medical device company and a contract medical research company amounts to the biggest conflicts of interest I have ever seen.
Nonetheless, beyond local media, the case got little attention at the time. What attention it did get focused on the magnitude of Chancellor Fox's commitments to outside organizations, not the conflicts they apparently caused (look here). Chancellor Fox apparently retired from the PPDI board in 2008 (look here) but did not retire from the Boston Scientific Board until 2011 (look here).
Since then, we found many more striking cases.
- A month later, there was the case of the president of the University of Miami, a board member of for-profit health insurance company UnitedHealth, whose lowest paid employees were on strike to protest their lack of health insurance, among other issues.
- It turned out the UnitedHealth board in particular seemed to be a refuge for multiple academic leaders, at least one of whom seemed partly responsible for allowing the then UnitedHealth CEO to collect many backdated stock options (look here)..
- Then there was the 2008 case of the conflict of interest involving an anti-health company. After Virginia Commonwealth University was criticized for taking money from giant tobacco company Philip Morris for medical research, it turned out that the then president of the university, Eugene Trani, was on the board of another tobacco company, Universal Corp (see post here).
- Then, in 2009, some attributed the problems at George Washington University's medical school that caused it to be put on probation to the conflict of interest of its provost and vice president for health affairs, John F Williams, who also sat on the board of Universal Health Services, which owned the university hospital (look here).
We posted about a number of other colorful cases since then (look here)
Although this evidence is admittedly case based and therefore anecdotal, it could be used to highlight the importance of the problem and develop support for its solution.
A Welcome Addition to Previous Recommendations about Countering Conflicts of Interest
For whatever reason, this issue somehow seemed to escape the attention of many of those who have written about conflicts of interest in health care. Even those who advocated taking a harder line on conflicts of interest have generally avoided this issue.
Brennan et al made recommendations about reducing conflicts of interest in 2006, but focused on students and faculty, not top leaders and executives (see post here).(3) The 2009 Institute of Medicine report set relatively tough standards for managing conflicts of interest affecting clinical research and teaching, which unfortunately since have largely been ignored. It did call for senior institutional officials to disclose their conflicts of interest, and for institutional boards of trustees to form conflicts of interest committees that would exclude conflicted individuals, but otherwise did not address conflicts of interest affecting academic leaders or institutional trustees. The 2013 Pew Charitable Trusts Conflicts-of-Interest Policies for Academic Medical Centers suggested restrictions on conflicts affecting faculty, trainees, and students, but again did not mention senior institutional leaders or boards of trustees.
Conclusion
So it is very nice to see that the issue of what we once called a new species of conflict of interest finally has made the big time. Whether it now gets any traction remains to be seen. Unfortunately, since conflicts of interest can be so profitable for the directly affected parties, I fully expect they will continue to oppose any restrictions. The money they have made will likely be used to deploy marketing and public relations personnel and legal counsel to counter any attempts to try to make this aspect of health care more honest.
As we have said again and again, the web of conflicts of interest that is pervasive in medicine and health care is now threatening to strangle medicine and health care. For patients and the public to trust health care professionals and health care organizations, they need to know that these individuals and organizations are putting patients' and the public's health ahead of private gain. Health care professionals who care for patients, those who teach about medicine and health care, clinical researchers, and those who make medical and health care policy should do so free from conflicts of interest that might inhibit their abilities to put patients and the public's health first.
References
1. Pisano ED, Golden RN,Schweitzer L. Conflict of interest policies for academic health system leaders who work with outside corporations. JAMA 2014;311(11):1111-1112. doi:10.1001/jama.2014.788 Link here.
2. Campbell EG, Weissman JS, Ehringhaus S et al. Institutional academic-industry relationships. JAMA 2007;298(15):1779-1786. doi:10.1001/jama.298.15.1779. Link here.
3, Brennan TA, Rothman DJ, Blank L et al. Health industry practices that create conflicts of interest. a policy proposal for academic medical centers. JAMA 2006;295(4):429-433. doi:10.1001/jama.295.4.429 Link here.
Wednesday, February 13, 2013
Non-Profit Hospital Executive Salaries Continue to Defy Gravity and Logic
The old saying is that nothing is certain except death and taxes. In health care, the other near certainty seems to be that compensation for health care leaders is big and always getting bigger.
Over the past few weeks several reports about the compensation of top executives of US non-profit hospitals and hospital systems have appeared. So it is time to do our latest round-up of incessantly buoyant hospital executive compensation, and argumentative hot air that seems to fuel it. I will first summarize the latest cases in alphabetical order by state, and then examine some common justifications for the seemingly anti gravitational nature of executive compensation in this part of health care.
Arizona
On AZCentral.com was an article about the CEO of a single relatively small public hospital system:
That may not seem like a lot of money as executive compensation goes, but consider the context:
Nonetheless, the CEO did not exactly feel rich:
She justified her pay by comparing it to what she thought the market would bear.
Members of the hospital system's board also justified the pay on the grounds that it was at the market rate:
Another board member also noted how hard CEO Bayless works:
California
In California a report focused in contrast on the bigger hospitals and hospital systems. California Healthcare News reported on the best compensated hospital executives in the state. In general,
Some specifics about the best paid executives:
The article provided the justification for Priselac's seven-figure compensation:
He did not offer how this performance was measured, how it compared to that of any other hospital, or whether anyone other than the CEO might have been responsible for that performance.
The survey results included the best compensated CEO of a health-district
The survey results also included the best compensated CEO for academic medical centers run by the (state supported) University of California:
Becker's Hospital Review provided information on the highest paid Connecticut hospital CEOs:
The report did not provide any justification for the pay levels, and I could find no further news coverage that was relevant.
Massachusetts
The Fitchburg (MA) Sentinel and Enterprise seemed to be the only media outlet which noted the compensation of hospital executives reported to the state attorney general. It listed compensation of some regional hospital leaders,
This should be viewed in the context of the medical center's current dire straits:
As we have shown again and again, the pay of top health care leaders seems to endlessly increase, without clear justification, regardless of the vicissitudes affecting the organizations they lead, their employees, their patients and society. This suggests that health care organizations, like many other organizations, seem to be run primarily for the benefit of their executives and their cronies, regardless of what happens to anyone else.
As we have frequently said, current policies about paying hired health care managers leave the managers unaccountable for the effects of their actions on patients' and the public's health, and worse, fail to deter and may even encourage ignorance of the health care mission, frankly mission-hostile behavior, self-interest, conflicts of interest, and outright corruption. Meanwhile, paying nearly all top managers as if they were brilliant, while setting much harsher standards for the employees who actually take care of patients, including health professionals, demoralizes those on whom patients actually depend for care.
As we have said endlessly,.... Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior.
If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.
Over the past few weeks several reports about the compensation of top executives of US non-profit hospitals and hospital systems have appeared. So it is time to do our latest round-up of incessantly buoyant hospital executive compensation, and argumentative hot air that seems to fuel it. I will first summarize the latest cases in alphabetical order by state, and then examine some common justifications for the seemingly anti gravitational nature of executive compensation in this part of health care.
