How Large Health Care Organizations Set the "Rules of the Game" to Dominate Health Care

The notion that health care is increasingly "dominated by large, bureaucratic organizations which do not honor ... [its] core values"(1) just made it into a main-stream, large circulation US medical journal.  A brand new commentary in the American Journal of Medicine(2) by Supri and Malone declared:
To explain why we have the most expensive health care system in the world and yet one of the lowest performing, we need to take a perspective that focuses on the US institution of medicine as a whole. We expose the hidden rules by which this institution operates and discuss how its powerful organizations shape, control and perpetuate this ailing system.

The article then described the main types of large, powerful health care organizations:
The US institution of medicine is not a single, comprehensive and cohesive system of health care. Instead, it is comprised of a myriad of large and powerful organizations, including insurance companies, Health Maintenance Organizations (HMOs), corporate for-profit hospital chains, and pharmaceutical companies. This institutional structure is large and vast, and has over the years become ever more labyrinthine.

Note that there are even more kinds of large and powerful health care organizations, including non-profit hospitals and hospital systems, employers acting as payers for health care, government agencies, device and biotechnology companies, health care information technology companies, public relations firms, medical education and communication companies, contract research organizations, professional societies, patient advocacy groups, accrediting bodies, health care charities, etc, etc, etc.  But the point is that the large organizations, not the patients, the physicians, nor the public dominate.

Supri and Malone suggested that each kind of organization sets the "rules of the game," that is, the priorities important to the organization, which are very different from the core values that many of us believe ought to guide health care:
Not only is the institutional structure large, it is dynamic, and actively creates, shapes, and maintains the institution of medicine. It does this through what we call setting the “rules of the game”; that is, by imposing the terms by which the system operates.

For example,
Insurance companies have set the rule 'restrict choice and coverage.' They enact this through their elaborate system of copayments and deductibles, exclusion clauses and loopholes, each designed to deter patients from claiming the health care they need, and to override physicians' medical judgment.

Similarly, it cited the rules for managed care, "manage care," that is, "restrict utilization of health care" regardless of patients' needs; the pharmaceutical industry, "charges as much as we want, because insurance will pay;" and "corporate hospital chains ... test as much as we want, because insurance will pay." Thus it made the point that US health care now is driven by the priorities of large organizations whose interests at best may disregard and at worst may conflict with providing the best possible care for individual patients.

Further, the resulting complexity is to the benefit of the large organizations:
As each organization has created its own 'rules of the game,' the institution of medicine has grown into a complex entity that few really understand. This very complexity actually works to the advantage of the organizations that comprise the system, creating an operating environment that allows them to siphon off billions of dollars. It is one of the main reasons why the cost of health care has spiraled out of control.

This is very important, and suggests that the system will just become more bureaucratic, complex and opaque until it finally collapses.

Finally, it raised the point that the organizations collude to promote their priorities at the expense of patients' and the public's health:
Although each organization sets their 'own rules of the game,' they are also strongly and deeply interlinked, and cooperate and collaborate to protect the system of health care that they have devised, so that it remains intact and continues to serve their own interests.

Although  Supri and Malone did not differentiate the leadership of large organizations from the organizations themselves, we have pointed out that the top leaders of various kinds of organizations seem to think alike, becoming a sort of de facto executives' guild, with a "superclass" of oligarchs at its pinnacle.  The guild may be enabled by these leaders' often huge compensation and other benefits and corporate arrangements that keep them shielded from the vicissitudes of daily life that patients, health care professionals, and lower level organizational employees must face.  Furthermore, the leadership of these organizations is often interlinked, for example, by leaders of one organization serving on boards of directors or trustees of others.

It is so nice for us at Health Care Renewal to have some company. It is a very important blow to the anechoic effect for these sorts of views to appear in a mainstream medical journal.

When I interviewed a motley group of physicians and health care professionals in the early part of the 21st century, many expressed concerns about how medicine had been taken over by large organizations which did not honor its values. The article published in 2003(1) in Europe which tried to summarize their concerns probably could not have been published at that time in the US, but its publication remote from its main topic only made it more anechoic. It may be that an article published in a respected American journal will generate some more echoes. Here is hoping that Health Care Renewal can help create some such echoes. 

Obviously, those who lead large organizations in health care will not be happy about that, so it is possible this article's appearance in a main-stream journal may incite some pushback, perhaps generated by the public relations machines of the large health care organizations (see this post about how Wendell Potter's excellent Deadly Spin documented how large organizations use propaganda and disinformation to undermine viewpoints that threaten their domination.)

In conclusion, I strongly support Supri and Malone's final sentiments:
The sum of the 'rules of the game' devised by these organizations has resulted in a fragmented, haphazard and broken system of health care. Reform is long overdue, and demands root and branch transformation of the 'rules of the game' governing the US institution of medicine. This requires us to understand these rules, who is setting them, and how these rules are being used to exploit the system of medicine. Only then can we begin to heal our ailing health care system.
Well said!

But now almost 8 years since the publication of "A Cautionary Tale," we still have a long way to go.

References


1.  Poses RM. A cautionary tale: the dysfunction of American health care.  Eur J Inte Med 2003; 14: 123-130.  Link here.
2.  Supri S, Malone K. On the critical list: the US institution of medicine. Am J Med 2011; 124: 192-193.  Link here. 

BLOGSCAN: The Place Where the Compass Spins

The 1 Boring Old Man blog is on a roll.  Read this summary post, see its amazing introduction below, then peruse the main page and the archives:
At the North Pole, the magnetic compass apparently spins at random, not knowing where to point. Is it because there’s no North? or is North everywhere? That’s the way I feel about this Atypical Antipsychotic story I’ve been preoccupied with for a couple of months. It’s like everyone’s walking around with a compass that doesn’t work any more. The Pharmaceutical Companies involved have forgotten what their products are used for. Many doctors seem to have forgotten why they became doctors. Whole industries have sprung up [Clinical Research Organizations, Clinical Research Centers, Medical Writing companies, etc] without being clear about what they’re even involved in. One has to move away from it all to avoid getting caught up in the confusion and becoming as blind as the other players. Once you get far enough away, it’s tempting to forget that it’s even there, that place where the compasses don’t work anymore.

"Government-Run Health Insurance" Run by Corporations? - Two Medicaid Examples

In the US, there seems to have been a constant argument between right- and left-wingers over "government-run" health insurance.  The right tends to disparage all aspects of "government-run" health care, and in the case of insurance, uses the alleged faults of the two big US government health insurance programs as examples.  (Medicare is a federal government health insurance program for the elderly and disabled. Medicaid is federal-state program for the poor.) 

For example, per the Associated Press via BusinessWeek, from a currently prominent Republican hopeful for President, former Minnesota Governor Tim Pawlenty,
The former Minnesota governor was the latest politician to participate in the Health Policy Grand Rounds program that Dartmouth-Hitchcock Medical Center has organized for its staff during the past two presidential campaign cycles. Using Medicare and Medicaid as examples, he criticized the notion that government-run health care will produce efficiency and said the answer lies in empowering consumers.

Republican Congressman Darrell Issa (California) wrote in 2010:
an expansion of the federal bureaucracy at that rate will greatly increase the incidence of waste, fraud and abuse in health care. Already Medicare, which accounts for 14% of all federal spending, is rife with waste, fraud and abuse. Even Attorney General Eric Holder has said, 'By all accounts, every year we lose tens of billions of dollars in Medicare and Medicaid funds to fraud.'

A recent analysis by the Government Accountability Office (GAO) estimated that federal subsidy programs cost taxpayers about $100 billion every year in improper payments, with Medicare and Medicaid accounting for more than half of that.

The left may advocate for government-run, "single-payer" insurance programs, perhaps using the alleged benefits of Medicare and Medicaid as examples.

Scholarly articles about health care policy may refer to Medicaid as a government "single-payer" system.  (For example, see: Robinson JC. The commercial health insurance industry in an era of eroding employer coverage. Health Aff 2006; 25:1475-1486. Link here.)

In any case, I suspect most of us think of Medicaid as an example of "government-run" health care insurance, regardless of whether we believe that is a good or a bad thing.

Yet the reality may be more complex. Two recent stories, one a follow-up on an old Health Care Renewal post, provide some dots to connect.

Connecticut HUSKY Medicaid Program

In 2007, we posted about how the state of Connecticut was going to end participation in the HUSKY state Medicaid program for poor children by four insurance companies/ managed care organizations.  They apparently refused to provide information about payments to physicians and denial of payments for prescription drugs to the state.  The two largest organizations involved were Anthem Health Plans (a subsidiary of WellPoint), and Health Net.  At the time, we noted that this case provided an example of the lack of transparency exhibited by major health organizations.

Late last year, the Connecticut Mirror documented more criticism of the HUSKY program based on a report that showed that participating companies were making big profits from it (but perhaps not from other state Medicaid programs): 
The three managed care companies in the state's HUSKY insurance program for low-income children and families recorded profits of $18.8 million last year, according to figures released by the state Department of Social Services.

In one part of HUSKY, the insurers made margins of at least 20 percent and spent less than 72 percent of their revenues on medical care.

The figures released this month drew criticism from members of the Medicaid Care Management Oversight Council, who are in the midst of considering moving HUSKY out of managed care.

In more detail, the relevant numbers were:
AmeriChoice, part of UnitedHealthcare, spent 62 percent of its revenue on medical care and posted a 22.9 percent profit margin in the HUSKY B program.

