The Lancet Emphasizes the Threats to the Academic Medical Mission

We just discussed an important article in the Lancet calling for major global reforms of health care education.(1)  An accompanying editorial(2) argued for the critical importance of upholding the mission of higher education, because that mission is critical to human civilization:

Louis Menand has investigated the current role of the modern university in his startlingly powerful book, The Marketplace of Ideas. Menand argues that: 'The pursuit, production, dissemination, application, and preservation of knowledge are the central activities of a civilisation.' More importantly still, 'the ability to create knowledge and put it to use is the adaptive characteristic of humans'. The goal of the university is 'to make more enlightened contributions to the common good'.

The editorial argued strongly for the revitalization of the university's mission:

'It is the academic's job in a free society to serve the public culture by asking questions the public doesn't want to ask, investigating subjects it cannot or will not investigate, and accommodating voices it fails or refuses to accommodate.'

The education of doctors, nurses, and public health workers must seek to: strengthen the overall intellectual culture of a society; define principles for public aspiration; give life to and enlarge the best and most proven ideas of the age; refine the grounds for the private exchanges that take place in our lives; facilitate the exercise of political power; and enable professionals to detect what is important and discard what is irrelevant, accommodate oneself with others, have common ground between colleagues across societies, ask good questions and find the means to answer them, and have the resources to adapt to national and global circumstances. Some readers might recognise that these words are adapted from John Henry Newman's On the Scope and Nature of University Education.

In England, Newman argued for the university as a centre of intellectual liberty, a vital force for progress in society. Menand writes about the university as a 'zone of autonomy'. The importance of tertiary education as a means to advance health, reason, democracy, and justice needs to be rediscovered.

But arguing so forcefully for upholding the academic mission makes sense only if that mission is under threat. The Lancet editorial only briefly alluded to why this might be:

What this Commission argues for is nothing less than a remoralisation of health professionals' education. For decades, health professionals have colluded with centres of power (governmental, commercial, institutional, even professional) to preserve their influence. The result? A contraction of ambition and a failure of moral leadership.

While the original article by Frenk et al suggested that health professionals' education has shortcomings, it did not argue that the academic mission is threatened.  Although the message of the accompanying editorial is that the mission needs a strong defense, it did not clearly explain the extent of the threat to it. 

However, this blog, Health Care Renewal, is largely concerned with threats to health care's core values, including threats to the mission of academic medicine, largely from concentration and abuse of power.  The largest set of threats come from the ascendancy of financial goals amidst the commercialization of health care (mentioned briefly both in Frenk et al and the editorial).  We have discussed the nature of the threats in detail.  For example,