Arizona
On AZCentral.com was an article about the CEO of a single relatively small public hospital system:
The leaders of Maricopa County’s public health-care system agreed to raise chief executive Betsey Bayless’ pay by 33 percent, bringing her salary to $500,000.
That may not seem like a lot of money as executive compensation goes, but consider the context:
The Maricopa Integrated Health System is a public hospital system that provides care for the Valley’s poor and uninsured. It is funded by federal and state health-care dollars and a special county levy paid by all county property-tax payers.
MIHS budgeted $3.5 million for market adjustments and merit raises for its employees in fiscal 2013. Bayless’ salary increase alone will consume one-quarter of the $500,000 the board had allocated this fiscal year to bring all employees’ pay in line with similar positions elsewhere.
The health-care system’s rank-and-file employees have received annual merit-based salary increases of no more than 2.9 percent since fiscal 2008.
Nonetheless, the CEO did not exactly feel rich:
Bayless said she did not request the raise and was not expecting it. She said she believes MIHS employees will understand that her salary has been comparatively low and that her replacement likely will be brought in at an even higher salary.
She justified her pay by comparing it to what she thought the market would bear.
'Any salary information will show you that my salary is always the lowest of any (hospital) CEO currently in the entire state, even the little-bitty hospitals,' Bayless said. 'On any measure, 375 (thousand dollars) is below market. So, do I feel undercompensated? I don’t know. But on any measure, it always comes in below market.'
Members of the hospital system's board also justified the pay on the grounds that it was at the market rate:
[Board Members Mary] Harden and [Terence] McMahon said they voted for the pay raise because a national search firm hired to find Bayless’ replacement set $500,000 as a minimum competitive salary for qualified candidates.
Another board member also noted how hard CEO Bayless works:
'The lady works 70-plus hours a week. She’s on call 24/7. So, I think the job warrants it. She works very, very hard,' Dewane said.I am sure health care professionals who also work long hours, and are frequently on call, but unlike managers, have to make decisions with real life and death consequences would understand, or not.
California
In California a report focused in contrast on the bigger hospitals and hospital systems. California Healthcare News reported on the best compensated hospital executives in the state. In general,
More than one in five non-profit hospital chief executive officers in California received compensation totaling $1 million or more in 2010, according to a new pay survey by Payers & Providers.
Altogether, 32 CEOs of the 154 surveyed received pay packages that ventured into the seven figures. That compares to 19 CEOs who received seven-figure pay packages in the only prior survey Payers & Providers conducted. That survey was published in June 2010, and relied primarily on data from 2007 and 2008.
Some specifics about the best paid executives:
Kaiser Permanente's George Halvorson is the most highly-compensated hospital system executive in California, receiving $7.74 million in 2010. That included more than $6 million in additional compensation. Halvorson is retiring as Kaiser's CEO in June.
Thomas Priselac, the chief executive officer of Cedars-Sinai Medical Center in Los Angeles, was the highest-paid standalone hospital CEO, earning $2.77 million in 2010. That included additional compensation of $1.6 million.
The article provided the justification for Priselac's seven-figure compensation:
According to an email response from Cedars-Sinai spokesperson Duke Helfand, Priselac's compensation 'reflects the top-tier clinical, research and educational performance the medical center consistently has delivered in his 19 years of leadership.'
He did not offer how this performance was measured, how it compared to that of any other hospital, or whether anyone other than the CEO might have been responsible for that performance.
The survey results included the best compensated CEO of a health-district
Michael Covert, the CEO of the two hospital Palomar-Pomerado Health system in San Diego County, was the highest-paid district hospital CEO, earning $1.09 million in 2010. He was among two district hospital CEOs to earn seven-figure compensation.
The survey results also included the best compensated CEO for academic medical centers run by the (state supported) University of California:
David T. Feinberg, M.D., is by far the highest-paid CEO among those who oversee the five research hospitals operated by the University of California. Feinberg, who runs Ronald Reagan UCLA Medical Center, earned $1.33 million in 2010 – the only seven-figure pay package among that cohort of CEOs, and nearly $450,000 more than the second-highest earner in that group, Mark Laret of UC San Francisco Medical Center.Connecticut
Becker's Hospital Review provided information on the highest paid Connecticut hospital CEOs:
Here are the nine CEOs who earned at least $1 million in 2011.
• Clarence Silvia, The Hospital of Central Connecticut: $2.76 million
• Marna Borgstrom, Yale-New Haven Hospital: $2.59 million
• Brian Grissler, Stamford Hospital: $2.24 million
• Elliot Joseph, Hartford Hospital: $1.74 million
(*CEO is now Jeff Flaks)
• Frank Corvino, Greenwich Hospital: $1.71 million
• Susan Davis, RN, Saint Vincent's Medical Center: $1.48 million
• Chris Dadlez, Saint Francis Hospital and Medical Center: $1.42 million
• John Murphy, MD, Danbury Hospital: $1.08 million
• Christopher O'Connor, Hospital of Saint Raphael: $1.04 million
The report did not provide any justification for the pay levels, and I could find no further news coverage that was relevant.
Massachusetts
The Fitchburg (MA) Sentinel and Enterprise seemed to be the only media outlet which noted the compensation of hospital executives reported to the state attorney general. It listed compensation of some regional hospital leaders,
Patrick Muldoon, president and CEO of HealthAlliance Hospital, a member of the UMass Memorial Health Care system, received a compensation package of $653,868 in 2010, the most recent year for which compensation data is publicly available.
The HealthAlliance system includes a 135-bed community hospital with services on two campuses in Leominster and Fitchburg.
Over that same period, Daniel P. Moen, former president and CEO of the 153-bed Heywood Hospital in Gardner, received a compensation package of $386,126.
Christine Schuster, CEO of Emerson Hospital in Concord, earned a total compensation package of $669,844. Emerson has 179 beds.
Lahey Clinic chief executive Howard Grant, who oversees a facility with 317 beds, was paid a total compensation package of $768,568 in 2010.
It listed the following compensation information for other executives:
Other big hospital administrators’ salaries, 2011
* $552,556.33 — Debra Carey, vice president
* $357,379.26 - Grace Wong, vice president
* $334,072.19 — Ivan Lisnitzer, vice president
* $312,182.24 — Paul Davis, assistant vice president
* $286,954.51 Renee Poncet, vice president
This should be viewed in the context of the medical center's current dire straits:
SUNY Downstate — which has a hospital and medical school in East Flatbush — is in such bad financial shape it could go broke by March, SUNY chairman Carl McCall has said.
As we have shown again and again, the pay of top health care leaders seems to endlessly increase, without clear justification, regardless of the vicissitudes affecting the organizations they lead, their employees, their patients and society. This suggests that health care organizations, like many other organizations, seem to be run primarily for the benefit of their executives and their cronies, regardless of what happens to anyone else.
