Tuesday, February 25, 2014

Say it isn't so Joe, Medical "thought leaders" might have conflict of interests

 The issue of possible conflicts of interest (COI) has arisen in regard to both the National Quality Forum,  (NQF) and the popular UpToDate.

 This article in the Journal Of Medical ethics discusses that issue in regard to the popular UpToDate which on its web site describes its self as "premier evidence-based clinical decision support resource". The journal article has this to say regarding several sections of UpToDate comparing it to another rival medical resource:

"All articles from the UpToDate articles demonstrated a conflict of interest. At times, the editor and author would have a financial relationship with a company whose drug was mentioned within the article. This is in contrast with articles on the Dynamed website, in which no author or editor had a documented conflict. We offer recommendations regarding the role of conflict of interest disclosure in these point-of-care evidence-based medicine websites."  It should be noted that the journal authors did not review all of sections but selected ones that involved subjects for which treatment was controversial and/or involved recommendations for specific treatments that wee provided by a single supplier.

Much more has been written about possible COI regarding the NQF.

Details regarding Dr. Charles Denham can be found in this article in "Modern Health Care. Quoting that article:
"
"Dr. Charles Denham, co-chair of NQF's Safe Practices Committee in 2010, received $11.6 million from San Diego-based CareFusion to promote the company's ChloraPrep line of skin-preparation products. Denham's committee at the NQF also recommended surgeons use ChloraPrep products to prevent surgical infections, the NQF said."

Dr.Christine Cassel,currently CEO of NQF left little doubt about her assessment of Denham action saying simply "He lied" when he mislead the NQF regarding his possible COI and business interests. Dr. Cassel was not affiliated with NQF at the time of the allegedly kickback  related activities.

Ironically enough now Dr Casell has the spotlight on her in regard to possible COI  regarding her role at NQF.ProPublica takes up that issue here. I say ironically because one aspect of Dr.Cassel's academic reputation has been in the field of medical ethics.Dr. Cassel has written and lectured extensively on medical ethics, authored or co-authored several publications in the field including "Ethical Dimension in Health Professions" and completed a fellowship in bioethics.

 So what is it that Pro Publica finds of concern in regard to Dr. Cassel's role at NQF. It is in regard to other compensated positions that she holds.For example Dr. Cassel is a board member for Premier Inc with a reported compensation  of  $ 235,000 and stock.Does a board member of a corporation not have a fiduciary duty to the corporation.?

Since she has earned the title of expert in the field of medical ethics it seems astonishing to me that she apparently does not consider it an ethical breach to play a leadership role in the NQF and to  receive compensation  from two organizations that could profit ( or loose) based on some recommendations made by that organization. Two ethicist interviewed by Pro Publica seem to disagree and Dr Roy Poses ( see here) who is absolutely untiring in his efforts to point out issues of COI in health care has this to say regarding Dr. Cassel's dual roles:


"However, in my humble opinion, the issue here goes even beyond a blatant and undisclosed conflict of interest.  That a top steward of a big for-profit health care corporation could simultaneously be the top leader of an influential non-profit health care quality improvement organization suggests that increasingly US health care is run by an insular group of insiders whose influence gets ever larger because of their collective power, not necessarily because of their dedication or ability to improving health care.  As ProPublica put it,
Rosemary Gibson, an author and senior adviser to The Hastings Center, a research group dedicated to bioethics in the public interest, said she wasn’t surprised at Cassel’s outside compensation. So much money permeates decision-making in Washington, she said, that participants have become oblivious.'The insiders don’t see it,' Gibson said. 'It’s like a fish in water.'

Update: 2/27/2014 Dr Cassel has resigned from her posts at Premier and  Kaiser.

Thursday, February 06, 2014

Obamacare may decrease employment but at least more folks can "pursue their dreams"

The situation involving recent projections about job loss and Obamacare from the Congressional Budget Office and the White House's reaction to it falls under the joint headings "you can't make this stuff  up" and  You gotta be kidding me"
Yes, the White House really said that now people will be able to pursue their dreams,which is one way of considering  having no job,and those blessed with less work can spend more time with their family as well as having the opportunity to retire early.


See here for Avik Roy's comments regarding the CBO projection of 2.5 millions job losses and the administration's reaction it which should have destroyed any feeble residue of credibility that Obamacare apologists  may still retain.

 No,CBO is not saying that 2.5 millions folks will be fired but rather there will be "a decline in the number of full time equivalent workers of about 2.0 million in 2017 , rising to about 2.5 million in 2014."

Basically the CBO says Obamacare will decrease employment by the millions.Here is Avik Roy's explanation of how that might be brought about.

"The new, larger estimate of the law’s negative impact on the labor force derives from three factors: (1) Obamacare’s employer mandate, which will discourage hiring and reduce wages offered by employers; (2) Obamacare’s $1 trillion in tax increases, which will discourage work and depress economic growth; and (3) the law’s $2 trillion in subsidies for low-income individuals, which will discourage many from remaining in the labor force."
If you were wondering  what the tax increase would be spent you should be reassured that it will all not be wasted as some of it will go to mitigate losses that insurance companies might experience because the plan is not working out quite as projected.See here for what Humana will get so far.In Obamacare's quirky version of social justice all the redistribution does not seem to go to the most disadvantaged making it seem a bit more like crony capitalism.

Wednesday, February 05, 2014

Are employee wellness programs just silly or can they be hazardous to health?

Leah Binder, writing in Forbes on line ( see here) argues that the answer is "maybe" at least as regards what she calls badly designed programs. She draws from a book from Al Lewis and Kiv Khanna entitled "Surviving workplace wellness".

Practicing internal medicine and pulmonary disease in the late 1970s I had not heard the term "wellness" until I was approached to consult for a large petrochemical company who believed they had a problem with some type of occupational lung disease at one of their facilities. ( The term risk factor was new to me as well)

Later while working part time at that company I sat in on a presentation from a consulting firm who was selling employee wellness programs.They showed slides with huge alleged savings from the detection of early disease in the employees. One cynical older HR person said yes that maybe be true but if we save those lives while folks are working will  we not  be shelling out more money in longer retirement payment because if we have both a health insurance program and a retirement program we will be paying now or paying later.

That argument aside Lewis and Khanna make a persuasive and humorous case for shelving most of what passes for employee wellness programs, which by the way are encouraged by Obamacare giving us reason 962 for never having passed the biggest crony capitalism con job  windfall ever.

The authors tell us that the "sum of value created when an employer plays doctor" can be put in a very small footnote,

stop smoking
eat better
get off your butt

Their analysis resonate with  the impression I had years ago .The difference is they have data to support their conclusions.