By contrast, the federal health reform law sets minimum medical care ratios for insurers of 80 percent or 85 percent, depending on the type of plan. The provision does not apply to Medicaid plans, but was cited as a benchmark in the council's discussion.

None of the insurers met those benchmarks in HUSKY B, which covers children whose family income does not qualify for Medicaid. Last year, it covered between 13,000 and 16,000 children, many whose families earned below 300 percent of the federal poverty level.

Aetna spent 70.5 percent on medical care and made a 20 percent margin, while Community Health Network of Connecticut, a non-profit with far more enrollees than the other insurers, spent 71.8 percent of its revenues on medical care and made a 20.6 percent margin.

Margins were lower, and medical care ratios higher, in HUSKY A, a Medicaid program that enrolled as many as 358,088 children and adults in 2009.

Community Health Network reported a 95.1 percent medical care ratio and a -0.3 percent margin. AmeriChoice spent 86.3 percent of its revenue on medical care and achieved a 3.5 percent margin, while Aetna had an 83.9 percent medical care ratio and 6.5 percent margin.

Overall, the medical care ratio was 90.7 percent for both HUSKY programs and all three insurers. The overall margin was 2.3 percent.

The insurers involved defended themselves by noting to participate in HUSKY they also had to participate in another program, Charter Oak Health Plan, "on which they lose money."

Last month, it looked to be the end of managed care in these Medicaid programs, again as reported by the Connecticut Mirror:
The Malloy administration announced plans Tuesday to move the HUSKY and Charter Oak health programs out of managed care and increase care coordination in the state's other Medicaid programs, an effort officials said would save money while giving the state more control over health programs that serve more than 500,000 people.

This article also noted:
In the current system, the state pays three managed care companies set fees for each HUSKY and Charter Oak member every month, and the companies use the money to pay medical claims. Critics say it gives the managed care companies an incentive to deny care since they get to keep the money not spent on medical costs.

So let us deal directly with the cognitive dissonance generated by these articles. In the ongoing US health reform debate, Medicaid is usually discussed as a "government-run" health care (insurance) program. Yet these news articles from Connecticut suggest at least in that state, part of Medicaid was out-sourced to mostly large, national, for-profit health insurance companies/ managed care organizations. Furthermore, as noted just above, these corporations seemed to be mainly calling the shots in how their part of Medicaid was run. So is this "government-run" health care (insurance)?

But wait, there is more....

Minnesota Medicaid Controversy

Last month, the Politics in Minnesota web-site ran a report on an unlikely reformer:
Dave Feinwachs is no stranger to the Capitol.

For three decades he was the general counsel to the Minnesota Hospital Association. In that capacity, he negotiated with state agencies and testified regularly before legislative committees on health care issues.

But early last year, Feinwachs said, he was ordered by his superiors at the hospital association not to provide any further testimony at the Capitol. The reason for the muzzle: his vocal insistence that health maintenance organizations (HMOs) should contribute money to help salvage the state’s General Assistance Medical Care program for indigent adults.

Feinwachs says he abided by the prohibition on testimony before legislative committees, but apparently it was not enough to keep him in the good graces of his employer. In November he was fired as the group’s principal attorney. Feinwachs will not discuss the reason for his termination, citing potential litigation. But it almost certainly had something to do with his ongoing zealous campaign to force greater transparency and accountability on the state’s HMOs - primarily Blue Cross & Blue Shield, HealthPartners, Medica and UCare - which receive roughly $3 billion annually to run health plans for many of the state’s poorest residents.

So here we go again. This article suggested that Minnesota had out-sourced a very large part of its Medicaid program.

Furthermore, it also appears that the state government knows little about what happens to the money it hands over:
In the next two years, Minnesota is slated to funnel about $6 billion to the state’s HMOs to provide health care for 550,000 of the state’s poorest residents. To put that figure in perspective, it is nearly 20 percent of the state’s expected 2012-13 general fund revenues - and nearly identical to the state’s projected $6.2 billion deficit. In coming up with a solution to Minnesota’s financial crisis, Feinwachs and others believe, legislators must at least have a clear accounting of this massive pot of health care dollars.

HMOs, meanwhile, are not exactly yearning for scrutiny, especially as they launch a pitch to administer even more of the state’s health care spending.

In addition, there is reason to believe that Minnesota may be paying a significant amount for administration:
Feinwachs believes that the administrative overhead collected by HMOs could be in the neighborhood of 16 percent. He concedes, however, that this is no more than a 'guesstimate' pieced together from the limited information that is publicly available.

Then, there is reason to suspect that the private (and nominally not-for-profit) HMOs that Minnesota pays to run Medicaid have resisted accounting for how the money they got was spent:
Past attempts to bolster accountability and transparency for HMOs have largely run into a brick wall. For instance, when legislators considered requiring the health plans to chip in on a plan to restore the General Assistance Medical Care program last year, they were told by officials from the Department of Human Services that such a move would be illegal. Efforts to provide more financial disclosure have been rebuffed by the argument that such information is proprietary and not subject to the state’s data practices rules. The complexity of Minnesota’s patchwork of publicly funded health care plans, which very few individuals clearly understand, has also helped forestall changes.

'We can’t let the complexity of data and information beat us down, and I think that’s what happened in the years past,' Hosch said. 'The systems almost seem like they’re deliberately complex in order to confuse us.'

Apparently in these parlous financial times, Mr Feinwachs got some attention. Last week, the state Governor announced his willingness to dig into the results of the state's out-sourcing of Medicaid, per the Minneapolis Star-Tribune:
It's high time that Minnesota started treating its nonprofit health plans for what they are -- some of state government's largest vendors.

Reforms announced this week by Gov. Mark Dayton's office are a promising first step toward scrutinizing health plan contracts for savings and finding new ways to rein in Minnesota's soaring medical costs.

Managing care for more than 500,000 low-income, disabled and elderly Minnesotans enrolled in state public health programs is a $3.1 billion-a-year business for health plans in Minnesota, with the state and federal government jointly footing the bill.

Over the past decade, the state's portion of this outsourced care has increased from 5 percent to 11 percent of the state budget, according to Dayton's office.

The state also has more than 249,000 people -- typically the sickest of the sick -- in a fee-for-service public program. That spending is also ripe for a cost-savings review.

On Wednesday, Dayton announced plans to do what good business leaders do in difficult financial circumstances. His administration is going to start driving harder bargains with health plans.

Key parts of the plan include making the contracting system more competitive, making financial information more transparent, and doing deeper auditing of plans' books to analyze administrative and medical expenses.

So again in Minnesota, it appeared that the state had out-sourced a large proportion of its Medicaid program, covering apparently two-thirds of the state's Medicaid patients. It appears that knowledge of the out-sourcing of most of Medicaid was relatively anechoic, and that even the state's former Governor Pawlenty was unaware of it (see his comments in introduction to this post). Despite the amounts of money and the numbers of people involved, up to now the state government had apparently very little information about how billions of dollars were being spent by private, albeit nominally non-profit health insurance companies/ managed care organizations.

Summary

Two cases from two states suggest that some proportion of Medicaid, perhaps a very large proportion, has been out-sourced to private corporations, both nominally non-profit and for-profit.

In fact, a Washington Post article last year suggested that 70% of Medicaid patients are in managed care plans, most of which are likely out-sourced, not run by state Medicaid agencies.

Our two cases above further suggest that government officials may know little about how the money given to these corporations was spent, and how the corporations managed the supposedly "government-run" health insurance.

So much for the notion that the US Medicaid program is "government-run" health insurance.  Whether one believes that government bureaucrats are good or bad at running health care, it seems that most Medicaid patients' care is managed by corporate, not government bureaucrats.

The likelihood that a substantial proportion of Medicaid patients actually get their health care coverage from corporations, be that non-profit or for-profit, raises some important questions.
- What proportion of the government funds provided these corporations goes to health care versus administration, overhead, etc?
-  What then is the proportion of all Medicaid money spent on health care versus administration, overhead, etc at the federal, state, and corporate levels?
-  What proportion of the revenue of major health insurers/ managed care organizations actually comes from tax-payers via Medicaid?
-  To what extent do health insurers/ managed care organizations influence clinical care through their role implementing Medicaid?
-  How transparent are their finances and their implementation of Medicaid?
-  How well are they supervised and regulated by national and state government?

Meanwhile, it appears that there is far more overlap between government and corporate health insurance and managed care than most of us realized.  That suggests the usual debate between the foes and proponents of "government-run" health care (insurance) was vastly too simplistic.  Maybe some of those involved in the debate should have known that.   

Meanwhile, the concerns I discussed in 2002 that "health care has become dominated by large, bureaucratic organizations" appear increasingly well-founded.  This domination seems to be increasingly facilitated by collaboration - or should that be collusion? - among government and private bureaucracies.  The danger, as we have repeatedly discussed, is that the leaders of these bureaucracies may feel increasing loyalty to the managers' and executives' guild, and decreasing pressure not to fulfill their own and their cronies' self-interest.  We need at least to have some frank discussions about the increasing corporatism of health care and all of society, and what to do about it. 