As we have frequently said, current policies about paying hired health care managers leave the managers unaccountable for the effects of their actions on patients' and the public's health, and worse, fail to deter and may even encourage ignorance of the health care mission, frankly mission-hostile behavior, self-interest, conflicts of interest, and outright corruption. Meanwhile, paying nearly all top managers as if they were brilliant, while setting much harsher standards for the employees who actually take care of patients, including health professionals, demoralizes those on whom patients actually depend for care.
As we have said endlessly,.... Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior.
If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.
Thursday, December 6, 2012
The Parts of Professionalism We Are Not Supposed to Discuss
A recent article in a a relatively obscure medical ethics journal dared to approach some important aspects of medical ethics that medical ethicists fear to discuss, but did not address the reasons for this fear or what to do about it. (Glenn JE. The eroding principle of justice in teaching medical ethics. HEC Forum 2012; 24: 293-305. Link here.)
The Basic Ethics Case - A Prescription for the Patient's Spouse?
Glenn began with a case typically discussed in medical school ethics courses:
This
The Politically Correct Way to Teach the Case
Glenn stated that there is a politically correct way for faculty to teach this case:
Now, of course, writing a prescription for a patient who does not actually need the drug in question, understanding that the patient will give the drug to someone else who does not have insurance coverage to pay for it, is dishonest. However, the larger point that Glenn made is that it is not politically correct to allow discussion about why the patient made such a request in the first place, and that this ought to be troubling.
Note that Glenn did not explain how he inferred what the "correct" answer was, nor its actual source within the institution.
Social Justice as Part of Professionalism, and its Avoidance
The article by Glenn then emphasized that some of the original conceptions of physicians' professionalism included social justice. A definition promulgated by Herbert Swick in 2000 expressly included these relevant competencies. Physicians ought to:
- subordinate their own interests to the interests of others
- respond to social needs and work toward the benefit of the communities in which they live and serve
- adhere to the core humanistic values of honesty and integrity, compassion, altruism, empathy, respect for others, and trustworthiness.
Glenn noted that these three competencies, however, have been turned into a more narrow imperative, that
Note that Glenn did not question why the issues of race, ethnicity, gender, religion, or cultural background became important in this context. He did further question why the issue of class did not. While
Glenn asked
Furthermore, he noted,
So, now seemingly getting to the key question,
The Key Question also Avoided
However, after this build up, Glenn then had trouble grappling with that question. He noted that the prices of various parts of US health care are rarely questioned, and wrote about some of the particular issues in pricing new technologies, including the costs of development of new drugs, the tax treatment of drug development, and whether the licenses drug companies obtain from universities to develop drugs are fairly priced. He also touched on the rising cost of medical school tuition and students' consequent assumption of large levels of debt. This was interesting, and provided some useful references, but never really directly addressed the key questions above: why was the discussion framed in terms only of current health economics, and more importantly, why did he and other ethicists feel they could not openly discuss any larger issues?
Only at the very end of the article did this appear
Glenn did not further explain these "financial incentives," detail further who had them, explain how they "work against the best interests of patients," and most importantly, explain how these incentives make "it difficult to talk with students about the ethical principal of justice in any meaningful way that is not hypocritical." He concluded only
Summary
So Professor Glenn argued that social justice has been considered part of health care ethics, and that ethicists should teach about it by questioning the current economic arrangements within the health care system. He then suggested that ethicists have been somehow pressured not do raise such questions, and that this pressure has something to do with perverse incentives and conflicts of interest prevalent within health care. However, he never actually addressed who pressured the ethicists, how the pressure was applied, and how that pressure was related to conflicts of interest.
Thus, it seems that authors in scholarly health care journals may now hint that there are certain things one must not discuss, that are taboo to discuss in health care, but cannot actually say what exactly is taboo, and why it became that way. Thus, the article by Glenn seems related to what we sometimes coyly call the "anechoic effect," that the issues we discuss on Health Care Renewal often do not seem to be considered topics of polite conversation. But in a strange recursive way, the article never could quite manage to discuss what it is it said others cannot discuss, which in a way just further validates the importance of the anechoic effect.
The Glenn article is reminiscent of another article we posted about. That article, by Souba and colleagues, found that there are many "elephants," that is, unmentionable subjects, in academic medicine, However, that article also never clearly defined what these unmentionable subjects actually are, other than subjects that displease those in power. Thus this too reinforced just how taboo these topics are. Even those willing to admit that taboo topics exist are still unable to name them.
At least the Glenn article did suggest, however vaguely, a relationship between conflicts of interest and the anechoic effect. We have documented that individual and institutional conflicts of interest are rampant in health care, including, and probably particularly academic medicine. For example, pharmaceutical companies (and also all sorts of other health care corporations) may pay medical school faculty members and administrators (as consultants, "key opinion leaders," speakers, advisers, even board members). The leaders of academic medicine seem particularly prone to such conflicts. For example, a majority of US medical school department chairs have significant financial relationships with health care corporations (see post here). We have shown how top medical school leaders may simultaneously serve on the boards of directors of health care corporations (see post here). Such health care corporations may now also support various aspects of medical academia (through research grants, "unrestricted" and other educational grants, other gifts to hospitals and universities, etc). Financial conflicts of interest may help to directly enrich many faculty and academic leaders, and indirectly enrich them by enriching their organizations. People who are personally profiting from relationships with health care corporations are unlikely to question such relationships. The leaders of organizations which depend on funding from such corporations are unlikely to question whether conflicts of interest might lead to corruption. People whose colleagues, friends, family members, or supervisors are personally benefiting from conflicts of interest may hesitate to challenge such relationships. Since these relationships permeate the economics of health care, is it any wonder that the entire topic has become taboo?
So the first step in challenging this taboo is to acknowledge it exists, and to not "shy away" from discussing it, as Glenn suggested. People are beginning to acknowledge there is an elephant in the room. Now we have to describe the elephant, discuss the elephant, and eventually figure out how to get the elephant out of the room.
Hat tip - to the Medical Professionalism Blog.
The Basic Ethics Case - A Prescription for the Patient's Spouse?
Glenn began with a case typically discussed in medical school ethics courses:
a scenario where a standardized patient asks the student at the end of the examination if his prescription can be written in his spouse’s name as the spouse has health insurance which includes prescription drug coverage while the patient does not.
This
poses the question as to whether it is ethical for physicians to deceive third party payers to secure coverage for their patients.
The Politically Correct Way to Teach the Case
Glenn stated that there is a politically correct way for faculty to teach this case:
Though we are never expressly instructed to tow [sic] a party line, there is a 'correct' answer to this ethical quandary as far as the institution we work for is concerned. Students who express a willingness to practice deception of third party payers for the good of their patients are to be commended for having their heart in the right place. However, we discuss many reasons why this action would not be a good solution to the problem. One of the issues is that to do so would be committing fraud.