• Abandonment of traditional prohibitions of the commercial practice of medicine - In the US, a Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be "commercialized, nor treated as a commodity in trade."  After then, it ceased trying to maintain this prohibition.  The result was increasing, now rampant commercialization.  See posts  here and here.
• Making money takes precedence over education -  A recent survey showing that more than half the faculty at multiple US medical schools felt they were valued more for how much money they brought in than their teaching or patient care abilities (here), confirming previous anecdotal reports (see here). 
• The medical school re-imagined as a biotechnology company -  In 2000, a Vice President of the American Association of Medical Colleges(3) wrote that research universities must respond to "societal demands that they become engines of economic development…."  Many universities now defend lax conflict of interest policies with similar arguments.  For more details, go here.
• Faculty become employees of industry - For numerous examples of this and other kinds of conflicts of interest, go here.  A survey by Campbell et al suggested that approximately two-thirds of medical academics get significant payments from industry.(4)
• Academics become "key opinion leaders" paid to market drugs and devices - Marketers regard "key opinion leaders" as salespeople who appear more credible because of their professional guise.  See anecdotal evidence here.  
• Control of clinical research given to commercial sponsors - A study by Mello et al showed how universities' grant administrators are willing to sign contracts giving commercial sponsors control over key aspects of human research studies.(5)  See post here. 
• Conflicts of interest allow manipulation and suppression of clinical research - Commercially sponsored research design, implementation, and dissemination are often manipulated to favor the sponsor's interests.  When such manipulation fails to produce favorable results, the results may simply be suppressed.
• Academics take credit for articles written by commercially paid ghost-writers - Such ghost-writing is often part of organized stealth marketing campaigns. 
• Whistle blowers are discouraged, or worse, and academic freedom is damaged.  Discussion of some examples of what may happen to whistle blowers is here.  The survey mentioned earlier (here) showed that about one-third of faculty fear they may be punished for speaking  out. 
• Leadership of academic medical centers by businesspeople - Ill-informed management may result from leaders who have no background or training in actual health care. 
• Leaders of teaching hospitals and universities become millionaires -  A recent example is here, and more may be found here.  Leaders of academic medical centers and the parent universities of medical schools often make more than $1 million a year in the US.  When such amounts are in play, executives may focus more on short-term measures that lead to even more pay than on upholding the mission. 
• Medical school leaders become stewards (as members of boards of directors) of for-profit health care corporations - A recent example is here, and a summary of how we discovered this phenomenon in 2006 is here.   The conflict of interest is severe because directors of for-profit corporations are supposed to have unyielding loyalty to the interests of the corporation and its stockholders, although they are frequently accused of acting mainly as cronies of the top hired executives (see here and here).
• Leaders of failed finance firms become stewards of academic medicine - We have found numerous examples, recently here, here, and here, of top executives and/or board members of the finance firms who helped bring on the global financial collapse also being trustees of medical schools, academic medical centers, or their parent universities.  Such "stewards" may bring to the academic environment the "greed is good" culture now pervasive in finance. 

So the threats are real and substantial.  However, their scope generally generally gets little attention.  Even when specific threats appear in the academic literature, their importance may be soft-pedaled, and their confluence with other threats ignored.  Of course, trying to discuss the full breadth and depth of these threats, as we endeavor to do on this blog, threatens in turn those who have personally profited from the current system.  Hence, we frequently cite the anechoic effect, the phenomenon that important threats to health care's core values are often just not discussed in polite company.

Therefore, we applauded the article by Frenk et al for concatenating some of the most important challenges to health care professionals' education, and we now applaud the Lancet editorial for emphasizing the threat to the academic medical mission.  We hope that these two articles, appearing in one of the most prestigious and well-read medical journals, will help to combat the anechoic effect.  Meanwhile, we will continue to blog about threats to core values in the hope that discussing them will lead to solutions.
References

1.  Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.  Lancet 2010; 376: 1923-1958.  Link here.
2.  Horton R. A new epoch for health professionals' education.  Lancet 2010; 376: 1875-7.  Link here.
3. Korn D. Conflicts of interest in biomedical research. JAMA 2000; 284: 2234-2237. Link here.
4. Campbell EG, Gruen RL, Mountford J et al. A national survey of physician–industry relationships. N Engl J Med 2007; 356:1742-1750. Llink here.
5. Mello MM, Clarridge BR, Studdert DM. Academic medical centers' standards for clinical-trial agreements with industry. N Engl J Med 2005; 352: 21.  Link here.

Deceptive Marketing, For-Profit Universities, and Health Care Education

Last week, reports about deceptive marketing and other questionable practices used by the growing for-profit higher education industry in the US appeared in the news.  For example, per Bloomberg:

Recruiters at U.S. for-profit colleges lied to entice students and encouraged them to commit fraud to qualify for aid, a report by the Government Accountability Office found.

Recruiters at all 15 colleges studied by the GAO, Congress’s investigational arm, misled potential students about the costs, duration and quality of their programs, according to a report obtained by Bloomberg News....

Other deceptions include:

“'college representatives exaggerated undercover applicants’ potential salary after graduation and failed to provide clear information about the college’s program duration, costs, or graduation rate,' the report said. 'Admissions staff used other deceptive practices, such as pressuring applicants to sign a contract for enrollment before allowing them to speak to a financial advisor about program cost and financing options.'

