In the past two days, we’ve outlined a number of concerns about news organizations, professional journalism organizations and academic institutions that are involved in health care journalism reporting or training while accepting sponsorship or funding from health care industry entities that are often subjects of what the journalists or trainees do or will write about. (Part one of series. Part two.) These practices may be good for corporate, organizational or academic institution coffers, but the sponsorship comes at a price – of potential damage to journalism’s integrity and to the public trust in journalism, news reports and news organizations.
We have touched on examples of our concerns involving:
Ben Bagdikian, journalist/educator/media critic, wrote to and about journalists:
“Never forget that your obligation is to the people. It is not, at heart, to those who pay you, or to your editor, or to your sources, or to your friends, or to the advancement of your career. It is to the public.”
In this final part of our three-part series, I talk about some of these issues in more depth, and from the perspective of my growing concerns over a 44-year career in health care journalism.
Perhaps few journalism organizations have tried harder to minimize conflicts of interest than the Association of Health Care Journalists (AHCJ), the leading professional organization for journalists who report on health care.
The two of us know AHCJ well, having been members almost since its launch 20 years ago. We’ve both served on AHCJ’s board, attended most of its 18 annual conferences, and served on many panels as speakers or moderators over the years. Gary wrote the AHCJ’s Statement of Principles, which was adopted by the Board in 2004.
AHCJ states that its educational arm, the Center for Excellence in Health Care Journalism, won’t take money from pharmaceutical companies, device makers, insurers or even most advocacy groups such as the American Cancer Society. That strict standard distinguishes AHCJ from some other journalism training organizations, which have no qualms about accepting money from companies that journalists routinely report on.
In fact, when AHCJ agreed to collaborate with the World Conference of Science Journalists (WCSJ), which meets in San Francisco this fall, it raised its own money for a health care track “because the broader funding of the conference includes funders that we would not take money from,” AHCJ Executive Director Len Bruzzese told us. As noted in part one of this series, WCSJ accepted $400,000 in support from drug company Johnson & Johnson and another $50,000 from drug company Bayer. Each of the funders that AHCJ lists for its track at WCSJ is a philanthropic foundation. Bruzzese added: “There is easier money out there if you’re willing to take it from other organizations that may want to have more influence than we believe they should have on journalists.”
Ben Harder, a journalist with US News & World Report, recently tweeted, “Pharma ads subsidize many health reporters’ salaries.”
Elisabeth Rosenthal, who now heads Kaiser Health News after a long career with the New York Times, tweeted in that same discussion, “Many of my articles in the NYT carried pop-up ads for pharma. Infuriating.”
Many journalists are aware of the drug industry’s attempts to gain positive attention by buying placement within the nation’s health care news. A few occasionally write or talk about it, as Harder and Rosenthal did publicly.
But I don’t think we talk often enough about why it matters if health care industry entities are allowed to advertise within, or sponsor, health care journalism content. Americans spend more than $3 trillion on health care. Conflicts of interest in health care and research are rampant. The Journal of the American Medical Association (JAMA) last month published a special edition all about health care conflicts of interest. JAMA included a Viewpoint article entitled, “Conflict of Interest: Why Does it Matter?” The first line: “Preservation of trust is the essential purpose of policies about conflict of interest.”
But who talks about conflicts of interest in health care journalism? In a Gallup poll, “Honesty/Ethics in Professions,” respondents rated journalists’ honesty and ethical standards below psychiatrists, chiropractors and bankers….and just above lawyers.
There is great potential harm in a further erosion of trust in journalism and in health care. There is a great potential harm in journalists – and the audience they serve – becoming numb to the presence of and influence of drug companies and other industry entities in the news and information disseminated to the public. There is, as we have begun to point out repeatedly in our review of news stories and PR news releases, advertising and marketing messages, often a polluted stream of contaminated information reaching the public. Often vested interests pollute that stream. (We will discuss these potential harms in more detail in part 3 of this series.)