Those Who Dismiss Healthcare (and Healthcare IT) Adverse Events Reports as Mere "Anecdotes" Have Lost - Supreme Court-Style

At my Sept. 2010 post "The Dangers of Critical Thinking in A Politicized, Irrational Culture" I wrote:

... It's the EMR "anecdotalists" (as opposed to the "Markopolists") who say that "anecdotes" of HIT-related injury are meaningless. They deem reports of safety issues and HIT-related misadventures and risk as simply "anecdotal", and that "anecdotes don't make evidence" (or "anecdotes don't make data").

For "anecdotes" of patient harm due to medical devices even from the most reliable of sources to be counted as "evidence" of device risk, apparently, the stories need to be blessed with Statistical Holy Water. The Holy Water must also be of a brand approved by the academic pundits.

For me, this is no longer merely a professional debate. My elderly relative became one of those "anecdotes" in May last year.

I address the casual, Dogbert-style, waving-of-the-hand "Bah!" dismissal of health IT harm "anecdotes" at numerous other posts as well, such as "
EHR Problems? No, They're Merely Anecdotal" and "Health IT: On Anecdotalism and Totalitarianism".

Bah! Your Health IT adverse events reports are anecdotes, and anecdotes don't make data!

In those posts I also mention how Australian informatics professor Dr. Jon Patrick had essentially hit the flaws of this argument out of the Southern hemisphere with a short editorial in the journal "Applied Clinical Informatics" entitled "
The Validity of Personal Experiences in Evaluating HIT." That essay is free at the link and is worth reading.

Interestingly and thankfully, the "anecdotes are meaningless" crowd have now lost, and lost big - Supreme Court style. In fact, the U.S. Supreme Court has shown far more common sense than many esteemed academics and industry pundits.

As noted in this post at Derek Lowe's pharmaceutical industry "In the Pipeline" blog, the company that made "Zicam", a zinc-based over-the-counter cold remedy, tried to defend shareholder suits that the company withheld case reports of Zicam causing permanent loss of smell via arguing that such reports "did not reach a level of statistical significance", i.e., were "anecdotal." The case went to the U.S. Supreme Court.

The Supreme Court would have none of that argument:

"Matrixx’s [Zicam's manufacturer - ed.] premise that statistical significance is the only reliable indication of causation is flawed. Both medical experts and the Food and Drug Administration rely on evidence other than statistically significant data to establish an inference of causation. It thus stands to reason that reasonable investors would act on such evidence.

The full court decision is at this link: http://www.supremecourt.gov/opinions/10pdf/09-1156.pdf (PDF file), but a passage I consider key to this issue is as follows:

... We conclude that the materiality of adverse event reports cannot be reduced to a bright-line rule ... Because adverse reports can take many forms, assessing their materiality is a fact-specific inquiry, requiring consideration of their source, content, and context.

This is common sense incarnate. It applies not just to drugs, but to medical devices, to health IT, and to other domains as well.

In essence, it is saying that adverse events reports, especially repeated ones, from trustworthy sources are not to be lightly dismissed, but should serve at the very least as red flags that there may be a systemic problem requiring further investigation.

One wonders how and if public healthcare IT vendors will begin disclosing "anecdotal" reports of their products causing patient harm to their own stockholders.

One also wonders if the academic anecdotalists (up to the level of the chair of the Office of the National Coordinator for Health Information Technology at HHS) will cease their unfettered dismissal of health IT AE reports as mere "anecdotes" and therefore let's roll out this 100% beneficent technology nationwide ASAP:

"Nothing [ONC has] found would give them any pause that a policy of introducing EMR's could impede patient safety." - David Blumenthal

That sounds a bit like the refrain of the makers of Zicam.

One might also wonder if the anecdotalists merely lack common sense, or are using this form of
epistemological dementia to obscure conflict of interest.

On a final note, my favorite comment at the aforementioned "In the Pipeline" blog story is this by anonymous commenter "Still Scared of Dinosaurs":

One of the most important ideas real statisticians must get into their heads is "Thou shalt not worship the 0.05 threshold". The whole concept of "statistical significance" for AEs is idiotic and the fact that Matrixx based any part of their defense on it indicates that their stupidity did not end when they named the company.

Perhaps this Dilbert cartoon is apropos to the Supreme Court decision:


-SS

Addendum:

I thought it appropriate to share these thoughts with the leadership of the Joint Commission, the organization that accredits healthcare organizations in the United States:

From: Scot Silverstein
Sent: Sunday, March 27, 2011 10:41 AM
To: MGiuntoli, Anita; Chassin, Mark; Schyve, Paul; Legaspi, Shirley
Cc: Ross Koppel; 'David Kreda'
Subject: Re: MATRIXX INITIATIVES, INC., ET AL. v. SIRACUSANO ET AL.

Not a complaint this time [about health IT failure - ed.], but an observation.

The JC has noted health IT risks in the Sentinel Events Alert "Safely implementing health information and converging technologies" of 2008.

The company that made "Zicam", a zinc-based over-the-counter cold remedy, tried to defend shareholder suits that the company withheld case reports of Zicam causing permanent loss of smell via arguing that such reports "did not reach a level of statistical significance", i.e., were "anecdotal." The case went to the U.S. Supreme Court.

The Supreme Court would have none of that argument:

"Matrixx’s [Zicam's manufacturer] premise that statistical significance is the only reliable indication of causation is flawed. Both medical experts and the Food and Drug Administration rely on evidence other than statistically significant data to establish an inference of causation. It thus stands to reason that reasonable investors would act on such evidence.

The full court decision is at this link: http://www.supremecourt.gov/opinions/10pdf/09-1156.pdf (PDF file), but a passage I consider key to this issue is as follows:

... Because adverse reports can take many forms, assessing their materiality is a fact-specific inquiry, requiring consideration of their source, content, and context.

This is common sense incarnate. It applies not just to drugs, but to medical devices, to health IT, and to other domains as well.

I believe JC should start to pay serious attention to "anecdotal reports" of health IT-caused patient injury, and consider reliable reporting of these events as an Accreditation standard.

As I noted in my July 2009 JAMA letter to the editor "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" in response to Koppel and Kreda's JAMA article on HIT industry practices, "hold harmless" and "gag" clauses must go, and be replaced with proactive reporting of healthcare IT-related "events."

Scot Silverstein

-- SS

The Institute of Medicine Releases Reports on Practice Guidelines and Systematic Reviews Which Generate Few Echoes

Two days ago, the prestigious US Institute of Medicine released two reports on important health care issues, clinical practice guidelines and systematic reviews.  Systematic reviews of the relevant clinical research have been advocated by evidence-based medicine proponents as the appropriate basis for clinical and policy decisions.  Clinical practice guidelines have been advocated by many health researchers, policy makers, and clinicians as the best way to encapsulate the evidence to inform clinical and policy decision making.  Both reports suggested series of standards for how systematic reviews and clinical practice guidelines should be developed. 

These topics are of general importance to clinicians, health services researchers, and health policy makers.  The Institute of Medicine, part of the US National Academy of Sciences, is one of the most authoritative sources of opinion on medicine and health care.  Therefore, one would think that these reports would have gotten wide notice, and would hardly required Health Care Renewal to create some echoes.

However, a Google News search today produced only six "hits" relevant to these reports, including the original press release.  All are in specialized medical/ health care news outlets.  None are in the national media, and none are from major medical/ professional journals or societies. 

Let me suggest a theory about why these two major reports have generated so few echoes so far.  Let me quote from the summary of the report on clinical practice guidelines:
Most guidelines used today suffer from shortcomings in development. Dubious trust in guidelines is the result of many factors, including failure to represent a variety of disciplines in guideline development groups, lack of transparency in how recommendations are derived and rated, and omission of a thorough external review process. To be trustworthy, clinical practice guidelines should:
• Be based on a systematic review of the existing evidence;
• Be developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups;
• Consider important patient subgroups and patient preferences, as appropriate;
Be based on an explicit and transparent process that minimizes distortions, biases, and conflicts of interest;
• Provide a clear explanation of the logical relationships between alternative care options and health outcomes, and provide ratings of both the quality of evidence and the strength of recommendations; and
• Be reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations.
Additionally, as reflected in the committee’s standards for developing trustworthy clinical practice guidelines, guideline development groups optimally comprise members without conflict of interest. The committee recognizes that in some circumstances, a guideline development group may not be able to perform its work without members who have conflicts of interest—for example, relevant clinical specialists who receive a substantial portion of their incomes from services pertinent to the guideline. Therefore, the committee specifies that members of the guideline development group who have a conflict of interest should not represent more than a minority of the group.

So it seems that the report on clinical practice guidelines emphasized two issues highly relevant to Health Care Renewal, the need for transparency in guideline development, and the need to avoid conflicts of interest affecting the development process. The two first standards for guidelines are about transparency and minimization of conflicts of interest.  Similarly, the report on systematic reviews also included fairly tough standards to minimize conflicts of interest.

We on Health Care Renewal go on and on about the need to maximize transparency in health care, and particularly in health care leadership and governance, and about the need to disassemble the now pervasive web of conflicts of interest that has entangled health care.  However, as we know, these are not popular topics among the leadership of health care, which includes many individuals who have greatly benefited from lack of transparency and pervasive conflicts of interest.  We know these topics make these leaders, and many of those who report to, or work or associate with them very uncomfortable.

So unfortunately, I am not surprised that the two new and likely authoritative reports from the Institute of Medicine, despite that organization's prestige, have started off relatively anechoic.  It also unfortunately likely that they will remain relatively anechoic. 

