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Sunday, March 30, 2014

Taking oaths of poverty...Not!

Those who deliver health care often express a very conflicted view of money in their profession. No one admits to being in it for the money. Yet,  I have yet to hear of any of my colleagues commit to an oath of poverty. There is a desire to live well enough, but what is enough is open to interpretation. That figure has different anchors from which various parties base their perception of what is good but not greedy.

What creates almost constant tension is the concern that the sources of the money, which drives the engines that are health care, make a difference. There are assumptions and perceptions about these sources which tend to go unquestioned, which I question. They include:

1. Money from commercial sources is unclean and corrupting.
2. Money from grants from non-profits or the state are not corrupting
3. Revenues from clinical practice are OK, unless somehow corrupted by funds from for profit entities

We have gone through various cycles of self reflection, accepting and rejecting funding partnerships with for profit entities, particularly pharmaceutical companies. In my opinion, the tensions arise because we make assumptions which simply are not true and can never be true. Institutions which deliver key services to people will always be less than perfect. The most important piece to recall is that the void left behind when key institutions fail is almost always worse than when they exist but function imperfectly.

I experience and try to direct a modestly sized operating unit which provides service to patients, training to various learners, and drives scholarly and performance improvement work. All of these endeavors require fuel, that is money. That is because those participating in these activities are almost exclusively "coin operated". Missions which provide their own margins are the easiest to sustain. Those which don't are at risk of going away, despite perceptions that they are important. Money is not everything but for activities which require the commitment of parties who require financial incentives to come to work, the economics become very uncompromising in a hurry.

Thus, what is the impact when we start to be picky about the sources of funds to support missions. I call into question the hierarchy of sanctity of fund sources as noted above. Wherever the money comes from will cloud our judgement. Yes, taking funds from commercial sources has its risks. I would argue that these risks can be mitigated by explicit transparency as to where the money comes from, how much was transferred, and where the funds went. I have seen the effects of the virtual complete cessation of industry money into medical training programs. We primarily used these funds to buy books and support small research projects. The hit occurred at the very time our other funding options became more limited. Our goals and missions are at times aligned with commercial entities such as drug companies. We should recognize this and use this alignment to maintain a differentiated source of funding.

The health delivery system and particularly academic health systems, have seen the federalization of their funding sources. I recently asked on of our finance heads what percentage of our revenues come from the federal government. They remarked that this was a very good question but they did not know off hand. I am fairly sure it is a large and growing percentage. Whether it be research grants, Medicare funds, Medicaid dollars passed through state middle men, or tuition backed by federal loans, a large percentage of key funds comes from a single source. Not such a good business model for long term sustainability in my opinion.

Furthermore, the assumption that federal or other state monies do not influence our thinking or behavior is to be questioned. These monies are by definition monies disbursed with primarily political considerations in mind. With money, there is always an underlying quid pro quo and with political monies, the payback must be something which has political value. In my opinion, the political leanings of academic health centers reflects the influence of federalization of the funding process. We have created an insular culture with few dissenting voices, which drives the expansion of state power in health care. It is unfortunate that the entire model based upon a narrowing source of funding becoming more and more sole source based is likely to prove unsustainable.

Finally, we derive huge sums of revenue from clinical activities. I am always annoyed when I read articles in clinical journals where authors claim they have not financial conflicts, yet the articles center around clinical activities which serve as their major source of revenue. Are we blind? If the intervention described in the paper focuses on a procedure which creates substantial margins to support you and your operating unit, is this not a fundamental financial COI, even you work for a non-profit entity?

If we are driven to a great degree by financial concerns (and we are), it really does not matter where the money comes from. Each source of money will create biases and blind spots, and influence our behaviors in both subtle and not so subtle ways. The effects will vary depending upon the sources but all sources provide incentives for both desirable and not so desirable behaviors. The beliefs that certain sources of funds are always substantially more corrupting than others is mistaken. Wherever the funds come from to support important missions, the rules in place with always drive certain parties to behave in less than virtuous ways, whether the monies derive from commercial or political activities. We cannot meet our missions without the financial resources unless we get buy in regarding oaths of poverty from those involved. That is not going to happen. We might as well be realistic and tap into robust and differentiated funding sources which includes both commercial and non-commercial sources to create a sustainable model.

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