Perednia: "Starting Over With Healthcare Reform Is, Unfortunately, a Matter of Religion"

Over at "The Road to Hellth" blog, Douglas Perednia MD has written an excellent piece entitled "Starting Over With Healthcare Reform Is, Unfortunately, a Matter of Religion."

The use of the term "religion" is not literal but figurative:

... In deciding what to do [in recent years], political leaders stopped dealing in experience, evidence and compromise, and began dealing in faith-based – almost religious – healthcare decision-making. Of course in this context we’re not talking about “faith-based” in its meaning of handed down from the one true God (or the many true Gods, depending upon your religion), but instead faith-based in the sense of having fixed and immutable beliefs about things like how to run healthcare or, indeed, the whole country.  It doesn’t matter what the available evidence shows or what human experience has been, the political religions of the left and right, Republicans and Democrats, won’t tolerate alternative facts, strategies or explanations.  Doing so would be sacrilege, remediable only by human sacrifice. 

The point of his post is that in the U.S. both political parties have abandoned all pretense of listening to science or reason and making compromises that benefit patients.  They are making all decisions on fervently-held, unshakeable ideological beliefs (and, I add in some cases, for personal gain no matter the consequences to the public).

I am reproducing the section of his essay on health IT, that illustrates his point well:

A third example is the sacrificial cult of electronic medical records.  [Sadly, that phraseology is all too apt - ed.]  Except for those who work at Departments of Medical Informatics or as physician “champions” for EMR vendors or health systems that are spending billions to implement the darned things, the vast majority of doctors and nurses will tell you that EMRs are a chainsaw to clinical productivity and the amount of time that we actually spend listening to and getting to know our patients and their problems.  Non-vendor, non-government studies that show that these systems save money or actually improve clinical results are scarcer than hen’s teeth, yet not a day goes by without having shamans in the Cult of EMR claim that we will see miraculous increases in efficiency, reductions in cost, improvements in health and a blooming of preventive medicine “any day now”.  

These claims are increasing in intensity and shamelessness.  This is at a time when it is admitted by some of the most respected scientific bodies (e.g., National Research Council, FDA, IOM, NIST) that the technology does not support clinicians' cognitive needs, is in fact disruptive and hard to use, and reports of harm are appearing.  Worse, they report - magnitudes of reported harm are unknown due to impaired information diffusion.  The impairment is both due to lack of regulation and regulatory authorities to report to (which allows opportunism), as well as due to business IT-modeled legal contracts with IP-protection and defects gag clauses.

The cult has grown so powerful that has been able to force clinics and hospitals to sacrifice themselves in the process; goaded by the awards and penalties handed out for the presence or absence of “meaningful use”.  It’s no great revelation that is a new technology is truly useful, beneficial and cost-effective, there is absolutely no reason that a government would need to mandate its use or bribe people to buy it.  Dr. Scot Silverstein at the Health Care Renewal blog has devoted his career to documenting the questionable engineering and lack of clinical awareness that goes into these systems, but you will not identify single iota of doubt in the pronouncements of the Office of the National Coordinator or the politicians who are receiving funds and advice from the “healthcare information technology” (HIT) industry.  Their minds are made up.  Don’t confuse them with the facts.

I wouldn't say I've "devoted my career" to documenting the problems only.  I've been spending considerable time now doing something about it.  This includes, in part, advising attorneys on both sides of the Bar on the problems they need to be aware of.

This knowledge will likely benefit plaintiff's lawyers and injured patients far more than the defense.  There is no defense for cybernetically harming people with poorly designed and implemented, experimental medical devices, used without patient informed consent, or for trying to conceal the malpractice via electronic legerdemain.

It is my belief that a fair share of cavalier health IT experimenters, dyscompetents and "creative medical history editors" responsible for the current shabby state (technically and ethically) of commercial HIT, a situation that could have been avoided via learning from the medical and technological past, will have a very unpleasant and costly time in the courtroom in future years. 

-- SS

Gruber at MIT to Senators: "I Promise To Be Good ... Next Time"

Frequently expressed on this blog are concerns about conflicts of interest and their corrosive effects upon healthcare (query link). We also have expressed concern about the mental gymnastics used by the privileged or those in positions of power to rationalize these COI's and/or justify keeping these COI's from the public's eye.

In a stunning display of academic arrogance, MIT economics professor Jonathan Gruber, who promoted and defended the administration's health care policies before the U.S. Senate Committee on Finance as well as the Health, Education, Labor & Pensions Committee, while collecting $400,000 from HHS for his services, literally blew off a letter of inquiry from Senators Grassley and Enzi regarding possible conflicts of interest. (See this Google search on the terms "jonathan gruber conflict of interest HHS".)

The professor has been a source of support for what many consider improbable arguments of the impact of current health care reform efforts, while being on the HHS dole.