Now, of course, writing a prescription for a patient who does not actually need the drug in question, understanding that the patient will give the drug to someone else who does not have insurance coverage to pay for it, is dishonest. However, the larger point that Glenn made is that it is not politically correct to allow discussion about why the patient made such a request in the first place, and that this ought to be troubling.
Note that Glenn did not explain how he inferred what the "correct" answer was, nor its actual source within the institution.
Over the first few years of having this conversation with young medical students, I have always come away feeling empty and flat. Framed as a session on the ethics of 'truth telling,' the conversation and the readings we provide to prepare for it works to obfuscate the much larger ethical issue impossible to tackle in an hour’s time. In essence, 'truth telling' is only a secondary ethical issue at play. The more important ethical issue is a question of social justice: what commitment do doctors have to poor patients and making sure that they get the health care services that they need?
Social Justice as Part of Professionalism, and its Avoidance
The article by Glenn then emphasized that some of the original conceptions of physicians' professionalism included social justice. A definition promulgated by Herbert Swick in 2000 expressly included these relevant competencies. Physicians ought to:
- subordinate their own interests to the interests of others
- respond to social needs and work toward the benefit of the communities in which they live and serve
- adhere to the core humanistic values of honesty and integrity, compassion, altruism, empathy, respect for others, and trustworthiness.
Glenn noted that these three competencies, however, have been turned into a more narrow imperative, that
doctors should treat patients with an equally high quality irrespective of their race, ethnicity, gender, religion or cultural background according to what is best for them. In most codes of professionalism, however, class is not expressly implicated.
Note that Glenn did not question why the issues of race, ethnicity, gender, religion, or cultural background became important in this context. He did further question why the issue of class did not. While
The professionalism code adopted by the American Board of Internal Medicine in 1999 was bolder and specifically states that doctors are to advocate for 'the best possible care [for their patients] regardless of the ability to pay'
Glenn asked
But where in the medical school curriculum do we teach medical students to be strong patient advocates and take on third party payers and hospital administrators? We now discuss the importance of prescribing generic drugs and we warn against the influence of big pharma, but when do we teach students to rebel against the high cost of medical education that drives students toward boutique medicine and fields of specialty care that offer the most money and most comfortable lifestyles?
Furthermore, he noted,
When it comes to justice in medical ethics instruction, the parameters of the discussion are usually constricted to focus on the conservation of health care resources and rationing care rather than providing more care to more patients.
So, now seemingly getting to the key question,
We have created an entire system where all the middlemen that stand between a patient and her health care are expecting to get rich. No oath or professionalism curriculum is structured to teach medical students how to ethically and morally navigate through that. How did the terms of the debate get so co-opted by the health care economists?
The Key Question also Avoided
However, after this build up, Glenn then had trouble grappling with that question. He noted that the prices of various parts of US health care are rarely questioned, and wrote about some of the particular issues in pricing new technologies, including the costs of development of new drugs, the tax treatment of drug development, and whether the licenses drug companies obtain from universities to develop drugs are fairly priced. He also touched on the rising cost of medical school tuition and students' consequent assumption of large levels of debt. This was interesting, and provided some useful references, but never really directly addressed the key questions above: why was the discussion framed in terms only of current health economics, and more importantly, why did he and other ethicists feel they could not openly discuss any larger issues?
Only at the very end of the article did this appear
the structure of our current medical system has created a network of health care providers, researchers, purveyors and administrators who have strong financial incentives to work against the best interests of patients. This situation makes it difficult to talk with students about the ethical principle of justice in any meaningful way that is not hypocritical, leaving it seldom emphasized relative to the other three core principles of medical ethics.
Glenn did not further explain these "financial incentives," detail further who had them, explain how they "work against the best interests of patients," and most importantly, explain how these incentives make "it difficult to talk with students about the ethical principal of justice in any meaningful way that is not hypocritical." He concluded only
How can we cultivate within our students an understanding of the threats to medical professionalism posed by the conflicts of interest inherent in the various financial and organizational arrangements in the practice of medicine? We start by not shying away from the conversation.
Summary
So Professor Glenn argued that social justice has been considered part of health care ethics, and that ethicists should teach about it by questioning the current economic arrangements within the health care system. He then suggested that ethicists have been somehow pressured not do raise such questions, and that this pressure has something to do with perverse incentives and conflicts of interest prevalent within health care. However, he never actually addressed who pressured the ethicists, how the pressure was applied, and how that pressure was related to conflicts of interest.
Thus, it seems that authors in scholarly health care journals may now hint that there are certain things one must not discuss, that are taboo to discuss in health care, but cannot actually say what exactly is taboo, and why it became that way. Thus, the article by Glenn seems related to what we sometimes coyly call the "anechoic effect," that the issues we discuss on Health Care Renewal often do not seem to be considered topics of polite conversation. But in a strange recursive way, the article never could quite manage to discuss what it is it said others cannot discuss, which in a way just further validates the importance of the anechoic effect.
The Glenn article is reminiscent of another article we posted about. That article, by Souba and colleagues, found that there are many "elephants," that is, unmentionable subjects, in academic medicine, However, that article also never clearly defined what these unmentionable subjects actually are, other than subjects that displease those in power. Thus this too reinforced just how taboo these topics are. Even those willing to admit that taboo topics exist are still unable to name them.
At least the Glenn article did suggest, however vaguely, a relationship between conflicts of interest and the anechoic effect. We have documented that individual and institutional conflicts of interest are rampant in health care, including, and probably particularly academic medicine. For example, pharmaceutical companies (and also all sorts of other health care corporations) may pay medical school faculty members and administrators (as consultants, "key opinion leaders," speakers, advisers, even board members). The leaders of academic medicine seem particularly prone to such conflicts. For example, a majority of US medical school department chairs have significant financial relationships with health care corporations (see post here). We have shown how top medical school leaders may simultaneously serve on the boards of directors of health care corporations (see post here). Such health care corporations may now also support various aspects of medical academia (through research grants, "unrestricted" and other educational grants, other gifts to hospitals and universities, etc). Financial conflicts of interest may help to directly enrich many faculty and academic leaders, and indirectly enrich them by enriching their organizations. People who are personally profiting from relationships with health care corporations are unlikely to question such relationships. The leaders of organizations which depend on funding from such corporations are unlikely to question whether conflicts of interest might lead to corruption. People whose colleagues, friends, family members, or supervisors are personally benefiting from conflicts of interest may hesitate to challenge such relationships. Since these relationships permeate the economics of health care, is it any wonder that the entire topic has become taboo?
So the first step in challenging this taboo is to acknowledge it exists, and to not "shy away" from discussing it, as Glenn suggested. People are beginning to acknowledge there is an elephant in the room. Now we have to describe the elephant, discuss the elephant, and eventually figure out how to get the elephant out of the room.
Hat tip - to the Medical Professionalism Blog.
Wednesday, October 3, 2012
Health Care Academics' Unrest and Bad Health Care Leadership?
