Modern Healthcare just put out their list of the "100 Most Influential People in Healthcare" for 2013. A look at what sorts of people are on this list says a lot about who runs US health care, and raises questions about who should.
Some Health Care Professionals, Lots of Hired Managers
I did some quick descriptive categorizations. (Counts were double checked but I am not guaranteeing accuracy. Categorizations were sometimes difficult for highly diversified organizations.)
First, less than one third of list members are physicians (31% by my count). I did not see any other health professionals on it (although I confess I did not look up the biographies of all 100).
Of these physicians, most are now functioning as hired managers, usually at the CEO level, of big health organizations. I found only a few who could be characterized as somewhat academic: Dr Atul Gawande, professor at Harvard Medical School, Dr Eric Topol, chief academic officer at Scripps Health, Dr Harvey Fineberg, President, Institute of Medicine, Dr Brent James, chief quality officer and executive director, Institute for Health Care Delivery Research, Intermountain Healthcare, and probably Dr Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine.
My counts of hired managers on the list included
CEOs of For-Profit Health Insurers - 5%
CEO of For-Profit Hospital Systems - 8%
CEOs of Non-Profit Hospital Systems - 21%
CEOs of Other For-Profit Care Delivery Corporations - 7%
CEOs of Drug/ Device/ Medical Supply Corporations - 2%
CEOs of Health Care Information Technology Corporations - 1%
CEOs of Non-Profit Trade Associations - 14%
CEOs and other Leaders of Professional or Medical Association - 5%
CEOs of Health Care Charities - 4%
CEOs of Other Non-Profit Organizations - 15%
Elected Government Leaders - 6%
Leaders of Government Agencies, Departments - 10%
Union Leaders - 2%
People Whose Organizations Have Issues
The list included quite a few people who lead organizations which have had issues of the sort we discuss on Health Care Renewal. For example, the list included the following among its top 10 most influential, in order of listed influence -
4. Stephen Hemsley, CEO of UnitedHealth Group - We have discussed concerns about his executive compensation and how it does not fit his organization's stated mission, or his organization's long list of ethical misadventures (most recently summarized here)
6. Mark Bertolini, CEO, Aetna - We most recently discussed how Aetna's leaders' pontifications on health policy seem mainly based on self-interest (here) We also discussed various other management, ethical and legal issues.
7. Richard Bracken, CEO, HCA - A long time ago, HCA was one of the first big health care corporations to have to make a billion dollar plus settlement for fraud, among other issues (look here). The company has had legal, ethical, and management issues since.
8. Joseph Swedish, CEO, WellPoint - He is new as CEO, but under previous leadership, the company amassed a record of misadventures while making its leadership very rich (summarized here, and look here for details.)
The list also included many other people whose organizations have been frequent fliers on Health Care Renewal. For example, the CEOs of Epic Systems (ranked 13), Tenet Healthcare (18), Cigna (20), McKesson Corp (24), Sutter Health (42), Johnson & Johnson (46), Pharmaceutical Research and Manufacturers of America (PhRMA) (48), HealthSouth (59), UPMC (69), and Steward Health Care System (86).
There are many other people on the list who lead organizations that have gotten unfavorable notice on this blog, and a few whose own extreme executive compensation garnered comment. As my science professors used to say, I leave their identification as an exercise for those interested.
Who Is Not on the List
It is interesting who is not on the list. There are no physicians in private practice. I would argue there are no physicians who are "pure" academics at the moment. There are no other health care research, health policy research, or public health academics.
I saw only one person on the list (Senator Charles Grassley - R, Iowa) who has been identified with the sorts of real health care reforms we discuss here. (Senator Grassely has investigated many instances of alleged conflicts of interest and fraud, and sponsored the Sunshine Bill to disclose better physicians' conflicts of interest.) I do not see anyone else who in my humble opinion is identified as a dissident within the current environment.
Many of the media accounts we have noted include people identified as experts who decried such issues as excessive executive compensation, mission-hostile management, conflicts of interest, ethical issues leading to legal settlements, or crime and corruption in health care. None of them save Senator Grassley are on this list.
The Modern Healthcare list of 100 most influential people in health care demonstrates the enormous influence of hired managers in modern health care. The vast majority of list members were hired managers. While the list did include some physicians, most of them were currently working as hired managers.
It also demonstrates the influence of the for-profit, industrial part of health care. It included 5 for-profit insurance CEOs, 8 for-profit hospital corporation CEOs, 7 for-profit health care delivery corporation CEOs, 2 for-profit drug/device company CEOs, and 1 for-profit health care IT CEO, a total of 23. It also included CEOs of multiple trade associations, some of which represent the for-profit side of health care (e.g., PhRMA, America's Health Insurance Plans). While it included leadership of many non-profit organizations as well, some of these organizations have clear financial links to the for-profit industrial side. These ties may include significant financial support from industry, significant holdings of health care corporate stock, or managers or board members with their own relationships to industry. (For example, see this discussion of conflicts of interest affecting the Gates Foundation, whose co-chair is 76 on the Modern Healthcare list.) Many of the large, non-profit hospital systems, 21 of whose CEOs are on the list, have major institutional conflicts of interest, and have many people with individual conflicts of interest among their leadership and on their boards of trustees.
As opposed to the influence of the for-profit industrial part of health care, the influence of government seems muted. The list included only 6 politicians and 10 government managers. Some of the politicians are notable proponents of smaller government, e.g. Senator Grassley, and specifically of a smaller role of government in health care, e.g., Governor Bobby Jindal, R, Louisiana. Nor do unions have much influence. Only two union leaders were on the list. There was little counterweight provided to industrial influence from academia, and an almost complete absence of those who might question the current US status quo of dominance of health care by commercial interests.
So here is the latest evidence that US health care is dominated by commercial interests (in an era of regulatory capture, revolving doors, and financialization) and professional, if often generic managers. This suggests why our health care system seems more about revenue (and thus is very expensive), and less about improving patients' and the public's health. True health care reform would require increasing the influence of people who have different priorities than the currently most influential.