For those of you following along at home….
Today Kaiser sought an injunction against the Gadlfy asking her to take down the web site that supposedly contains the confidential information. The Gadfly has just emailed me telling me that the judge did not grant that order, but instead set a hearing for next week.
Health Affairs is out with one of its fun articles looking at the physician labor force. Here’s the press release which basically explains that on a county level and controlling for a bunch of other confounding variables (like race, income, etc), places with more specialists have higher mortality rates than those that have relatively more primary care doctors. Here’s the full article from Johns Hopkins’ workforce specialist Barbara Starfield.
There are also some follow up articles with commentary. One by David Goodman, another of those socialist reprobates at the Dartmouth School who’ve been causing trouble in this arena for a long time, asks that given that we test the health impacts of every drug on the market extensively based on studies, why don’t we similarly seem to care in any empirical way about the health impacts of our structuring of the physician workforce? To be fair he does point out some limitations of the county-based study (e.g.. in California, Los Angeles county is huge, Placer County is not), but overall he thinks that COGME and others backing physician (and specialist) workforce expansion should do more to justify themselves.
The group from the Robert Graham Center in Washington DC point out the relatively obvious–specialists make (and generate) more money for themselves and the economy, and therefore you can argue that the creation of a specialist is better for overall economic growth than that of a generalist. I think their tongue is firmly wedged in their cheek, but surely a bright economist in the THCB reader corps can remind us of the "products versus services" argument from Econ 101–after all as it said in the Hitchhikers Guide to the Galaxy, the telephone sanitizers aren’t that productively useful no matter how much they get paid. (Until of course the civilization dies out from a disease caught off a dirty telephone)
Finally Edward Salsberg is director of the Center for Physicians Workforce
Studies at the Association of American
Medical Colleges. In other words he represents the
status quo of the current residency and training environment. He
thinks that any number of factors but not necessarily an "excess" of
specialists are to blame for this mortality differential, and that we should reorganize the system to better integrate PCPs and specialists. Somehow I suspect that by "reform" he doesn’t mean getting rid of specialists or reducing the residency places provided for them and the money the taxpayer provides to the AAMC members for those places!
Let’s all be real for a moment. Every doctor with a quarter of a
brain who is going through the hassle of med school and residency
realizes that for a couple more years in fellowship they can double or
triple their salary if they reject pediatrics and general practice and
head to orthopedic surgery or diagnostic radiology. Even with the
downturn in some specialist’s income in some parts of the country in
the 1990s that’s still the case as this list shows. So the demand for those residency
slots is high.
Furthermore because specialists can create their own demand (see
Fuchs et al ad nauseam for this) and we have in a system where payers
are prepared to stick in 15% more money each year apparently ad infinitum, there’s no real incentive for
the specialists themselves to limit their own numbers. And of course
the government is paying, and paying alot, to subsidize those
residency slots (at least $22,350 per slot per year), and the US government will almost always do what its
interest groups, in this case medical schools, AMCs and their students, want.
In other countries, the money available for specialty care is centrally
limited, and so the specialists are happy that their supply is limited,
so they and the government are happy to keep those specialist residency
slots down.
The current Administration is unwilling to take on the AMA, or the specialty societies over physician income, or the AAMC over residency slots, or today’s medical students and their families who want their son to be the highly-paid sub-specialist. And it would also be unwise for the Administration to take them on directly given that it has no real reason to care much about the overall state of the physician workforce compared to the myriad other things wrong with the health care system that it blithely ignores. So the top down approach of limiting residency slots is not going to happen.
So I’m left with two questions. First, does this have any minor impact on the whole pay for performance notion? And can Medicare start thinking about this "impact of specialty mix on outcome measure" as something that far down the road it might think of "rewarding", in order to have a very, very long term impact on specialty mix. Second, if the answer is no, as I’m sure it is, why does Health Affairs keep on pissing into the wind by printing this stuff, if no one is going to take a blind bit of notice!