Last month we discussed a recent, large scale study of physician burnout, and wondered whether it would finally inspire some discourse about why physicians are really so upset. In particular, we hypothesized, based on some real, if limited data, that physician angst, dissatisfaction, burnout, etc may mainly be a response to the problems with leadership and governance of health care organization we post about on Health Care Renewal.
After that post, one of our scouts found a very interesting and relevant article from earlier this year which got little attention at the time, but deserves more. [Pololi LH, Krupat E, Civian JT, Ash AS, Brennan RT. Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools. Acad Med. 2012; 87: 859-69. Link here.]
Study Design
This was a cross-sectional survey of faculty at 26 medical schools in the US, selected to be similar to the general population of medical schools in the country. At each school, 150 faculty were randomly chosen stratified by sex and age, and then the sample was enriched to include additional minority faculty and women surgeons, for a total of 4578.
The faculty were sent a multi item survey to assess their perception of the organizational culture of their institutions, and asked about their intentions to continue in or leave their current positions and academic medicine. Responses to each survey item were allowed to be from 1 = strongly disagree, to 5 = strongly agree. The items on the survey were combined into various scales. A number of items on the survey seemed to be related to issues we frequently discuss on Health Care Renewal. These items ended up in three different scales, entitled Relatedness/Inclusion, Values Alignment, and Ethical/Moral Distress. The survey items are listed below, grouped by issue, with the scales into which they were combined noted.
Issue: Mission-Hostile Leadership
Administration only interested in me for revenue (Reverse coded) (Values Alignment)
Institution committed to serving the public (VA)
Institution's actions well-aligned with stated values and mission (VA)
Institution puts own needs ahead of educational/clinical missions (RC) (VA)
My values well-aligned with school's (VA)
Institution awards excellence in clinical care (VA)
Institution does not value teaching (RC) (VA)
Have to compromise values to work here (Ethical/Moral Distress)
Issue: Deceptive, Unethical Leadership
Felt pressure to behave unethically (Ethical/Moral Distress)
Need to be deceitful in order to succeed (EMD)
Others have taken credit for my work (EMD)
Issue: Generation of the Anechoic Effect by Suppression of Free Speech, Academic Freedom, Dissent, Whistle-Blowing,
Feel ignored/ invisible (RC) (Relatedness/Inclusion)
Hide what I think and feel (RC) (R/I)
Reluctant to express opinion/ fear negative consequences (RC) (R/I)
So in summary, the survey contained quite a few questions about mission-hostile management, comprising nearly all of the Values Alignment scale, some questions about deceptive or unethical leadership, all in the Ethical/Moral Distress scale, and some about generation of the anechoic effect by suppression of free speech, academic freedom, dissent, and whistle-blowing, all in the Relatedness/Inclusion scale.
Results
The response rate was 52% (N=2381.)
Unfortunately, the article did not include the distributions of the responses to individual survey items, and only included the mean and standard error of the scale scores. The values for the scales of most interest were:
Relatedness/Inclusion 3.56 SE= 0.022
Values Alignment 3.25 SE=0.028
Ethical/Moral Distress 2.36 SE=0.022
Note that the article did not address the degree individual items, especially those listed above, contributed to variation in the scale scores.
A small majority of faculty indicated their intentions to stay at their institutions (57%). Of the remainder, 14% were considering leaving their school due to dissatisfaction, and another 21% were considering leaving academic medicine due to dissatisfaction. The remainder were considering leaving due to personal/ family reasons or to retire.
The authors did complex multinomial logit modeling to assess the relationships among the various scales, demographic factors, and intention to leave. Most relevant to us, Relatedness/Inclusion was significantly related to intention to leave the institution due to dissatisfaction (Coefficient -0.69, p lt 0.001, OR =0.50), as was Values Alignment (-0.39, p=0.04, OR=0.68), but not Ethical/ Moral Distress. Furthermore, Relatedness/Inclusion was related to intention to leave academic medicine due to dissatisfaction (-0.48, p lt 0.001, 0.62), as was Ethical/Moral Distress (0.60, p lt 0.001, OR =1.82). The article did not address whether individual survey items, including those of most interest listed above, were related to intention to leave. The article also did not address whether responses to the survey or intention to leave varied across faculty characteristics, medical school characteristics, or individual medical schools.
Summary and Comments
This very large survey of faculty from multiple US medical schools showed that more than one-third were considering leaving their institutions or academic medicine due to dissatisfaction, indicating a striking prevalence of faculty distress. Their responses to questions about perceived organizational cultural and leadership problems, including those possibly related to leadership's perceived hostility to the mission, leadership's perceived dishonesty or unethical behavior, and leadership's suppression of dissent, free speech, academic freedom, and whistle-blowing were related to their intentions to leave due to dissatisfaction.
These results suggest the hypothesis that much of faculty angst may be due to the sorts of problems with leadership and hence organizational culture that we discuss on Health Care Renewal. Since this was a cross-sectional survey, it certainly does not offer scientific proof of this hypothesis. Note that there is other evidence from numerous cases discussed in Health Care Renewal, qualitative studies and our much smaller study published only in abstract form that also supports this hypothesis (look here).
One part of the author's discussion of their findings was particularly relevant:
After that post, one of our scouts found a very interesting and relevant article from earlier this year which got little attention at the time, but deserves more. [Pololi LH, Krupat E, Civian JT, Ash AS, Brennan RT. Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools. Acad Med. 2012; 87: 859-69. Link here.]
Study Design
This was a cross-sectional survey of faculty at 26 medical schools in the US, selected to be similar to the general population of medical schools in the country. At each school, 150 faculty were randomly chosen stratified by sex and age, and then the sample was enriched to include additional minority faculty and women surgeons, for a total of 4578.
The faculty were sent a multi item survey to assess their perception of the organizational culture of their institutions, and asked about their intentions to continue in or leave their current positions and academic medicine. Responses to each survey item were allowed to be from 1 = strongly disagree, to 5 = strongly agree. The items on the survey were combined into various scales. A number of items on the survey seemed to be related to issues we frequently discuss on Health Care Renewal. These items ended up in three different scales, entitled Relatedness/Inclusion, Values Alignment, and Ethical/Moral Distress. The survey items are listed below, grouped by issue, with the scales into which they were combined noted.