Also,

In one case cited by the report, a GAO investigator posing as an applicant was told to lie on an aid application about the number of household members to qualify for grants. When the investigators told college employees that they had $250,000 in savings, officials at three colleges told them to hide their savings in order to qualify for financial aid.

In addition,

For-profit colleges overstated the quality of their programs and the organizations overseeing their accreditation, the report said. One recruiter told an investigator posing as an applicant that his school was accredited by the same one that accredits Harvard University.

'It’s the top accrediting agency,' the recruiter said, according to the report. 'Harvard, University of Florida --they all use that accrediting agency.'

Recruiters exaggerated their colleges’ benefits and graduation rates, the report said. A beauty college recruiter said barbers earn as much as $250,000 a year, while the Bureau of Labor Statistics said 90 percent of barbers make less than $43,000 annually, according to the report.

A later report by the Dow Jones news service named some of the corporate players whose educational "institutions" were involved in dubious schemes.

Colleges operated by Apollo Group Inc. (APOL), Corinthian Colleges Inc. (COCO) and Washington Post Co.'s (WPO) Kaplan Higher Education unit were among the schools the U.S. Government Accountability Office found provided 'deceptive and otherwise questionable information' to agents who posed as prospective students in an undercover investigation of for-profit student recruitment tactics.

It is tempting to look for parallels with health care, once a calling like higher education, but now increasingly an "industry," often run, as we have documented endlessly, by people with little experience or knowledge about how health care is actually done on the ground, with little sympathy for the values of health care professionals, and given strong incentives to maximize the money coming in, whatever it takes.

However, the issue goes beyond these parallels. In fact, many of the bigger for-profit education corporations provide considerable health care education, including the three named above. The University of Phoenix, a subsidiary of the Apollo Group Inc, offers a Masters of Science in Nursing degree. Several of the "brands" of Corinthian Colleges Inc offer offer "diploma and/or degree programs in health care." Kaplan University, a subsidiary of Kaplan Higher Education Corporation, has a School of Health Sciences.  So it seems likely that many health care professionals, or would-be health care professionals, have been enticed by the sorts of sales practices documented in the report. 

There are no known for-profit US medical schools.  However, as we have discussed, many US students go to for-profit "off-shore" medical schools, often in the Caribbean, who mainly "educate" US citizens who want to practice here (as opposed to all the schools in countries other than the US whose main goal is to educate doctors for their own countries.)  Some of these off-shore schools are owned by big US corporations.  One can only wonder whether their recruitment tactics are similar to those of the for-profit "universities" located in the US. 

We have discussed deceptive marketing of hospitals, drugs and devices, but now it seems that deceptive marketing is even more widespread in health care than we originally thought, along with the take the money and run ethos that has infected so much of the business world.

If we truly want to reform health care to improve quality and access, and control costs, we need to restore the focus to care, the care of the patient, and away of the false pursuit of economic efficiency that only seems to benefit the quick buck artists. 

Members of the Board of Now Bankrupt Lehman Brothers as Leaders of Health Care?

In our own Providence Journal, Michael Hiltzik commented about the Valukas report on the fall of the once proud Lehman Brothers.  He asserted that one of the lessons learned from the case is the "folly of relying on self-discipline and self-regulation in the financial markets," particularly given the irresponsibility of the top leaders of financial corporations. In particular,

I’d love to hear an argument for allowing any of Lehman’s independent directors, who seem seldom to have asked a penetrating question, ever to serve on a corporate board again.

As I write, those 10 directors, who pulled down better than $100,000 cash a year to sit jointly in the driver’s seat for Lehman’s race to disaster, still boast at least 15 company directorships among them. Does this make you confident that corporate America is in good hands? Me neither.