Sigh. Well KP, an organization that (I repeat) I have much respect for, is not taking my advice in the tawdry little business of whether they or the Gadfly released patient data onto the Internet. If you go to the Gadfly’s website you’ll see both that she has received a notice from Kaiser’s lawyers about an impending court date which presumably will order her to take her mirror site down (something that should please Kaiser), and has requests from two more journalists for interviews (something that probably won’t please Kaiser).
Can calmer heads prevail here? Are there any on either side?
Just in case you missed it, Pharmaceutical Executive interviewed me about a whole range of stuff. Out of that they chose some allegedly wise words I had about Disease Management and EMRs in a feature in the February issue. Interestingly enough they were a little dubious about my statements (that didn’t make it into print) about the coming reduction in the salesforce workforce, and that was a couple of weeks before Pfizer said it was canning 30% of its salesforce.
There’s a long and not too revealing article about Harvard health economist David Cutler in the NY Times magazine. It’s called the The Quality Cure? and I will try to get to some comments on what’s wrong with it later today. Meanwhile here’s what I said about it in my FierceHealthcare newsletter
Unlike most critics, Cutler doesn’t think high healthcare costs are necessarily a problem. After working on the failed Clinton effort, Cutler teamed up with another young economist named Mark McClellan to study the economic costs of heart disease. Their contrarian conclusion: Americans are getting their money’s worth when it comes to their healthcare costs, at least in cardiac care. The Times fails to note, however, that many of Cutler’s concepts are either not that new or are contradicted by several other leading health economists.
Grand Rounds is up over at Orac’s blog and it’s done in the style of a TV narrative called What to watch this week. My post is part of Boston Legal, which apparently has James Spader and Captain Kirk in it these days. I should watch more TV!
Not on topic for health care, other than they’ve given me lots of minor heart attacks down the years, but Chelsea Football Club is 100 years old today. We haven’t won the league for 50 years, but we’re well on top this year so it should be a great celebratory season. Oh, and we may be on track to win the European Champions league! Happy birthday, to the Chels!
So there’s another version of the fraud that was exposed somewhat last summer, involving recruiting a whole lot of patients for unnecessary surgery. The Blues in particular seem to have been badly hit by this new scam. However, speaking as a British male born since the NHS stopped routinely brutalizing babies in the late 1940s, I was particularly horrified at what one 24 year old male was prepared to go (my emphasis added below) through to make a little extra cash and get a holiday on the beach in LA.
A 24-year-old Phoenix man underwent an endoscopy, colonoscopy, sweaty palms surgery, nasoplasty and a circumcision at one clinic — all unnecessary, said Blue Cross/Blue Shield investigator Tom Brennan. The man lost sensitivity in his hands as result of the palm surgery, a procedure that involves collapsing a patient’s lung to clamp a nerve near the spine that controls perspiration.
The Sex in the City plot where Charlotte converts to Judahism always made me wonder–what if a guy had to convert? How far would he have had to go, and was this individual trying to join up?
Forbes has an article out called The Dark Side of Whistleblowing which discusses the growth of somewhat dubious methods to make cash by insiders at the scene of the crime reporting and documenting government rip-offs by contractors, rather than the individual trying to stop the practices themselves. They focus on the case of TAP pharmaceuticals which after its "alleged" misbehavior agreed to pay a fine in order to stay in the Medicare program, but more recently had all its executives involved in the scam if not exonerated, at least found not guilty in their criminal trials. In fact this controversy over how culpable is the whistleblower is famous enough that it’s the basis for a book by John Grisham (on of his better ones, The Partner) in which a whistleblower has in fact secretly set up the scam that he’s blowing the whistle on. (I haven’t given away the main part of the plot so you’re still safe to read it) . In general I don’t think anyone really doubts that TAP was sailing pretty close to and in fact beyond the wind. The entire Medicare Part B, infusion center resale of pharmaceuticals has been rife with little scams for many years, whether they are strictly within the letter of the law or not, and in some ways the recent change in pricing in that market contained in the MMA has got something to do with trying to reduce the level of confusion that makes those scams so possible. But of course the Industry Veteran has a much finer interpretation of the real implications of this issue to those searching out their future in the world of big pharma:
In the piece on whistleblowing from Forbes, The author makes the required genuflections at capitalism’s altar by disparaging the archaic Civil War era legislation and a legal system that pays someone $126 million for ratting out his company. Despite such obeisance, the sheer facts of the case, together with some reflexive fairness that the author couldn’t quite squelch, obliged him to grudgingly admit that the informer did the right thing even if his compensation does seem excessive. My wry reflection concerns the fact that a young person starting out in the pharmaceutical industry can do good and well by pursuing a career as a whistleblower rather than some other position. I base this on the fact that too many land mines and matters of chance stand in the way of ascending to the CEO’s office where one can earn unconscionable sums in the manner of Hank McKinnell or Sidney Taurel. On the other hand, the Pharma companies routinely defraud the public and all levels of government, as well as other, large corporations. Given the fact that the various tattlers in the cases cited below came from mid-management positions, whistleblowing certainly appears as a more feasible career goal.