Issue: Mission-Hostile Leadership
Administration only interested in me for revenue (Reverse coded) (Values Alignment)
Institution committed to serving the public (VA)
Institution's actions well-aligned with stated values and mission (VA)
Institution puts own needs ahead of educational/clinical missions (RC) (VA)
My values well-aligned with school's (VA)
Institution awards excellence in clinical care (VA)
Institution does not value teaching (RC) (VA)
Have to compromise values to work here (Ethical/Moral Distress)
Issue: Deceptive, Unethical Leadership
Felt pressure to behave unethically (Ethical/Moral Distress)
Need to be deceitful in order to succeed (EMD)
Others have taken credit for my work (EMD)
Issue: Generation of the Anechoic Effect by Suppression of Free Speech, Academic Freedom, Dissent, Whistle-Blowing,
Feel ignored/ invisible (RC) (Relatedness/Inclusion)
Hide what I think and feel (RC) (R/I)
Reluctant to express opinion/ fear negative consequences (RC) (R/I)
So in summary, the survey contained quite a few questions about mission-hostile management, comprising nearly all of the Values Alignment scale, some questions about deceptive or unethical leadership, all in the Ethical/Moral Distress scale, and some about generation of the anechoic effect by suppression of free speech, academic freedom, dissent, and whistle-blowing, all in the Relatedness/Inclusion scale.
Results
The response rate was 52% (N=2381.)
Unfortunately, the article did not include the distributions of the responses to individual survey items, and only included the mean and standard error of the scale scores. The values for the scales of most interest were:
Relatedness/Inclusion 3.56 SE= 0.022
Values Alignment 3.25 SE=0.028
Ethical/Moral Distress 2.36 SE=0.022
Note that the article did not address the degree individual items, especially those listed above, contributed to variation in the scale scores.
A small majority of faculty indicated their intentions to stay at their institutions (57%). Of the remainder, 14% were considering leaving their school due to dissatisfaction, and another 21% were considering leaving academic medicine due to dissatisfaction. The remainder were considering leaving due to personal/ family reasons or to retire.
The authors did complex multinomial logit modeling to assess the relationships among the various scales, demographic factors, and intention to leave. Most relevant to us, Relatedness/Inclusion was significantly related to intention to leave the institution due to dissatisfaction (Coefficient -0.69, p lt 0.001, OR =0.50), as was Values Alignment (-0.39, p=0.04, OR=0.68), but not Ethical/ Moral Distress. Furthermore, Relatedness/Inclusion was related to intention to leave academic medicine due to dissatisfaction (-0.48, p lt 0.001, 0.62), as was Ethical/Moral Distress (0.60, p lt 0.001, OR =1.82). The article did not address whether individual survey items, including those of most interest listed above, were related to intention to leave. The article also did not address whether responses to the survey or intention to leave varied across faculty characteristics, medical school characteristics, or individual medical schools.
Summary and Comments
This very large survey of faculty from multiple US medical schools showed that more than one-third were considering leaving their institutions or academic medicine due to dissatisfaction, indicating a striking prevalence of faculty distress. Their responses to questions about perceived organizational cultural and leadership problems, including those possibly related to leadership's perceived hostility to the mission, leadership's perceived dishonesty or unethical behavior, and leadership's suppression of dissent, free speech, academic freedom, and whistle-blowing were related to their intentions to leave due to dissatisfaction.
These results suggest the hypothesis that much of faculty angst may be due to the sorts of problems with leadership and hence organizational culture that we discuss on Health Care Renewal. Since this was a cross-sectional survey, it certainly does not offer scientific proof of this hypothesis. Note that there is other evidence from numerous cases discussed in Health Care Renewal, qualitative studies and our much smaller study published only in abstract form that also supports this hypothesis (look here).
One part of the author's discussion of their findings was particularly relevant:
Our findings are congruent with metaanalyses of 25 years of organizational justice research outside medicine. These studies suggest that employee perceptions of organizational justice and an ethical climate are related to increased job satisfaction, trust in leadership, enhanced performance, commitment to one’s employer, and reduced turnover.I believe that the study by Pololi et al adds to the evidence that physician distress is a symptom of a dysfunctional system in which major health care organizations have been taken over by leaders more devoted to self-interest and short-term revenue than the values prized by health care professionals and academics. This applies obviously to academic medical institutions, but also to other organizations that might have been expected to defend such professional and academic values, such as professional associations, accrediting organizations, and health care foundations. As we said before, if physicians really want to address what is making them burned out and dissatisfied, they will have to regain control of their own societies, organizations, and academic institutions, and ensure that these organizations put core values, not revenue generation and providing cushy compensation to their executives, first.
The scale of ethical/moral distress (see Table 1) reflects reactions to the prevailing norms and possible erosion of professionalism and increased organizational self-interest. There is a growing belief that organizations influence and are responsible for the ethical or unethical behaviors of their employees.To our knowledge, faculty perceptions of 'moral atmosphere' and 'just community' embedded in our survey have not been previously investigated in academic medicine, even though the ethical concepts of professionalism and justice can be used to guide the pursuit of excellence in the missions of medical schools. Several scholars have called for academic medicine to attend to its social justice and moral mission. Faculty perceptions
of organizational justice are pivotal to the critical issue of professionalism in medicine. The ethical/moral distress scale in the survey reported here included items such as 'the culture of my institution discourages altruism' and 'I find working here to be dehumanizing.' (See Table 1 for other items in this scale.) In that ethical/moral distress was more strongly related to intent to leave academic medicine entirely than intent to leave one’s own institution, these negative feelings among faculty must be particularly disheartening to them and may color major career decisions.
Monday, May 21, 2012
The Case of the Vanishing Graduate Medical Education Funds
While primary care falters in the US, those who teach it seem to feel increasingly poverty stricken. Now it appears that one reason for this is an amazing example of multiple failures of transparency and accountability. Let me work through it, begging your pardon for a little bit of "inside baseball," medical education style. The results suggest how we desperately need some medical disciples of Sherlock Holmes.
Background
My personal experience and increasing data suggests that most medical school faculty believe that their teaching is not valued by their institutions because teaching brings in no external funds. In 2004, Dr Catherine DeAngelis, then the editor of JAMA, wrote "few medical schools provide adequate, if any, reimbursement for teaching time."(1) (See this 2005 post.) This seems absurd on its face, since what are medical schools for if it is not to provide teaching.
However, there is evidence of this mission-hostile behavior. In 2007, we quoted from a revealing interview with Dr Lee Goldman, Executive Vice President for Health and Biomedical Sciences at Columbia University,(2) who stated that "taxpayers," faculty who "generate more [money] than they cost," are valued most, and implied that faculty who focus on teaching are regarded as "welfare recipients," who bring in less external funding, and are valued least. In 2010, we noted the results of a large-scale survey presented by Dr Linda Pololi in which 51% of faculty felt that the administration only valued them for the money that they brought in, and half felt that their institutions did not value teaching.(3)
Yet while faculty seem to believe that educational institutions receive little if any money to pay for teaching, it is not clear why the believe something so counter intuitive, and it is less clear what money actually goes to pay for medical education.
US Government Funding for Graduate Medical Education
However, several recent publications affirm that actually a lot of money goes towards one important form of medical education, yet the specifics of the money flows are shrouded in secrecy. In the May, 2012, SGIM Forum, Dr Mark Liebow and colleagues summarized some of what is known about federal support of graduate medical education, that is, education of interns, residents, and other house officers.(4) There are two streams of money that flow from Medicare to US hospitals:
These two streams are of considerable size:
So, the 200 largest hospitals get about $2 billion in direct GME money (and presumably about another $4 billion in indirect money). This averages then to about $10 million DGME and $20 million indirect GME per hospital.