That’s why I think that this issue demands and deserves a deeper dive. Why now? Because, as outlined in this series, there are a growing number of questionable alliances between a growing number of news organizations and health care industry sponsors. Money is exchanging hands and I ask “Why? Why do news organizations enter into these arrangements? Why do they feel they need to? Have they exhausted all other options?” I want to shine a light on a collection of news organization practices. I’m raising the same types of questions that journalists often raise as they report on various issues. But I’m asking them because I don’t see enough journalists talking about it when their own organizations accept industry money.
In a Journal of the American Medical Association Viewpoint article, a pair of behavioral economists contend that doctors should be paid by salary, rather than the fee-for-service arrangements under which most of them now operate.
While most conflict of interest research and debate in medicine tends to focus on physicians interacting with pharmaceutical and device companies, how doctors are paid is one important source of conflict that’s largely ignored in medical literature, they said.
Fee-for-service compensation arrangements, they propose, create incentives for physicians to order more, and different, services than are best for patients.
“Paying doctors to do more leads to over-provision of tests and procedures, which cause harms that go beyond the monetary and time costs of getting them,” said George Loewenstein, the Herbert A. Simon University professor of economics and psychology at Carnegie Mellon University, in a statement. “Many if not most tests and procedures cause pain and discomfort, especially when they go wrong.”
He and Ian Larkin, an assistant professor of strategy at UCLA’s Anderson School of Management, said that a commonly proposed solution to the problem involves requiring physicians to disclose their financial interest for a given procedure. But disclosure of conflicts has been found to have limited, or even negative, effects on patients.
Loewenstein and Larkin argue that the simplest and most effective way to deal with conflicts caused by fee-for-service arrangements is to pay physicians on a straight salary basis. Several health systems well-known for high quality of care, such as the Mayo Clinic, the Cleveland Clinic and the Kaiser group in California, pay physicians salaries without incentives for volume of services performed.
Moving more physicians to straight salary-based compensation might have benefits not only for patients, but also for physicians themselves, they said.
“The high levels of job dissatisfaction reported by many physicians may result, in part, from the need to navigate the complexities of the fee-for-service arrangements,” said Larkin. “Instead of focusing on providing patients with the best possible medical care, physicians are forced to consider the ramifications of their decisions for their own paychecks.”
Political biases aside, the transition process for the new administration—both as to President Donald Trump and his Cabinet nominees and White House advisers—does a great service for nonprofit health systems by highlighting critical conflict-of-interest concerns. The last several weeks’ headlines provide health system general counsel with a rare opportunity to offer practical board education based on current events.
The president’s personal asset divestiture plan, announced on Jan. 11, along with the broader public scrutiny of key administration members’ business interests, present an important teaching moment on identifying, resolving and managing conflict-of-interest issues. And that’s a subject on which many health system boards could use continuing guidance, given the strictures of the duty of loyalty.
Neither the particulars of the administration’s potential conflict issues nor the details or adequacy of the president’s divestiture plan needs to be addressed here. Instead, the issues themselves provide something of a checklist that can help health system boards ensure their internal conflict-of-interest policies and processes are as fulsome as possible. Strong conflict-of-interest inquiries are critical to protect the reputation of the organization and its board members, and to sustain key business arrangements.
It is important to note that the rapid growth of health systems, the equally rapid diversification of their businesses and investment portfolios, and the expanding diversity of board members’ backgrounds in board membership significantly complicate the conflict-of-interest review process.
The “Trump Transition” conflicts checklist logically could include the following:
The landscape that encompasses the totality of the president’s family business interests and those of his Cabinet appointees—and their relationship to the ethics of government—is many layered. It nevertheless offers certain valuable analogies for the health system board—for which the duty of loyalty is sacrosanct. It isn’t all that great a leap to go from Trump’s transition issues to the conflict-of-interest policies of a nonprofit health system board. And it should be noted that the breadth of scrutiny of transition-related conflicts of interest likely hasn’t gone unnoticed by health-care industry regulators, including but not limited to state charity officials. Regulators may be far more likely than before to apply greater sensitivity to issues and relationships that may present conflict issues and their broader legal implications.
JAMA Internal Medicine series highlights pervasiveness of problems