If I were a schoolkid today and an aunt or a teacher asked me what I wanted to be when I grow up, it’s clear that I’d answer with "whistleblower" because the prospects for risky, exciting and noble activity is greater there than in becoming a fiduciary officer. It used to be that when kids told their elders they wanted to become firemen, ballplayers or astronauts, their parents would begin deflecting them from these choices in favor of one of the professions or business. These traditional aspirations of the middle class offered the promise of stability, prestige and good money. The beauty of the whistleblower choice is that it provides kids with the perfect response to parental objections. "How many people, mom, in business or the professions walk off with a $126 million haul at the age of 53?"
Within the pharmaceutical industry I feel that my words of encouragement represent sermons for the choir. Even today I see in Reuters that the Justice Department is investigating GlaxoSmithKline for failing to provide government agencies with best-pricing on some drugs. More creatively still, an Associated Press story announced the premier of a tell-all movie by an ex-Pfizer rep while another ex-Pfizerite has published a tell-all book with its own gory details about being a Viagra salesman. In short, if the prospect of cashing in as a whistleblower appears too farfetched, then books and the movies offer a more conservative opportunity to make out by denouncing Big Pharma.
As a quick coda, I was modestly amused that while it may not be the Veteran’s newly preferred way to wealth, the titans of big pharma are still managing to get by. You may have thought that Merck had a tough year last year, what with the Vioxx problem and that nasty little stock collapse, but that didn’t stop CEO Gilmartin raking in a tidy $34 million in stock options. Meanwhile the relatively impoverished Hank McKinnel over at Pfizer, where shareholders saw their worth drop 30% in 2004, found that his annual compensation went up 72%, albeit to a mere $16 million — although that doesn’t count even more stock option grants and the use of the corporate jet for personal travel. Eli Lilly’s President Sidney Taurel had according to the Indianapolis Star‘s initial version of events to struggle by on $4.7 million but somehow I suspect that he got an easy ride from the hometown paper which somehow missed the minor fact picked up by the AP and printed in the next day’s paper that his actual compensation counting options was $15 million. Although the poor chap will have to start paying for his corporate jet rides from now on.
And I know that you Silicon Valley folk think options don’t count, and yes my 200,000 options for my failed start-up were never worth much and now are worth nothing. But being given millions of dollars worth of options "in the money" does count as real compensation, even if there’s a chance that the value of the shares underlying those options can go down — something that shareholders of Merck, Lilly and Pfizer know only too well — as this chart below tells you.
Those of you with memories that stretch back to the dog days of summer last year may remember the somewhat curious incident of the Kaiser Permanente Thrive campaign coming up in THCB. If you missed it, here’s a brief recap.
KP has been running a $40m advertising campaign in California and elsewhere under the tag line "Thrive". By the way, the voiceover is done by everyone’s favorites Presidential spokesperson (No, not Fitzwater, Myers or McLellan–CJ Cregg!) Quite what the campaign has to do with the delivery of health care I have no idea, but that’s why I was thrown out of advertising finishing school. It seems to me no better or worse than any other corporate makeover campaign, and as KP is in general on the side of the angels it didn’t worry me too much.