Thus, teaching, at least the teaching of interns, residents, and other house-staff does pay, and much more than trivial amounts. (Note that these amounts are not for teaching of medical students, which ought to be supported by other funding streams.)
Why then do faculty think that teaching does not bring in any money?
The GME Money Vanishes
An article by Dr Saima I Chaudhry and colleagues in the American Journal of Medicine begins to explain, although the explanations are found between the lines.(5)
First of all, while the graduate medical education money is paid by the government to the hospitals, the government does not publish what it pays to individual hospitals:
The government also does not hold the hospitals accountable for how they spend this money, nor for the quantity or quality of education they supply in exchange for it.
Remarkably, Chaudhry et al imply that that the people who run graduate medical education teaching programs also may not know how much money their hospitals receive from the government to fund their programs. The introduction to their article noted:
The article reported on a survey of internal medicine residency program directors which asked about "their knowledge of D[G]ME funding for their programs, the transparency with which funds are distributed to them, and their desire to influence this disbursement." The researchers sent surveys to 372 member programs, representing 97.1% of all US internal medicine residencies. They got 268 responses, a 72.0% response rate.
The main results were that only 159/268 (59.3%) of program directors had tried to find out how much DGME money their programs received, and of those, only 84 (52.8% of those enquiring, but only 31.3% of all respondents) actually knew how much money their programs got.
Of the 92 program directors who did not even try to discover how much money their programs received, approximately 21% said that "no one would tell me," 21% said that the "information would be inaccurate," 14% said they "don't know who to ask," and 2% were "afraid to ask."
Summary
US medical school faculty, especially those in primary care, increasingly feel pressured to perform activities that they perceive brings in money from external sources. They tend to believe that their own teaching somehow does not bring in any money, and that their careers will fail if they do not put more emphasis on other activities that the institution views as more profitable.
However, literally billions of US government dollars go to support the education of house staff, including the salaries of faculty who teach interns and residents, who probably are the majority of physician faculty. Faculty probably do not know this, because the government does not publish the amounts given to individual hospitals, nor demand of the hospitals any accountability for how they spend the money they receive.
Presumably, the top executives of each hospital know how much money the government gives them. Nonetheless, the majority of physician leaders of residency programs are never told these amounts, apparently because their hospital executives kept the amounts secret. Many of those educators who have tried to find out the figures were unsuccessful. Some did not even try to find out based on beliefs that their attempts would be unsuccessful, any amounts they discovered would be inaccurate, the people who knew the amounts were hidden, or that it would be dangerous to their careers to even try.
Thus billions of dollars of money flowing from the government to fund graduate medical education seems to have vanished in an amazing example of widespread deficiencies in accountability and transparency.
There are many people who blame government for many social ills. In this case, one can blame the US Congress for not writing a law that makes the money flows transparent and hospitals accountable for providing good educational value for the money provided. One can also blame the executive branch, particularly the Center for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services (DHHS) for not making the money flows and the values received for them transparent.
There are a few people, including this author, who also blame the leadership of health care organizations for many of the problems besetting health care. In this case, one can blame top leadership, presumably CEOs and chief financial officers (CFOs) of hospitals for hiding the amounts of money they receive from Medicare to finance graduate medical education. One can also blame the physician leaders of residency programs for not insisting that they know the true sources of financial support for their programs, obtain budgets that reflect this support, and recognition that their faculty really do bring in external funds for their teaching of house staff (and are thus valuable "taxpayers" in Dr Goldman's parlance.)
It is amazing that such amounts of money have been flowing for years mostly in secret. The secrecy has fueled incorrect, and in retrospect, bizarre ideas about the funding of medical education, and the value of medical educators to their institutions. This secrecy, in turn, has helped suppress the morale of medical educators, support the control of managers of health care professionals, and distort the flow of money within academic institutions and to compensation for certain favored individuals.
Would our dysfunctional health care system not be better off if we demanded transparency and accountability from its leaders? In particular, the US government should make payments to hospitals for graduate medical education completely transparent, and develop a system to hold these hospitals accountable for how they spend the money. Meanwhile, top leaders of hospitals receiving this money should make the amounts transparent, first to the people who are supposed to be doing the education that the money pays for, and to the public at large. This would allow those running the relevant educational programs to develop reasonable and realistic budgets, to treat their faculty with respect, and to demonstrate what value they provide for the money received.
The ongoing anechoic effect, and related deception and secrecy fostered by leaders in health care are major reasons our health care system is so dysfunctional, that costs are so high, and access and quality so poor. True health care reform would ensure health care leaders put the mission before their personal enrichment, and act ethically with accountability, transparency, and honesty.
References
1. DeAngelis CD. Professors not professing. JAMA 2004; 292: 1060-1. Link here.
2. Goldman L, Halm EA. A view from the top: general internal medicine from the perspective of a chair and dean. SGIM Forum, April, 2007. Link here.
3. Pololi L, Ash A, Krupat E. Faculty Values in the Culture of Academic Medicine: Findings of a National Faculty Survey. Link here.
4. Liebow M, Jaeger J, Schwartz MD. How does Medicare pay for graduate medical education? SGIM Forum, May, 2012. Link here.
5. Chaudhry SI, Khanijo S, Halvorsen AJ, McDonald FS,Patel K. Accountability and transparency in graduate medical education expenditures. Am J Med 2012; 125: 517-522. Link here.
Background
My personal experience and increasing data suggests that most medical school faculty believe that their teaching is not valued by their institutions because teaching brings in no external funds. In 2004, Dr Catherine DeAngelis, then the editor of JAMA, wrote "few medical schools provide adequate, if any, reimbursement for teaching time."(1) (See this 2005 post.) This seems absurd on its face, since what are medical schools for if it is not to provide teaching.
However, there is evidence of this mission-hostile behavior. In 2007, we quoted from a revealing interview with Dr Lee Goldman, Executive Vice President for Health and Biomedical Sciences at Columbia University,(2) who stated that "taxpayers," faculty who "generate more [money] than they cost," are valued most, and implied that faculty who focus on teaching are regarded as "welfare recipients," who bring in less external funding, and are valued least. In 2010, we noted the results of a large-scale survey presented by Dr Linda Pololi in which 51% of faculty felt that the administration only valued them for the money that they brought in, and half felt that their institutions did not value teaching.(3)
Yet while faculty seem to believe that educational institutions receive little if any money to pay for teaching, it is not clear why the believe something so counter intuitive, and it is less clear what money actually goes to pay for medical education.