In 2009, the IOM issued an authoritative report on conflicts of interest in medicine and health care which suggested fairly tough standards to decrease such conflicts and their influence (also see post here).  Since 2009, I just found 53 citations to that report in the medical literature using the ISI Web of Science, for a rate of 27/year.  In 1999, the IOM issued a report on medical errors, "To Err is Human."  Since then, it has received 1374 citations, a rate of 115/year. 

As we noted above, the topic of conflicts of interest seems to make the powers that be in health care very uncomfortable.  In contrast, "To Err is Human" was widely interpreted to mean that physicians make a lot of dangerous errors, and the best way to decrease them is to impose more controls by bureaucrats, managers, and executives (even if that was not its intent).  Thus, that report could be twisted to fit the talking points of the powers that be, and hence has been anything but anechoic.

So while Health Care Renewal is hardly a powerful tool for creating publicity, I thought we should try to get the word out about the new IOM reports on clinical practice guidelines and systematic reviews.  Every little bit helps.

Meanwhile, the deathly quiet reception these reports have gotten so far emphasizes the need to combat the anechoic effect.  As long as the powers that be can command billions of dollars to influence the health care conversation through their marketing, public relations, and lobbying departments, expect the discussion not to question what they do, and how they benefit from the status quo to the financial and health detriment of patients and the population.

We will not be able to truly reform health care until we can speak openly about what threatens health care values and what needs to be done about these threats.

Michael Cisco – An army is a horror: a festival of unrealities, and entrancing body of hallucinations mutilated with surgical precision

Michael Cisco, The Narrator, Civil Coping Mechanisms, 2010.


“THE NARRATOR—the new novel by Michael Cisco, author of The Traitor and The Divinity Student—is also his most sophisticated. Cisco’s prose, by turns phantasmagorical and exhilarating (reminiscent one moment of Robbe-Grillet, the next of Artaud, with a tinge of Thomas Ligotti, the imaginative virtuosity of Gene Wolfe or M. John Harrison), is like a stark sequence of strong iron bars, brimming with dark ambiance. Combining unmatched craft with masterful storytelling, this is literate fantasy unlike any other, intricate as the most elaborate dream, in which the narrator himself is the most ambiguous thing of all.”

“If William Burroughs was helping Cormac McCarthy rewrite Blood Meridian as dark fantasy, it might look something like this. The Narrator is wonderfully grotesque and slippery book, a meditation on the nature of violence chock-full of palpable, haunting and shocking strangeness.” — Brian Evenson

“Cisco wields words in sweeping, sensual waves, skillfully evoking multiple layers of image and metaphor… a gem of literate dark fantasy, concisely illustrating the power, both light and dark, of words and meaning." —Publisher’s Weekly

“A festival of unrealities, and entrancing body of hallucinations mutilated with surgical precision by a masterful literary maniac.” —Thomas Ligotti

"Michael Cisco’s meticulously imagined new-goth dreamtime is a somberly menacing thing conjured by Borges channeling Kafka channeling Browning that teaches us again and again just how continent the universe really can be. Duck and cover." — Lance Olsen

“Few writers within the realm of nonrealist or "weird" fiction has more right to feel unjustly neglected than Michael Cisco, who over the course of several novels, including his critically acclaimed debut, The Divinity Student, has forged a singular path in creating visionary, phantasmagorical settings, uniquely alienated characters/anti-heroes, and genuinely creepy happenings. Cisco is, at this point, sui generis, and brings a healthy absurdism and dark sense of humor to his fiction as well. Following on his incendiary and utterly stunning The Traitor, Cisco now offers up The Narrator, a novel that would have made my top 10 of the year if I had encountered it soon enough. Unfortunately, as far as I can tell, the novel has only been reviewed in a handful of places to date.
In the novel, the narrator Low is conscripted as a Narrator (a recorder of events) into an army to fight against the "blackbirds," who possess lighter-than-air armor. But first, our hero must play a waiting game in a city of cannibal queens and uncanny dead things, with priests for both the living and the dead, and the strange remnants of a mighty imperial power that must be avoided at all costs. Once mobilized, Low sets off on a journey that is by turns absurd, surreal, deadly, and one of the great feats of the imagination thus far in this new century - and one that includes scenes and moments I've never experienced in any other work of fiction.”
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“In Michael Cisco’s The Narrator, the narrator Low is conscripted into an army to fight against the “blackbirds,” who possess lighter-than-air armor. But first, our hero must play a waiting game in a city of cannibal queens and uncanny dead things, with priests for both the living and the dead. The Edak, strange remnants of a mighty imperial power, must be avoided at all costs. Once mobilized, he sets off on a journey that is by turns absurd, surreal, deadly, and one of the great feats of the imagination thus far in this new century. The novel is possibly also the most neglected of the year. Michael Cisco, the Amerikan Kafka, deserves your attention.
1—As a Series of Brilliant Scenes, Paragraphs, and Sentences.
I’ve rarely come across so many instances where I was simultaneously in the moment of the novel but also recognizing that I was encountering images, snippets, set-pieces unlike any I’d ever read before. Sleepwalkers that bruise the surface of reality as they glide past, assailants who skim the surface of the water in armor that’s lighter than air, conjurings with unexpected consequences, refugees from an insane asylum who assemble as soldiers. “It’s as if a giant were pushing us along the road, blithering to itself.”
2— As the Nightmare Answer to a Question From a Film. Bonant looms like a cliff out of the water, “projecting suddenly above them, too high to see. It’s like a black egg with an opening in the front—it sweeps toward them, as oblivious to them as a passing god, but the men are suddenly quailing and dizzy. They vomit, collapse clutching their chests and abdomens. Blood drips from their skin, smears their teeth as the gums burst, and they die under the influence of that black ship’s mere proximity.” …And inside, the answer to the riddle of a giant skeleton in the captain’s chair in A—-, “naked with long heavy white limbs. His massive body sits, like a sack of grain, on a marble cenotaph… bleached muscle, wanly shadowed with a lace of veins and arteries.” There are connections that make no sense at all and yet by dint of the power of the imagination and the communicative property of art…make sense. (G + A + MC = absurd heresy)
3—As an Extended Treatise on the Negation of Meaning that Is War. “An army is a horror. It’s a horrible thing.” There are many battle sequences in The Narrator, and they all translate as action without meaning, sometimes so chaotic that even individual action is hard to discern within the movements. As near as is possible in text, Cisco conveys the jerky, roving, incomprehensible experience of men on foot shooting at each other across broken, often hilly ground. The individual meaninglessness of it and the group rationalization of it. (Group rationalization undercut by the lack of an Order from On High later in the novel, which would’ve driven the point home better.) The result is to come close to conveying the derangement required to wage war… while simultaneously demonstrating that the more a writer repeats battle scenes, the more the result becomes boredom and skipping of pages. That the more you invest in too many similar scenes, the more the meaninglessness recedes and the more purposelessness closes in on the reader, until what was pointed before seems like kids playing with rifles in the backyard. To retreat from purposelessness would mean to advance toward tighter editing. But where to cut?
4—As a Series of Experiments in Narration, Eel-Slippery. The narrator of The Narrator may not be the narrator of the entire novel. Where does his narration really begin and end? What to make of the asides between chapters? Of meeting another narrator, who in a sense begins to narrate the tale in a different way. What of the accounts of others, which the narrator narrates by adding notes like “an unhurried, slow inhalation” and “Her voice dropped there.” And “She caressed the air by her knees with stiff old hands, seeming to coax the guillotine blade out of the sparkling air so that I for a moment saw it.” Should we be worried? Should we care?
5—As the Most Surreal Science Fiction Novel Ever. A place that alters all who enter it. Flying things that seem intelligent. A cathedral like a science lab or…something else? The drone of a tower, that can kill. “Those aren’t people. Their guns aren’t guns.”
6—As the Tale of the Ride of the Valkyries, Through the Exploits of Saskia. “Here comes from somewhere behind the asylum, a woman all in armor. She has a short sword with a basket hilt on her right side and a flapped holster on her left hip… A pleasing, and weirdly familiar face. I could say she looks like da Vinci’s ‘Lady with Ermine’ if there had ever been such a thing. Strange thing to think.” If there’s a hero of The Narrator, it is this battle-tested woman who joins the narrator’s army and never falters in her bravery under fire. She’s a deliberate counterpoint to the senselessness of war—an entity with a tactical purpose who brings order by simple focus. “From the window I see Saskia herself darting across the water. The [soldiers] are shooting at her. She zig-zags with astounding speed and in the next moment is right alongside them. She whirls around toward the rear of the boat, gesticulating wildly, then suddenly hurtles back toward us in fantastic back-and-forth curves, her legs pumping.” Saskia is perhaps the only character who remains consistent from beginning to end, and in a sense she gains her own agency as narrator because of it.
7—As an Extended Dream From Which You Will Not Awaken. “In the distance, a white something bobs in the water asleep. It slobbers and mutters… Its slobberings wriggle through the water like black eels. In a vision no one present can see, the ocean turns to fluid mirror, like mirage, where it crashes over the white figure, the mirror froth rolls away across the surface of the water like mercury and Low’s outstretched hand draws the black saliva from the glistening antiseptic mouth of the sleeper to form elegant, calligraphic loops and ornate signatures of unreal sharpness on the reflecting surface. A down of phosphorescent ash spins from them as they move, forming glowing coils that sink into the black below the silver, whirring and snapping like whips. They seem to drag Low’s arm to and fro. Who is narrating this?”
Saskia. Makemin. Low. Nardac. Punkinflake. Thrushchurl. You’ll remember all of them. By the end, the book will be buried in your skull.” - Jeff VanderMeer