However, there are a bunch of people who do have reasons rightly or wrongly for disliking Kaiser, and this small group of dissidents discovered quite a treasure trove of base sloppiness. For example, the URL KaiserThrive was never reserved by KP, so the dissidents took it and launched a parody campaign called "Thieves" on it. Then they discovered some of the strategy documents linked with the campaign on an openly available web site, and copied and posted them on their website. Finally, they discovered a KP web site (or possibly one of its contractor’s sites) that had reams of KP’s diagrams and blue prints for its HealthConnect EMR project–which are all presumably proprietary and at least somewhat confidential. This site was also mirrored by a couple of KP gadflys (long after it was put up on the web originally).
I posted about this on August 30, 2004 and lo and behold a few days later that KP site with the wiring diagrams was taken down. None of this in my view contained damaging internal documents of the "Dodgeball" style that Merck was exposed for earlier this year. But apparently I didn’t look hard enough. Somewhere buried in all the wiring diagrams was some patient information, which the anti-KP Gadfly had assumed was test data. Apparently not. According to KP, there are some 140 identifiable patient records in there somewhere. This week Kaiser sent a cease and desist notice to the Gadfly (which was sent on to me) asking for the removal of all web pages, and stating that the Gadfly had broken the employment agreement signed when joining KP. The letter also threatened prison time, huge fines et al.
It’s a bit ironic that KP has pulled out the big legal guns on this. and got The story is the SJ Mercury News today, (correction posted roughtly 4.15pm PST Friday after I was contacted by Barbar Feder, the SJ Merc journo who wrote the story) amazingly enough not because Kaiser leaked it to put pressure on the gadfly, but because one of the 140 patients they called was a member of the Merc staff and got a call about it! Barbara thereafter contacted the KP public relations people and extracted the story out of them as well as finding the Gadfly’s blog and getting some comments from her. It is still nonetheless ironic for Kaiser to be calling out the legal big guns because the when you consider that the patients they are panicking by telling them that their information is on the web have had it sitting there since at least 2002. There is clear evidence at this URL that the site was publicly up as of 2002, and I know it was available to be looked at on the web until at least August 30, 2003 2004 (typo corrected), because I went to look at it then. I must stress that I didn’t know that there was any patient data in it, and in wandering around the mirror site (you’ll have to go to the Corporate Ethics blog to discover the link as THCB is too lilly-livered to link directly!) I never found any patient data. But presumably I was looking in the wrong place.
According to the Corporate Ethics site, the Gadfly in one of her attempts to get at Kaiser tried to get them for a HIPAA privacy violation because of this posting, but apparently they were cleared of this. It’s quite amusing really that they are now coming after her for the same thing for which they apparently were not guilty.
When you dig a little deeper, this is a typical story of a lack of common sense in corporate policy. Like the McLibel trial in the UK when McDondald’s stupidly went after two penniless anarchists for passing out leaflets about their food being inedible and blew $10m in legal fees and all its goodwill in Europe in the process, or a recent case of a friend of mine whose job offer at Carly’s HP was withdrawn because of a one word discrepancy on a background check from Choicepoint (yeah, that trustworthy bunch) with NO-ONE at HP’s human resources group having the nous to investigate and find out the truth, Kaiser is not stopping to think about how to resolve this issue sensibly. The Gadfly is an ex-employee who was fired and has since seen her financial life go into cataclsym.
The Gadfly is flat broke, and said in a private email to me that she’d welcome jail time as it would get her health care coverage! So why did Kaiser fire her? Obviously there are two sides to that story, but is there no way that they can make it up to her and come to a reasonable settlement without pushing her and themselves to all these extremes? This is not good PR for what’s generally a noble organization, and some of the grown-ups there need to get hold of this whole issue pretty quickly. Perhaps if a senior KP person took it upon themselves to have a fair review of the case, and figure out a way to make a reasonable settlement, their organization’s own sloppiness wouldn’t have to become a major fiasco. At the least presumably they can get her some of the health care coverage she needs at a price they can afford!. Right now the Gadfly is finally welcoming the attention, and if KP keeps pushing this way it’s likely to get much worse for them before it gets better.
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