US Government Funding for Graduate Medical Education
However, several recent publications affirm that actually a lot of money goes towards one important form of medical education, yet the specifics of the money flows are shrouded in secrecy. In the May, 2012, SGIM Forum, Dr Mark Liebow and colleagues summarized some of what is known about federal support of graduate medical education, that is, education of interns, residents, and other house officers.(4) There are two streams of money that flow from Medicare to US hospitals:
Direct GME (DGME) payments help hospitals pay the salaries of residents, teaching faculty, and support staff. DGME is the product of three numbers: a per resident amount that varies by hospital, adjusted annually for inflation; the number of residents in the hospital (capped for each hospital at 1997 levels); and the fraction of discharges from the hospital that are Medicare beneficiaries. The Indirect Medical Education (IME) payment is a percentage amount added on to each DRG payment. The percentage is calculated via a complex formula (the only US statute containing an exponent!), where the key factor is the ratio of interns/residents to beds (IRB ratio).
These two streams are of considerable size:
Of the $9.2 billion Medicare paid for GME in 2010, $3 billion was for DGME and $6.2 billion for IME. The money is paid to hospitals sponsoring training programs rather than to the training programs or other hospitals where training occurs. While about 1,100 hospitals receive GME payments, 66% goes to the 200 hospitals that have the largest numbers of residents.
So, the 200 largest hospitals get about $2 billion in direct GME money (and presumably about another $4 billion in indirect money). This averages then to about $10 million DGME and $20 million indirect GME per hospital.
Thus, teaching, at least the teaching of interns, residents, and other house-staff does pay, and much more than trivial amounts. (Note that these amounts are not for teaching of medical students, which ought to be supported by other funding streams.)
Why then do faculty think that teaching does not bring in any money?
The GME Money Vanishes
An article by Dr Saima I Chaudhry and colleagues in the American Journal of Medicine begins to explain, although the explanations are found between the lines.(5)
First of all, while the graduate medical education money is paid by the government to the hospitals, the government does not publish what it pays to individual hospitals:
It has been previously reported that the amount of GME funding individual hospitals receive is not publicly reported by the Centers for Medicare and Medicaid Services,....
The government also does not hold the hospitals accountable for how they spend this money, nor for the quantity or quality of education they supply in exchange for it.
Remarkably, Chaudhry et al imply that that the people who run graduate medical education teaching programs also may not know how much money their hospitals receive from the government to fund their programs. The introduction to their article noted:
It is unclear how much program directors know about the amount and flow of DME funds to their programs. Program directors' beliefs about the transparency of funding to their programs, or their desire to influence how funds are distributed to them, also are unknown.
The article reported on a survey of internal medicine residency program directors which asked about "their knowledge of D[G]ME funding for their programs, the transparency with which funds are distributed to them, and their desire to influence this disbursement." The researchers sent surveys to 372 member programs, representing 97.1% of all US internal medicine residencies. They got 268 responses, a 72.0% response rate.
The main results were that only 159/268 (59.3%) of program directors had tried to find out how much DGME money their programs received, and of those, only 84 (52.8% of those enquiring, but only 31.3% of all respondents) actually knew how much money their programs got.
Of the 92 program directors who did not even try to discover how much money their programs received, approximately 21% said that "no one would tell me," 21% said that the "information would be inaccurate," 14% said they "don't know who to ask," and 2% were "afraid to ask."
Summary
US medical school faculty, especially those in primary care, increasingly feel pressured to perform activities that they perceive brings in money from external sources. They tend to believe that their own teaching somehow does not bring in any money, and that their careers will fail if they do not put more emphasis on other activities that the institution views as more profitable.
However, literally billions of US government dollars go to support the education of house staff, including the salaries of faculty who teach interns and residents, who probably are the majority of physician faculty. Faculty probably do not know this, because the government does not publish the amounts given to individual hospitals, nor demand of the hospitals any accountability for how they spend the money they receive.
Presumably, the top executives of each hospital know how much money the government gives them. Nonetheless, the majority of physician leaders of residency programs are never told these amounts, apparently because their hospital executives kept the amounts secret. Many of those educators who have tried to find out the figures were unsuccessful. Some did not even try to find out based on beliefs that their attempts would be unsuccessful, any amounts they discovered would be inaccurate, the people who knew the amounts were hidden, or that it would be dangerous to their careers to even try.
Thus billions of dollars of money flowing from the government to fund graduate medical education seems to have vanished in an amazing example of widespread deficiencies in accountability and transparency.
There are many people who blame government for many social ills. In this case, one can blame the US Congress for not writing a law that makes the money flows transparent and hospitals accountable for providing good educational value for the money provided. One can also blame the executive branch, particularly the Center for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services (DHHS) for not making the money flows and the values received for them transparent.
There are a few people, including this author, who also blame the leadership of health care organizations for many of the problems besetting health care. In this case, one can blame top leadership, presumably CEOs and chief financial officers (CFOs) of hospitals for hiding the amounts of money they receive from Medicare to finance graduate medical education. One can also blame the physician leaders of residency programs for not insisting that they know the true sources of financial support for their programs, obtain budgets that reflect this support, and recognition that their faculty really do bring in external funds for their teaching of house staff (and are thus valuable "taxpayers" in Dr Goldman's parlance.)
It is amazing that such amounts of money have been flowing for years mostly in secret. The secrecy has fueled incorrect, and in retrospect, bizarre ideas about the funding of medical education, and the value of medical educators to their institutions. This secrecy, in turn, has helped suppress the morale of medical educators, support the control of managers of health care professionals, and distort the flow of money within academic institutions and to compensation for certain favored individuals.
Would our dysfunctional health care system not be better off if we demanded transparency and accountability from its leaders? In particular, the US government should make payments to hospitals for graduate medical education completely transparent, and develop a system to hold these hospitals accountable for how they spend the money. Meanwhile, top leaders of hospitals receiving this money should make the amounts transparent, first to the people who are supposed to be doing the education that the money pays for, and to the public at large. This would allow those running the relevant educational programs to develop reasonable and realistic budgets, to treat their faculty with respect, and to demonstrate what value they provide for the money received.
The ongoing anechoic effect, and related deception and secrecy fostered by leaders in health care are major reasons our health care system is so dysfunctional, that costs are so high, and access and quality so poor. True health care reform would ensure health care leaders put the mission before their personal enrichment, and act ethically with accountability, transparency, and honesty.
References
1. DeAngelis CD. Professors not professing. JAMA 2004; 292: 1060-1. Link here.
2. Goldman L, Halm EA. A view from the top: general internal medicine from the perspective of a chair and dean. SGIM Forum, April, 2007. Link here.
3. Pololi L, Ash A, Krupat E. Faculty Values in the Culture of Academic Medicine: Findings of a National Faculty Survey. Link here.
4. Liebow M, Jaeger J, Schwartz MD. How does Medicare pay for graduate medical education? SGIM Forum, May, 2012. Link here.
5. Chaudhry SI, Khanijo S, Halvorsen AJ, McDonald FS,Patel K. Accountability and transparency in graduate medical education expenditures. Am J Med 2012; 125: 517-522. Link here.
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