Sen. Grassley and Sen. Enzi have thus written Dr. Susan Hockfield, President of MIT, to "encourage" the professor to be a little more forthcoming in his replies.

The letter to Hockfield and a copy of the original letter to Prof. Gruber can be downloaded here (PDF).

On Jan. 26, 2010 Gruber was asked some very specific questions by letter (summary below, see full letter at link above for details).

He was asked by the Senators:

• To identify each contract, grant or cooperative agreement he has executed with the federal government, including the White House and HHS and its operating divisions, during the past five years. For each contract, he was asked to respond to a series of detailed questions on: specifics of work performed, federal official serving as contact, start/end dates, amount of compensation, plus a request for copies of the contracts, grants, cooperative agreements, and a copy of the deliverables;
• To identify which of the contracts are "sole source", and provide the reasons the contracts were sole source, what official made that determination, and who is the federal official with whom he negotiated the sole sourcing;
• To answer similar questions about contracts with state and local governments and private entities and individuals he had executed in the past five years;
• To identify all interviews or statements made to the media on healthcare reform since the federally funded work began, and if asked during the interview or if he did so voluntarily, to state if he revealed the HHS relationship; and
  
• To answer similar questions on all speaking engagements.
  

To these detailed inquiries, the response was this (emphases mine):

February 23, 2010

Dear Senators Grassley and Enzi:

This letter responds to your letter to me dated January 26, 2010.

I appreciate your commitment to the principle of transparency in government and can assure you that I never intentionally withheld my two HHS contracts from Congress. Indeed, my contracts were publicly disclosed on the federal government website, www.usaspending.gov.

[Prof. Gruber seems to confuse the passive "publicly disclosed" with active "public disclosure," and apparently misses the point that a possible conflict of interest is an obligation of the principal(s) to disclose when they publish or speak, not an obligation of the audience to discover ex post facto via governmental or other websites - ed.]

As you know, my professional research focuses on public finance and health economics and throughout my career I have worked with Democrats and Republicans alike on the critical issue of health care reform. I served as a consultant to then-Governor Mitt Romney in connection with health care reform efforts in Massachusetts and have also testified before the Congress on these issues.

[That worked out rather poorly, according to Massachusetts Treasurer Tim Cahill - ed.]

I was invited to testify jointly by the Majority and Minority Members of the Senate Finance Committee in the Summer of 2008 on the interaction of health insurance and the tax code and have testified more recently as well. In addition, over the past year in connection with my economic analysis work for HHS, I have worked closely with the staffs of both the Senate Finance and the Senate HELP Committees in evaluating various health care reform proposals and assessing how such proposals might be scored by the Congressional Budget Office.

To the best of my recollection, during the course of my health care reform work with Congress, no Member or staffer ever asked me whether I held any government contracts. Given that the staff saw the time that I was devoting to this effort, in retrospect, I suppose I assumed they understood I was being paid for that work.

[Assumed you were being paid ... to the tune of nearly half a million dollars? - ed.]

Both my congressional testimony and the health care opinion pieces that I have authored reflect my longstanding policy views -- and were in no way influenced by my contracts with HHS, which related to technical economic modeling designed to determine the costs of various health care reform policy options.

[Which raises another question: was that 'modeling' influenced by the HHS money? - ed.]

It certainly did not occur to me that anyone would view my HHS contracts as relevant to my independent, long-held opinions regarding the economics of health care reform. [Really? - ed.] I regard the contract work I performed for HHS and my public speaking and writing as being independent and unrelated. But I do recognize the public interest in these disclosure issues and will certainly consider them in the context of future appearances on the Hill or in the media.

[I note that "I will consider them" (i.e., disclosure 'issues') is an ambiguous statement, as opposed to "I will disclose my possible conflicts" - ed.]

Thank you for your work on these issues.

Sincerely,

Jonathan Gruber

In other words, I guess the public does have a right to know about my possible conflicts of interest when a major portion of the US economy's about to be up-ended, and I'll be a good boy and team player - next time. By the way, regarding your detailed questions, you do good work, but get lost.

Academic contempt for disclosure of conflicts of interest seems to know few bounds. I doubt the letter to the MIT President will accomplish very much.

Let's hope the responses from the healthcare IT vendors to Sen. Grassley's inquiries are more forthcoming than this academic one.

Finally, it occurs to me that profligate spending of almost a half million dollars for the sole-source consultation of a single (already salaried) professor raises a concern about cherry-picking for theories supporting a certain point of view, and shows questionable governmental fiscal responsibility.

That is the size of a research grant that could support, say, a significant fraction of the time of a half dozen academic collaborators with a diverse set of theories and views.

-- SS

Disclosure: I have not received a penny from HHS, government, academia, industry, or even Tinkerbell or the Tooth Fairy for these views.