I feel as though I am going towards war, that towers vastly above around and behind its pawns, the enemy soldiers and us. War fashioned the interior. The war story is waiting to be lived again and to make all of us its own characters. We will step into our places while the overture plays a melody of themes that will play out in full and in order later on. It’s magic, because I do what I don’t want to do, and there’s no power that I can feel being brought to bear on me. If a hand had me by the collar, and I were being dragged away, I could struggle. If Makemin or Saskia would only point to me, order the others to catch or kill me, or even only threaten me, I could run. But there is no power here to resist. I simply go along. Hating, and rebelling at heart. Something like the sweeping power of the tides sets everything all too smoothly in motion. I feel war’s unreal presence, like blank mindless insanity shining happily from these rocks, watching us bring ourselves to it, for its delectation. We’re going to kill and die at war’s fiat in this beautiful place, nothing more.
What can I say about Michael Cisco that I have not said before? He remains one of our best and also one of our most underappreciated, and with his newest work, The Narrator, he once again proves how vital his work is. It reads like an ode to the absurdity of war, Low, a studying Narrator at school is drafted into the army despite the relevant excusatory paperwork in a episode of bureaucratic ineptitude worthy of a Kafka novel. Narrators seem to exist to maintain the narratives of people and events, and Low is often referred to as being the one who will tell the story of the war after it is all over. As a result, he has no skill in battle and instead is forced to act as a medic and a translator. He has no intention of serving, but having been “seen” by an Edek, a sort of supernatural blind woman who will know if he deserts, he has no choice but to join up and is unable to flee throughout the novel. He becomes a sort of living casualty of the war, dragged along in its wake while forced to watch his companies become infected by it and die, until he is the only one left.
The war in question seems, at least to this reader, to be completely pointless. The commanding officer, Makemin, seems to flit between an obsessive and overwhelming desire for victory and throwing himself into the proceedings of his divorce that is taking place far away back home. Saskia’s fury is fuelled by desire for revenge, but her recklessness often places her in almost suicidal situations, calling into question her sanity. His only real friend, the mortuary student he meets in the town of Trey, Jil Punkinflake, loses all sense of his mischievous former character, and by the end of the novel has almost become a kind of submissive animal. In fact, due to the low number of people who actually showed up, the group is forced to augment itself with lunatics from an abandoned asylum, making the whole situation only more absurd. All we are told about the war is that it is an attempt to weaken a competing power by destroying one of their allies, but no one seems to know what the war is really about. Those who care about the result like Makemin only seem to want victory for the sake of victory, unaware of what they will actually gain by it. Low, like the reader, seems equally confused by the whole thing and becomes increasingly more important to the war effort despite his best efforts to avoid getting involved. Despite this, he remains powerless and unable to change anything.
The novel evokes the same kind of dreamlike atmosphere of Cisco’s other work, some of the finest scenes seeming almost unreal, such as when the students go grave robbing and find all the corpses have burrowed out of their coffins and joined into a homogeneous mass. His work is so stunningly original, there is nothing else like it out there and this is only reinforced by The Narrator, with ideas like the cannibal queen, the flying anti-gravity bracelet wearing blackbirds, and the final scenes inside the inland’s interior. Branching out from his usual protagonist heavy focus to incorporate more of an ensemble cast also allows Cisco to do more with characterization than in his previous novels, and is very welcome because he creates such interesting characters. The spirit eaters from his previous novel, The Traitor, also make an appearance, alongside his equally unique new concepts. It also goes without saying that his stylization is first rate and his prose is some of best in the business.
The Narrator is a powerful book, but more importantly it is vital. It speaks to the reader about war in the way that the great anti-war novels do, like Céline’s Voyage au bout de la nuit, about both the horror and the absurdity of war. War is the antithesis of all human logic and the ultimate form of nihilism, it creates nothing. In its futility it is so absurd that it is almost comical, something that Celiné understood, and at times Cisco captures perfectly; war is pathetic. From the start Low knows that nothing good will come of the war and he is only proven right. It might be his best novel yet. My favourite novel of the year, if you only buy one book that I recommend for 2010, buy this one.” - Paul Charles Smith

“A man named Low is the narrator, and also The Narrator, of The Narrator. But it isn't quite that kind of twisty turny ho-ho I've got you now dumb reader! sort of book. Just as The Traitor was about the rise of the state, The Narrator is about how the state exists via ideo-linguistic concent. Narrators in Cisco's imaginary Europe--there's a da Vinci in this setting at least, along with magic and spirits--tell the stories the wealthy and powerful need everyone else to hear. Competition is pretty fierce actually, and our man Low is a polyglot of significant ability. He'd need to be as the world he navigates and narrates is awash in languages both written and spoken. Indeed, the wealthy often commission the creation of their own alphabets (not fonts, alphabets) from Narrators like Low.
And poor Low has been drafted, and his conscription has been cemented by the supernatural gaze of an Edek, a blind remnant of once-great imperial power. Low is not happy. "An army is a horror," is how he decides to start his story, "It's a horrible thing. They say you might change your mind about that when the country is invaded and your people are suffering wrong, but for me this is all just more horror, more army-horror." Not a sentiment one often hears today, but then again today the narrators of contemporary wars don't really concentrate on conflicts between the armed forces of countries that have a rough military parity, do they?
Low quickly falls in with a bunch of other people about as well-suited to engage in war as he is. There's Jil Punkinflake, a sort of priest of death and dying, who is actually jovial and fun, as his fantasy name suggests. In any other fantasy novel about war, he'd be the guy singing songs and falling headfirst into buckets for comic relief. There's also Makemin, the brave and resolute commander who definitely deserves a fragging. There's even a kick-butt fantasy heroine with a strong arm and a stronger will. Of course, she also spent a fair amount of time in the lunatic asylum, as one would.
Low's forces are hoping that the spirits in a far-flung corner of the land will support their operational goals over those of their enemies. The Narrator and the narrator and Our Narrator run up against the central question of history--what the hell is actually going on, and why are people even bothering to risk their lives doing things like securing a harbor? One is reminded of the only funny thing ever to come out of the mouth of a Maoist: when Zhou Enlai was asked about the historical impact of the French Revolution of 1789, he responded, "It's too early to tell." Well poor Low is right up against it, and as the guy in charge of telling the story of the war he's in for his side without the benefit of hindsight, or any stake in the outcome of the war, or even safety, he's come up a bit short.
There are many exciting battles and action scenes in The Narrator--the enemies are called blackbirds because they use lighter-than-air metal wristlets and anklets to fly for short distances. Low's squad is augmented by loonies from the mental hospital, and they're always fun, if unpredictable, in battle. Low is a medic and a translator, so spends a lot of his time observing the fight and then watching his friends die. Then he is given a magic charm that will allow him to lead his team more or less safely past the Lake of Broken Glass--a neverending windstorm of glass shards that swoops around every so often--and ruins proximity to which causes people to sicken and die (radiation?), to finally petition the gods for success. Too bad the whole point of having a narrator around is to have a story for posterity, so nobody really cares what Low thinks or says in the moment. There is even a traditional "meet the enemy and he is us" moment, when Low encounters the narrators from the other side of the war. They don't really know what the hell is going on either.
The Narrator is about the dual frustrations of the intellectual in an era of endless conflict--they're smart enough to know what's not going on ("They hate our freedoms!"), but can't get anybody to believe it. There's also no lone intellectual smart enough to know what actually is going on, despite the tendency to speak definitively on historical subjects. Quick, why did the Soviet Union fall? Really? Is that all? Is that the only reason? The only five, the only ten? And anyway, Low isn't half as smart as he'd like to be, or as his troops hoped he would be.
One might get the sense that Cisco is "subverting" fantasy tropes here, but of course these days apparently every fantasist in the world gets to make that claim if they do anything other than photocopy The Lord of the Rings and hand it in as their manuscript. But one might say that Cisco is a subverter along the lines of China Mieville rather than the my-elves-are-different crowd. So why is Cisco so obscure while Mieville is popular? Editorial pique, I suppose is most of it. The rest is probably a mix of personal charisma, Fortuna, and Cisco not whipping up enough monsters for the fanboys. Sad, that. If only Bruno Schulz had survived his war experience and launched a great fantasy trilogy, then Cisco would be richer than ten Bolivian Nazis! In another world, perhaps the world of The Narrator, this may have already happened.” - Millhouse van Houten