It also should not make us confident that health care, and academic medicine, in the US and elsewhere, are in good hands. Hiltzik declined to name the members of the Lehman board, or identify the other organizations that they lead.  One can find a list of the directors who presided over the demise of Lehman in the company's 2008 proxy statement. It turns out that while they were presiding over Lehman's collapse, they also were presiding over the direction of some major health care organizations, to wit:

MICHAEL L. AINSLIE Director since 1996

Trustee of Vanderbilt University [including the School of Medicine]

JOHN F. AKERS Director since 1996

ROGER S. BERLIND Director since 1985

MARSHA JOHNSON EVANS Director since 2004

Ms. Evans served as President and Chief Executive Officer of the American Red Cross from August 2002 to December 2005.

RICHARD S. FULD, JR. Director since 1990

serves on the Board of Trustees of ... New York-Presbyterian Hospital

SIR CHRISTOPHER GENT Director since 2003

Non-Executive Chairman of GlaxoSmithKline plc.

JERRY A. GRUNDHOFER

Mr. Grundhofer is a director of Ecolab, Inc ["As a leader in infection prevention, Ecolab provides products, tools, training and service to healthcare facilities to help prevent the spread of healthcare acquired infections.]

ROLAND A. HERNANDEZ Director since 2005

HENRY KAUFMAN Director since 1995

a Member of the Board of Trustees of New York University [including the School of Medicine]

a Member of the Board of Governors of Tel-Aviv University [including the Sackler Faculty of Medicine]

JOHN D. MACOMBER Director since 1994

[Also, a member of the board of directors of Warren Pharmaceuticals, "a privately held biotech company, incorporated in 2001 for the purpose of developing proprietary tissue-protective technologies."

So, collectively, the confidence uninspiring members of the board of the now defunct Lehman Brothers also were on the boards of two major US and one major Israeli university that include well-known medical schools, one major health care related charity, one major British multi-national pharmaceutical company, a prestigious academic medical center, a large public for-profit US company with major health care interests, and a small, privately held biotechnology company. 

We have another vivid illustration in the aftermath of the global economic collapse, and in an ongoing health care crisis, how some of the problems of health care, and academic medicine in particular, may have been at least enabled by leadership more used to working in an increasingly amoral marketplace than to upholding the academic mission. All health care organizations, for-profit and not-for-profit, those in the US and those in other countries, need leaders who value their health care and academic missions more than simply the money they may bring in.

Everything is Up to Date in Kansas City, Except the Health Care University CEO's Knowledge of Her Own Budget

They say everything is up to date in Kansas City, so maybe it should not be a surprise that it is the source of a new and colorful tale of how leaders of health care organizations are different from you and me.  The Kansas City Star reported about the professional life of the recently fired CEO of Kansas City University of Medicine and Biosciences:

Hiring the CEO

There’s an often-told story about how Karen Pletz, the fired president of the Kansas City University of Medicine and Biosciences, got her job in the first place.

On a flight from Phoenix to Kansas City in 1995, a stranger sat next to her: Jack Weaver, then chairman of the university’s board of trustees.

Pletz, with a law degree and a career in banking, so impressed Weaver that he proposed she join the board. When the trustees met her, they asked her to apply for the president’s job.

The CEO's Compensation

Big paydays: Pletz’s compensation skyrocketed from $261,000 in fiscal 1999 to nearly $1.2 million — about $250,000 more than the president of Johns Hopkins University made.

Also,

Pletz’s million-dollar compensation package put her among an elite group of university presidents.

A review of the latest available tax records — for the fiscal year ending June 30, 2008 — shows that the leaders of other osteopathic medical schools in the region were being compensated far more modestly.

While Pletz was making $1.2 million, the CEO of the larger Des Moines University received $347,000. A.T. Still University of Health Sciences in Kirksville, Mo., where osteopathy got its start, changed CEOs nine months into the year. Both were paid about $50,000 a month; their combined compensation was $609,000.

The last time the Chronicle of Higher Education included free-standing medical schools in its survey of compensation of private college and university presidents, in 2006, Pletz was one of only seven making seven figures.

