A Remedy for Corruption

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Transparency International's New 2017 US Corruption Barometer

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

From the press release, here are the key results:

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

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

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

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

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

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

Note that:

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

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

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


Also,

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

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




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



Media Response

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

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

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

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

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

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

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

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

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

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


Summary


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

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

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

Transparency International modestly suggested its results indicate

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


1. Transparency in political spending:

Make all spending on politics genuinely transparent, with:

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

- transparency on political spending by publicly traded companies

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

2. Prevention of revolving doors:

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

3. Establishing who owns what:

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

4. Strengthening the ethics infrastructure:

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

5. Protection of whistleblowers:

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

6. Providing basic access to information:

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

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




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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Furthermore, City Councilman Robert Yost

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Even local government officials were kept in the dark.

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

Furthermore,

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

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

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

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

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

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

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

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

That base salary was $1.1 million.

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

Thereafter,

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

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

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

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

Retchin will make important contributions to Ohio State.

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

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

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

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

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

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

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

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

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

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

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

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

Furthermore,

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

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

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

Summary

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

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

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

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

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

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