“The Narrator is an illumination of the power of story upon the history of men.
Michael Cisco is one of the best-kept secrets in fantasy and horror. His work is brilliant, evocative and unforgettable. Yet, he’s almost unknown outside of certain circles involving certain handshakes and certain badges and certain secret locations that may or may not include either Thomas Ligotti’s secret bunker on the Isle of Man, or the attic room of H. P. Lovecraft’s house in Providence.
Joining into this secret cabal is quite simple. Purchase one of the brilliant, mind-bending works of surrealist dark fantasy and read it. Do this again, if you have the courage for it.
Case in point: The Narrator, published in black ink upon white paper by Civil Coping Mechanism, an Independent Press, adumbrates and illuminates the power of story upon the history of men. The narrator is, literally, a Narrator, at a Narrator’s College, where he is training to be a Narrator. In this reality, reminiscent of China Mieville’s New Weird Crobuzon except older and far stranger, Narration is important in the flow of everyday life. Picking up the tone and color of everyday reality and reshaping it through the judicious application of Narration preserves the fabric of power structures that keep the world in control.
Unsurprising something happens to throw the whole arrangement akimbo: the Narrator is drafted to fight in a war. The war, being a semi-rational horror, and guided by semi-rational officers drafts, the narrator will now be a Narrator for the war.
What do Narrator’s do, exactly? Flashes and asides reveal the mangled ravings, journalings and dreamings of their work, wherein reality seems to be shaped and reshaped, but whether real comes before the imagery or the imagery before the real is open for discussion in the dense, rewarding text. Early in the novel, the Narrator searches for his assigned unit and further orders in a city that is alien to him, and us. Two religions exist simultaneously, one of life and one of death. The death religion takes center stage, while the Ekhets of the life religion seem to force death upon the world with their knowing gaze.
The novel is perhaps best understood by the cannibal queen. She lives in hiding, away from the crowds, in decadence. She sees the Narrator and invites him to her solitude to alleviate her sorrow with love. She had devoured her husband. At first, this pariah seems to be outcast. Not so; she is embraced by the death cult. She runs and hides not from shame, but from the reverence of the crowd, who would worship her. This early revelation adumbrates the horrors to come. What is an abomination on par with cannibalism more than warfare? It is celebrated by society like the cannibal queen’s horrific act.
I reveal too much. There are wonders to discover more than this. Unforgettable imagery illuminates the manuscript without a single illustration. The festival of the dead, like a grotesque chaos of the battlefields to come, foreshadows with wonder what will later appear in terror. Embalmers’ celebrate their death faith by sewing the dead limbs upon their own bodies, lips upon lips, limbs upon limbs and dance maudlin through the streets. War is at once archaic in it’s musket tactics, like something from a Russian novel, yet more so with the floating irons of the enemies, the mecha-like war machinery of the allies, and the gorgeous fabulism of the world the army crosses in their march of death and dismemberment.
War, destroyer of narrations, brutishly marches onward with a beauty of language that could also undermine the horror of the experiences present, to readers who seek the stark brutality of crime or war literature. But, this is dark fantasy — dark fabulism. If anything, the weakest section of the text — the battle scenes — are weakest not because they aren’t enjoyable, but because they are described too beautifully. The bodies of the dead enemy hovering over the ground with their flying irons, the dismembering brutality of the war machines, the ancient horrors and religious rites, the wounds of the dead and the screams of the dying — all described with a grace that risks alienation from the text. The horrors presented are not given room to be horrible, but are too strange to be truly and genuinely beautiful as a whole. To me and my enjoyment of the text, it creates the quintessential “Grotesque” experience, like staring into the nightmares of Heironomous Bosch while drinking too much absinthe with Jan Svankmeyer and Franz Kafka.
If anything I have said in my description moves you, do consider joining the cabal of afficianados. We are surprisingly few, but always growing, as we are — all of us — evangelists. Prepared to draft any we meet into the text.” - J.M. McDermott


An army is a horror. It's a horrible thing. They say you might change your mind about that when the country is invaded and your people are suffering wrong, but for me this is all just more horror, more army-horror.
It's through rags of fast-moving smoke that I first catch sight of Tref. I'm standing in the pass, to one side of the pumice road, looking down from my perch on the massed roots of some dusty old cork oaks. The city below me is like a shining, smoking lake, thrusting its troubled glints into my eyes and make them smart. Overhead, the sun is lost in a white sky without circumference, above the flashing waters of the city. (p. 5)
For the past ten years or so, Michael Cisco has been one of "those" authors, writers whose talents are recognized by those in the know, but who have never enjoyed a mass readership. His most recent novel, The Narrator, is perhaps simultaneously his most "accessible" (if such an execrable adjective might be employed here) and his most accomplished and sophisticated work to date. Cisco is a master stylist, who creates dark, twisted, imaginative vistas from the juxtaposition of adjectives. Take for instance the opening paragraphs quoted above. We learn that the narrator, whose name incidentally is Low, is narrating a war. However, we quickly move away from the clichéd "war is hell/horror" motif and into a setting that is strange, full of "fast-moving smoke," with a city being akin to a "shining, smoking lake" while the sky is white. Wherever this setting might be, we're no longer in Kansas, Toto.
Cisco's stories tend to be quite atmospheric, going beyond lush, descriptive landscapes. People too make up an environment and in one early scene, he foreshadows certain thematic (and plot) elements by his portrayal of two segregated and yet complementary religious orders:
A carefully ramified division of labor regulates the operation of the life and death priests. Life priests, urbane, serene, dressed in satiny white and cream gowns, preside at weddings, tend the sick and perform healings when they can; death priests, subdolous and mordant, dressed in shabby subfusc, officiate at funerals, conduct autopsies and embalm bodies, attend to the dying and insane, and cast our even imbibe possessing demons. Life priests are permitted and encouraged to marry; death priests, while not enjoined to celibacy, are forbidden to marry or to bear children... There is no enmity between these two groups of priests, although they are compelled to avoid each other as a rule in order to maintain a pure distinction. When they do meet, a complicated protocol governs the exchange of formalities. In fact, since no one is ever born in the death precincts, all death priests are delivered into this life by life priests of the previous generation. Naturally, all life priests are ushered into whatever dream comes after by the generation of death priests who will bury them in the death district. (pp. 13-14)
In his previous works, Cisco tended to rely more on elements such as this to create the "weirdness" that served as a thematic staple in his stories. Here in The Narrator, at 307 pages his longest work to date, he goes further. Through the character of the Narrator Low, he explores not just the weirdness of the locale and the strangeness (and hell) of war, but the very semantics that underlie our conceptualizations of the world and the medium of language used to express it. Several authors utilize the "unreliable narrator" trope to underscore the hidden undercurrents of the narrative, but Cisco is one of the few authors I have encountered who have attempted to undermine the very narrative structure itself through the creation of a character whose purpose is to tell and retell events until the events are forgotten and what is left becomes Story.
As someone whose original field of study was cultural history, I quickly became intrigued by Cisco's plumbing of the semantic depths that bind together the two main strands of historia, History and Story alike. At first, the war Story took some getting used to; frequently, events felt disjointed and out of sequence. Then a little over halfway into the novel, things become crystallized in an encounter between Low and another narrator:
Makemin is a good narrator. He has his own story, a revenge story, and its power has revived in the men the will to fight. He will get his way. They will fight. They believe him. I failed. I failed as a narrator, because I didn't tell them that I had had to get my pack from where it fell and was tangled in the bracken by the path, and that Makemin was wrong to believe himself alone in the moments after he struck me. (p. 195)
From this point, The Narrator begins to come into its own as a narrative about narratives and the weird interstices that underlie memory, communication, and the symbols embedded in the actions of which we partake and the words we speak. What becomes apparent by the novel's end is not the paramount value of "Truth," but that "truths" can emerge that have little in common with the events that engendered them. I hesitate to say this is the "point" of the story, as I believe Cisco is exploring (and deconstructing) several other points in addition to this one, but certainly this is a key element that I took from The Narrator.
The Narrator is Cisco's most engaging work, as the reader has the trappings of a war/army narrative to grasp as an entry portal. Prior knowledge of his earlier writings is not necessary, although there are a few glimpses here and there that hint at some deeper connection with his earlier tales, although these never intrude upon the narrative core. As stated above, Cisco's descriptive, evocative prose signals the alienation felt by the characters and it is this sense of estrangement that makes this novel a captivating read even for those readers who are not fain to read such narratives. Highly recommended.” - Larry Nolen