The CEO's Spending Decisions

She spent disproportionately on administration versus education:

Spending on the university’s primary mission — educating medical students — didn’t keep pace with the school’s rapidly growing administrative costs. From fiscal 1999 to 2008, the amount spent on educating students and other program services rose 59 percent. At the same time, administration expenses jumped 384 percent.

Other executives were paid well:

For Douglas Dalzell, executive vice president for institutional development, the compensation was $437,000 in fiscal 2008, more than double his pay in 1999. For Richard Hoffine, chief financial officer, it was $616,000, more than triple.

Dalzell’s compensation frequently rose in five-figure increments. Hoffine’s pay increased by as much as $127,000 in a single year.

The board fired Dalzell on Dec. 31, and Hoffine resigned over the New Year’s weekend.

She spent copiously on entertainment and items less well defined:

Along with the generous compensation paid to Pletz and her top lieutenants, the university was spending large sums on special events and other activities.

Shortly before a retreat for university managers in 1998, the university spent $15,000 to have 26 members of the Kansas City Symphony play for faculty and department heads at the Folly Theater. The object was to demonstrate with music how teamwork and good leadership produce the best work.

Records show that expenses for graduation activities jumped 47 percent in just three years, from $199,000 in 2005 to $294,000 in 2008.

Entertainment costs averaged $84,000 a year.

In fiscal 2002, the university spent more than $197,000 for various services at the Fairmont hotel — now the InterContinental — on the Plaza.

Even 'miscellaneous expenses' exploded, according to the university’s tax forms: They were about $81,000 in fiscal 2001 and $1.4 million in fiscal 2005, the last year they appear on tax reports.

The university also was spending as much as $739,000 a year on expenses for 'healthcare leadership,' tax records show.

Pletz defended the spending on graduation and other ceremonies because of their importance to medical students and their families.

Graduation is 'a whole weekend of events,' Pletz said. Many homecoming activities were held at the Fairmont, she said.

As to what the healthcare leadership spending entailed, Pletz said she didn’t know.

Executives hired their relatives:

Family members and friends, including Pletz’s daughter and a top associate’s daughter-in-law, were added to the payroll in administrative positions. The university’s nepotism policy allowed a lot of leeway.

And then there was the mysterious Health Policy Institute (as reported separately by the Kansas City Star):

After HCA, Inc., acquired the large, nonprofit hospital group Health Midwest in 2003, opportunity came knocking for Health Midwest executive Barry Seward:

An appointment as president of the Kansas City University of Medicine and Biosciences’ new Health Policy Institute.

It was an unpaid position, but Seward didn’t have to work for free. He received consulting fees of as much as $177,300 a year from the university, tax records show.

Seward’s son, Michael, became the institute’s unpaid vice president. The younger Seward also has a paying job as the university’s director of grant development.

Along with his consulting income, Barry Seward has had the fringe benefit of extensive travel for the institute.

The Health Policy Institute’s budget was $62,909 in 2008, tax records show. A few thousand dollars of that went to office overhead. The rest was spent on travel and meals.

Ms Pletz justified the Health Policy Institute thus:

Pletz said the institute’s position papers are widely distributed.  Eight are posted on the institute’s Web site

However,

they average about 240 words. Stem-cell research took five paragraphs; pandemic flu got three.

Neither the Health Policy Institute web-site nor a Google search revealed any experience or expertise in health policy on the part of its President.  I would note also that Institute's position paper on "healthcare workforce" failed to note the shortage of primary care physicians, and the paper on integrative medicine advocated for more access to, more insurance coverage for, and more medical school training in complementary and alternative medicine without acknowledging the lack of evidence supporting many "CAM" treatments.
The Role, Such As It Was, of the University Board

Current board chairman Danny Weaver, who also is the university’s acting president, won’t discuss why she was fired. Pletz, who says she’s proud of her work for the school, won’t get into specifics.