“A few years ago I talked about The Traitor by Michael Cisco and some of you even ran out to buy that wonderful short novel. Well, I'm back to tell you about Cisco's follow-up The Narrator, in the hope of getting the same result.
A man named Low is the narrator, and also The Narrator, of The Narrator. But it isn't quite that kind of twisty turny ho-ho I've got you now dumb reader! sort of book. Just as The Traitor was about the rise of the state, The Narrator is about how the state exists via ideo-linguistic concent. Narrators in Cisco's imaginary Europe—there's a da Vinci in this setting at least, along with magic and spirits—tell the stories the wealthy and powerful need everyone else to hear. Competition is pretty fierce actually, and our man Low is a polyglot of significant ability. He'd need to be as the world he navigates and narrates is awash in languages both written and spoken. Indeed, the wealthy often commission the creation of their own alphabets (not fonts, alphabets) from Narrators like Low.
And poor Low has been drafted, and his conscription has been cemented by the supernatural gaze of an Edek, a blind remnant of once-great imperial power. Low is not happy. "An army is a horror," is how he decides to start his story, "It's a horrible thing. They say you might change your mind about that when the country is invaded and your people are suffering wrong, but for me this is all just more horror, more army-horror." Not a sentiment one often hears today, but then again today the narrators of contemporary wars don't really concentrate on conflicts between the armed forces of countries that have a rough military parity, do they?
Low quickly falls in with a bunch of other people about as well-suited to engage in war as he is. There's Jil Punkinflake, a sort of priest of death and dying, who is actually jovial and fun, as his fantasy name suggests. In any other fantasy novel about war, he'd be the guy singing songs and falling headfirst into buckets for comic relief. There's also Makemin, the brave and resolute commander who definitely deserves a fragging. There's even a kick-butt fantasy heroine with a strong arm and a stronger will. Of course, she also spent a fair amount of time in the lunatic asylum, as one would.
Low's forces are hoping that the spirits in a far-flung corner of the land will support their operational goals over those of their enemies. The Narrator and the narrator and Our Narrator run up against the central question of history—what the hell is actually going on, and why are people even bothering to risk their lives doing things like securing a harbor? One is reminded of the only funny thing ever to come out of the mouth of a Maoist: when Zhou Enlai was asked about the historical impact of the French Revolution of 1789, he responded, "It's too early to tell." Well poor Low is right up against it, and as the guy in charge of telling the story of the war he's in for his side without the benefit of hindsight, or any stake in the outcome of the war, or even safety, he's come up a bit short.
There are many exciting battles and action scenes in The Narrator—the enemies are called blackbirds because they use lighter-than-air metal wristlets and anklets to fly for short distances. Low's squad is augmented by loonies from the mental hospital, and they're always fun, if unpredictable, in battle. Low is a medic and a translator, so spends a lot of his time observing the fight and then watching his friends die. Then he is given a magic charm that will allow him to lead his team more or less safely past the Lake of Broken Glass—a neverending windstorm of glass shards that swoops around every so often—and ruins proximity to which causes people to sicken and die (radiation?), to finally petition the gods for success. Too bad the whole point of having a narrator around is to have a story for posterity, so nobody really cares what Low thinks or says in the moment. There is even a traditional "meet the enemy and he is us" moment, when Low encounters the narrators from the other side of the war. They don't really know what the hell is going on either.
The Narrator is about the dual frustrations of the intellectual in an era of endless conflict—they're smart enough to know what's not going on ("They hate our freedoms!"), but can't get anybody to believe it. There's also no lone intellectual smart enough to know what actually is going on, despite the tendency to speak definitively on historical subjects. Quick, why did the Soviet Union fall? Really? Is that all? Is that the only reason? The only five, the only ten? And anyway, Low isn't half as smart as he'd like to be, or as his troops hoped he would be.
One might get the sense that Cisco is "subverting" fantasy tropes here, but of course these days apparently every fantasist in the world gets to make that claim if they do anything other than photocopy The Lord of the Rings and hand it in as their manuscript. But one might say that Cisco is a subverter along the lines of China Mieville rather than the my-elves-are-different crowd. So why is Cisco so obscure while Mieville is popular? Editorial pique, I suppose is most of it. The rest is probably a mix of personal charisma, Fortuna, and Cisco not whipping up enough monsters for the fanboys. Sad, that. If only Bruno Schulz had survived his war experience and launched a great fantasy trilogy, then Cisco would be richer than ten Bolivian Nazis! In another world, perhaps the world of The Narrator, this may have already happened.” - Nick Mamatas

“Michael Cisco, whose book The Traitor I reviewed here, has another book out! I'm reading it -- slowly, as the time mid-semester is precious and split between editing and everything else I want to do, but I just have to talk about The Narrator.
Short version: please go and buy it. Cisco is one of those writers (lamentably few) who write genuinely unusual things. It's a shame he's not more widely read (although I suspect that many of the folks who insist they want new and unusual really don't), and something that needs to be fixed. So read the book, you won't regret it.
It's a little less aggressively strange than The Traitor, but it drips with the same vivid and visual malaise -- white skies, sick trees, vividly drawn snatches of the landscape otherwise drowned in radiance or fog. The language is half-delirious, and the beginning of the book evokes both Notes From Underground and Felix Krull. Low, the protagonist and a student in the college that prepares Narrators (people who recite events until only words encountering them remain, replacing the actual memory of the event), is not supposed to be drafted -- but he is, due to bureaucratic indifference and incompetence of the college administrators. His panicked efforts to avoid draft reminded me of the desperation with which my high school classmates applied to colleges -- the student status granted the draft deferral, and those who were not lucky enough to get in often faked a variety of psychiatric ailments. Low's efforts brought forth this visceral memory in me, all those boys who didn't want to go to the army because they knew it will forever change them; possibly into people they wouldn't like.
Another piercing recognition came when Low describes the separation of priesthood into white and black -- an Orthodox Christian tradition, where only black priesthood (monks) are allowed to rise to the top of the hierarchy, while the white priesthood (parish priests) are usually married and childed. Cisco takes this separation to the next logical extreme, and Life and Death churches are born, even though the similarity with Orthodox Christianity are quite clear.
Then there's the war itself -- Low as the narrator is supposed to document the story, but he has as much trouble as anyone else guessing the point of it all. The looming unease and the whispered uncertainty of it again reminded me of fear of my classmates of being sent to Afghanistan -- that hushed and unknown conflict fought for no discernible reason. It is always tempting to load the story with perceived meanings of the moment and attribute them to writerly intent -- and frankly, many writers aren't clever enough to hide their intent. Not so in this case, where the intent becomes irrelevant since instead we can have meaning.
And this is really something I love about Cisco's writing -- in all the strangeness, there are always these moments of acute, almost painful recognition and identification. I don't know if yours will be the same as mine, but I'm sure you'll find a few there -- be those in the dreamlike wanderings across strange cities and battles, in the unusual crew Low joins, in the palpable terror of the mysterious Edeks. Cisco writes like no one else, and this book is unlike any other, although filled with echoes of things one remembers and Cisco somehow knows.” - Ekaterina Sedia


Cisco’s blog

A Jury Finds Johnson and Johnson's Risperdal Marketing "Willfully Deceptive," but What Will It Take to Change Company Leadership?

For Johnson and Johnson, it's deja vu all over again, as reported by the Spartansburg (SC) Herald Journal:
A Spartanburg jury decided that Johnson & Johnson and a subsidiary violated South Carolina's Unfair Trade Practices Act, but the company will wait until damages are determined next month before it decides whether to appeal the jury's decision.

Also,
The jury decided Tuesday the company willfully violated the act by sending a 2003 letter to doctors that attorneys for the state said sought to minimize the risk of hyperglycemia — or high blood sugar — and diabetes reported by patients using Risperdal.

The letter was sent to about 700,000 doctors nationwide — 7,200 of those in South Carolina.

The jury decided that warning labeling included with the drug was also willfully deceptive.

This is not the first such lawsuit involving Risperdal,
South Carolina's lawsuit was the fourth state lawsuit to go to trial.

In West Virginia, claims involving Risperdal were dismissed with prejudice last December following the company's appeal.

In October, a jury in Louisiana awarded almost $258 million in civil penalties to the state. Janssen will appeal that decision.

In a jury trial in Pennsylvania in June, a judge dismissed the state's case against Janssen.

Note that we posted about the Louisiana verdict here.

The hits, they just keep on coming for Johnson and Johnson, which has been recalling a dizzying array of products due to manufacturing problems.  A new recall was just announced today, and there have been 20 separate recalls since mid-2009.

Just eight days ago we contrasted the opulent compensation given the Johnson and Johnson CEO in 2010 (about $29 million) with the company's poor financial performance, seeming inability to make pure, unadulterated, safe products as manifested by multiple recalls, and ethical problems as indicated by legal settlements and guilty pleas. Today we have added another recall, and a jury verdict against the company finding its marketing was deceptive.  So the cognitive dissonance evoked by comparison of executive pay and corporate dysfunction continues. 

Is there any degree of organizational dysfunction that could possibly induce a health care corporate CEO to feel shame for continuing to extract millions from the flailing beast?  Is there any degree of disconnection between executive compensation and corporate performance that could possibly induce complacent corporate boards to feel shame for enriching the hired executives who presided over the mess?

Probably not.  The events surrounding the global financial collapse suggested that somehow expecting corporations to regulate themselves was at best foolishly naive (e.g., see here).  Presumably former US Federal Reserve Chair Allan Greenspan really thought that markets could regulate themselves, and that fraud could not exist because markets in his idealized view would punish it themselves,
he didn't believe that fraud was something that needed to be enforced or was something that regulators should worry about....

But then he later admitted: 
Those of us who have looked to the self-interest of lending institutions to protect shareholder's equity – myself especially – are in a state of shocked disbelief
We do not yet seem to be at the point that will we generate enough "shocked disbelief" about the misbehavior of current health care organizations to realize that they will not police themselves, and a true health care reform movement will have to figure out how to reasonably regulate them.  (I submit that perusing the archives of Health Care Renewal will suggest that we should have been at that point years ago.)

If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

Despite Poor Financial Results, Diminishing Pipeline, Multiple Settlements of Legal Cases, Outgoing Pfizer CEO Got Over $24 Million

It is the season for share-holders' meetings of big US publicly held corporations, and as the proxy statements prepared for these meetings, prepare for more eye-popping, jaw-dropping examples of executive compensation. 

Pfizer's 2010 CEO Compensation
The AP (via the Wall Street Journal) just noted the compensation given to Jeffrey Kindler, the outgoing (in 2010) CEO of Pfizer, Inc, the world's largest pharmaceutical company:

Former Pfizer Inc. Chairman and CEO Jeffrey B. Kindler may have left the world's largest drugmaker abruptly last December, but he didn't leave empty-handed thanks to a compensation package valued almost $22 million.

Kindler received a 60 percent increase last year over his 2009 compensation, according to an Associated Press analysis of a Pfizer regulatory filing Tuesday.

The New York-based drugmaker gave Kindler a salary and performance-related bonus totaling $4.9 million, a $4.5 million severance payment and more than $12 million in stock and option awards. The company also will continue his health coverage for 12 months 'at active employee rates,' the filing said.

In fact, perusal of the new 2011 Pfizer proxy statement shows that Kindler, who stepped down on 5 December, 2010, made even more based on Pfizer's own calculations, $24,688, 849. Curiously, Ian Read, the CEO after 5 December, and previously Group President, Worldwide Pharmaceutical Business, received $17,396,112, despite only being CEO for 26 days.

Pay for What Kind of Performance?

These opulent pay packages stand in contrast to Pfizer's performance under Kindler and its financial results in 2010:
Kindler was ousted by Pfizer's board unexpectedly Dec. 6 after four years of languishing share prices and several failures of promising drugs in late testing, including a successor to cholesterol fighter Lipitor, the world's top-selling drug. Pfizer will lose U.S. patent protection in November for Lipitor.

Also,
Pfizer's 2010 net income fell 4 percent to $8.26 billion, or $1.02 per share. Revenue totaled $67.81 billion, up 36 percent, thanks to $18.1 billion from sales of Wyeth products.

Its stock price slipped 4 percent to close 2010 at $17.31, while the Standard & Poor's 500 index climbed 12.8 percent.

Furthermore, the compensation given the former and current CEO also stood in sharp contrast to Pfizer's amazing track record of recent unethical behavior.   Pfizer paid a $2.3 billion settlement in 2009 of civil and criminal allegations and a Pfizer subsidiary entered a guilty plea to charges it violated federal law regarding its marketing of Bextra (see post here).  Pfizer was involved in three other major cases from then to early 2010, including two involving settlements of fraud charges, and one in which a jury found the company guilty of violating the RICO (racketeer-influenced corrupt organization) statute (see post here).  The company was listed as one of the pharmaceutical "big four" companies in terms of defrauding the government (see post here).  Pfizer's Pharmacia subsidiary settled allegations that it inflated drugs costs paid by New York in early 2011 (see post here).   Just yesterday a settlement was announced in a long-running class action case which involved allegations that another Pfizer subsidiary had exposed many people to asbestos (see this story in Bloomberg).

Despite Pfizer's recent dismal financial performance, clotted drug pipeline, and unfortunate ethical/ legal track record, the company's board compensation committee reported thus:
The Committee believes that Pfizer’s executive compensation program implements and achieves the goals of our executive compensation philosophy. Pfizer’s executive compensation philosophy, which is set by the Committee, is to align each executive’s compensation with Pfizer’s short-term and long-term performance and to provide the compensation and incentives needed to attract, motivate and retain key executives who are crucial to Pfizer’s long-term success.
Who Provided "Stewardship" of Pfizer?
So I had to ask: who were these people who thought that compensation of over $24 million was somehow "aligned" with declining profits, declining revenues, little output of new drugs, and multiple legal settlements of charges like fraud and violating the RICO act?

Here is a list of Pfizer's board of directors in 2010, and some relevant affiliations, taken from Pfizer's web-site, and where indicated, elsewhere (color coding to be explained below)

- Dennis A. Ausiello, M.D. -
Jackson Professor of Clinical Medicine at Harvard Medical School and Chief of Medicine at Massachusetts General Hospital since 1996.
Member of the Institute of Medicine....
Director of TARIS BioMedical, Inc.
(per Research!America bio) advisor to drug delivery and biosensing start-up companies Entra, BIND Biosciences, and Seventh Sense Biosystems, Inc., to drug-discovery startup companies Promedior and Pulmatrix, to Proventys, an evidence-based medicine delivery system, and to Ore Pharmaceuticals and Polaris, investment and venture capital companies working in the biotech and device area.

- Michael S. Brown, M.D. -
Distinguished Chair in Biomedical Sciences since 1989 and Regental Professor since 1985 at the University of Texas Southwestern Medical Center at Dallas.
Member of ... the Institute of Medicine,....
Director of Regeneron Pharmaceuticals, Inc.

- M. Anthony Burns -
Chairman Emeritus since 2002, Chairman of the Board from 1985 to 2002, Chief Executive Officer from 1983 to 2000, and President from 1979 to 1999 of Ryder System, Inc., a provider of transportation and logistics services.
Life Trustee of the University of Miami.

- Robert N. Burt -
Retired Chairman and Chief Executive Officer of FMC Corporation, a chemicals manufacturer, and FMC Technologies Inc., a machinery manufacturer....
Life Trustee of the Rehabilitation Institute of Chicago

- W. Don Cornwell -
Chairman of the Board and Chief Executive Officer of Granite Broadcasting Corporation from 1988 until his retirement in August 2009 and Vice Chairman until December 2009.
(per Wallace Foundation web-site) He previously served as vice president, investment banking division, of Goldman Sachs.

- Frances D. Fergusson, Ph.D. -
President Emeritus of Vassar College since 2006 and President from 1986 to 2006. Served on the Mayo Clinic Board for 14 years, the last four years as its Chairman, and as President of the Board of Overseers of Harvard University from 2007 through 2008.

- William H. Gray III -
Co-Chairman of GrayLoeffler, LLC (formerly the Amani Group), a business advisory and consulting firm. Chairman of the Amani Group from 2004 through September 2009.
Currently Director of ... J. P. Morgan Chase & Co.

- Constance J. Horner -
Guest Scholar from 1993 until 2005 at The Brookings Institution....

- James M. Kilts -
Founding Partner, Centerview Partners Management, LLC, a private equity firm, since 2006.
(Per Centerview Partners web-site) Centerview Partners' investment banking advisory business serves some of the largest companies globally in a broad range of industries, with particular expertise in Food & Consumer Products, Financial Institutions, General Industrials, Healthcare, Media & Entertainment ....
The firm has executed many significant transactions in recent years, including:
Altria's $113 billion spin-off of Philip Morris International, its $62 billion spin-off of Kraft and its $11.7 billion acquisition of UST...
Facet Biotech's $722 million sale to Abbott Labs;
OSI Pharmaceuticals' $4.0 billion sale to Astellas Pharma;

- George A. Lorch -
Chairman Emeritus of Armstrong Holdings, Inc., a global manufacturer of flooring and ceiling materials,....

- John P. Mascotte -
Retired President and Chief Executive Officer of Blue Cross and Blue Shield of Kansas City, Inc.,...

- Suzanne Nora Johnson -
Retired Vice Chairman, Goldman Sachs Group, Inc.,...
Director of American International Group, Inc., .... Board member of the American Red Cross, The Brookings Institution, ... and the University of Southern California.
(per Milken Institute web-site) on the board of numerous not-for-profit organizations, including ... RAND Health ....
She is on the Advisory Board of Councilors of Harvard Medical School

- Ian C. Read -
President and Chief Executive Officer since December 2010.

- Stephen W. Sanger -
Chairman of General Mills, Inc.
Currently Director of ... Wells Fargo & Company.

- William C. Steere, Jr. -
Chairman Emeritus of Pfizer Inc. since 2001.
Currently Director of Health Management Associates, Inc.
Director of the New York University Medical Center ...; and Member of the Board of Overseers of Memorial Sloan-Kettering Cancer Center.

Of Pfizer's 14 directors (excluding its CEO), seven have or had leadership positions at teaching hospitals, academic medical centers, medical schools or their parent universities. Three have or had leadership positions at other influential non-profit health care organizations. 


Two had leadership positions at potentially competing pharmaceutical or biotechnology companies.

Two had leadership positions at companies that finance pharmaceutical, biotechnology and other health related companies.

One had a leadership position at a health insurance company.

One had a leadership position at a for-profit hospital operating company.

Four had leadership positions in financial services corporations, including some that were implicated in the global financial collapse, and/or required massive federal bail-outs to avoid collapse.

It seems that every time we look at the boards of directors or trustees who are supposed to provide stewardship to a troubled health care organization, we see a similar pattern.  Just as we recently said about the Johnson and Johnson board, ....
 
Summary
 
So here we have the latest striking case that indicates the confluence of forces that can lead to health care dysfunction. Not only has the compensation given to health care leaders got so large that it is per se a cause of increased health spending, but also, and more importantly, such compensation often provides perverse incentives that perpetuate mismanagement, raising costs and lowering quality. This situation appears to be enabled by governance (or "stewardship") by individuals who are often fellow members of the CEOs' club, and hence who may feel more sympathy with the executives they are supposed to supervise than the stockholders whose financial interests they are supposed to protect, or the public whom the companies' products and services are supposed to benefit. Moreover, these individuals often have conflicts of interest which may mitigate against objective scrutiny of the executives they are supposed to oversee. Finally, these individuals often may come from corporate cultures which do not espouse the values that we in health care are supposed to uphold. (See this post and its links for other examples of the sorts of people who are supposed to provide stewardship to health care organizations.)


So to repeat once more-

I strongly believe that there needs to be much more investigation, academic, journalistic, and perhaps legal, of the identity, nature, and culture of the leaders of health care, and their relationships. A few bloggers cannot do it all. Obviously, the anechoic effect mitigates against medical and health care academics looking into their own leaders. However, failing to understand who is leading our march to the brink of health care failure ought not to be something such academics would want on their conscience.

Finally, and obviously, health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research.

If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

ADDENDUM (23 March, 2011) - See also comments by Merrill Goozner on the GoozNews blog.

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