Danny Weaver, son of Jack Weaver, will say only that more than one person in September brought 'extremely serious' issues to the board’s attention that led to Pletz’s termination.

University administrators kept the governing board in the dark for months at a time about important issues, Weaver said.

But it was the board Weaver has led since 2004 that approved Pletz’s salary and incentive package. The board, which met just twice a year, approved the university’s budget, but it did not monitor the way money was actually spent. And it did not routinely review key filings the university made to the Internal Revenue Service.

How the board justified Peltz's compensation:

Questions about her salary and incentives, Pletz said, should go to the university’s trustees.

'Compensation was a board decision,' she said. 'It was the board’s responsibility.'

She said she thought the board was interested in retaining top managers.

'It was a very team-oriented approach,' Pletz said. 'If the performance was there, the compensation was there.'

In addition,

Weaver defended the compensation the board granted Pletz.

'Based on her production and what she brought to the university, her compensation was within reason,' he said.

However, apparently none of her production had to do with familiarity with her own university's budget:

The spending figures are all line items in tax documents called 990 forms that nonprofit corporations, such as the university, must file each year with the IRS. The forms are available to the public.

Pletz could not say what the line items on the 990 forms represented.

'Any questions about the 990, I would not be able to answer for you,' she said. 'You’re going back a number of years, and I really don’t have direct knowledge about those line items and what they would have been comprised of in any given year.'

Of course, the board might not have caught that problem, since they seemed equally unfamiliar with the budget:

Weaver, who has been on the board since 2001, said he has never reviewed the documents.

'I never see the 990s as the chairman. … The board never saw the 990s,' he said. 'That’s the business of the president and the CFO.'

Weaver said he had no idea how the university could run up $1.4 million in miscellaneous expenses. He 'couldn’t even gather a guess' on the entertainment costs.

And Weaver said he could only speculate on what 'healthcare leadership' expenses were: Perhaps they were expenses Pletz and her vice presidents incurred in their work with community organizations.

Summary

So here we have a particularly colorful example of how the leaders of health care organizations are different from you and me.  The CEO of one osteopathic health care university got more than one million a year despite her lack of any experience or expertise in health care, and her unawareness of her institution's budget, which apparently included lavish spending on administration and other expenses unrelated to the educational mission.  She nominally reported to a board of trustees which seemed completely clueless about her activities, but happy to pay her for "production" of what they did not know. 

So, as I wrote last week about out-size compensation given for no clear reasons to CEOs and other top executives of not-for-profit hospitals in three US states...

Although the executives of not-for-profit health care organizations generally make far less than executives of for-profit health care corporations, collectively, hired managers of even not-for-profit health care organizations have become richer and richer at a time when most Americans, including many health professionals, and most primary care physicians, have seen their incomes stagnate or fall. They are less and less restrainted by passive, if not crony boards, and more and more unaccountable. In a kind of multi-centric coup d'etat of the hired managers, they have become our new de facto aristocracy.


Or as we wrote in our previous post, executive compensation in health care seems best described as Prof Mintzberg described compensation for finance CEOs, "All this compensation madness is not about markets or talents or incentives, but rather about insiders hijacking established institutions for their personal benefit." As it did in finance, compensation madness is likely to keep the health care bubble inflating until it bursts, with the expected adverse consequences. Meanwhile, I say again, if health care reformers really care about improving access and controlling costs, they will have to have the courage to confront the powerful and self-interested leaders who benefit so well from their previously mission-driven organizations. It is time to reverse the coup d'etat of the hired managers.

A final note - we have heard a lot from health policy "experts" in this time of interest in health care reform, and millions of words about health policy have been dispensed by such "experts" during the continuous health care "crisis" of the last 30 years.  This case demonstrates how little one needs to know about health policy to run a university "Health Policy Institute" to churn out health policy position papers, especially when the university CEO and board of trustees are equally unkowledgeable.

Hat tip to Prof Margaret Soltan on the University Diaries blog.