I wrote my mini paper on the ethical challenges of the pharmaceutical industry—specifically, the issue of gifting physicians with lunches, dinners and office supplies. I used to be a drug rep so I can speak on this with some authority.

I came into the industry in 2008, so I never saw the extravagant gifts like vacation packages and tickets to Orlando Magic games. My company had done away with that in the mid-2000s due to a great deal of pressure (and scrutiny) from the general public.

I did, however, bring doctors and their staff lunches, take them out to dinners and supply them with pens, notepads, medical instruments and other drug paraphernalia. I remember the looks on the patients’ faces when I would walk into a packed waiting room bringing bags of piping hot food from Macaroni Grill. The looks I got were not very nice.

In 2009, the pHRMA organization, a pharmaceutical advocacy group, announced that they were changing their code of ethics in terms of what was appropriate in rep interactions with doctors. As a result of their updated code, several companies (including mine) got rid of the notepads, pens and many of the other office supplies that we were giving doctors. We were only allowed to give educational material (like a poster on the common causes of asthma) and lunches and dinners had a spending threshold where before it was pretty much unlimited.

Pretty much all of the big companies agreed to the new code of ethics even though it was voluntary.  I assume that Pfizer didn’t want to look bad if GlaxoSmithKline was going along with the changes. So the heavy hitters all jumped in.

Even though my company made changes in how reps interact with physicians, I don’t feel like it really helped that much. Perhaps it helped in a very small way with public perception of pharma (and that’s why I think that they all did it—for the publicity) but it did very little to influence the culture of the organization.

When a company is built on deceit and dishonesty, twisting the truth when it benefits them and encouraging employees to “tell the best story” when selling their products it will not turn into a morally upright company simply because the leaders have decided to stop giving notepads to doctors. Despite the change of several big pharmaceutical companies to adopt the practices of the pHRMA code, there is absolutely no shortage of drug industry scandals, off label promotions and FDA sanctions for misconduct.

The pharma industry was one of the most corrupt and backward industries I have ever worked for. However, I do consider it an extremely valuable experience in terms of my development as a leader and as an individual and I would never take it back. I gained clarity in what I stand for and believe in and I learned that company culture is extremely important. Leaders have to BE what they want to see in people instead of offering lip service and industry buzzwords to create the “feeling” (not a reality) of being an outstanding company.

I truly believe that good ethics in a company starts with great leaders, which is why I’m really glad that I’m taking this course and learning how to develop myself in this area.

My husband and I often watch TedTalks on our Apple TV. About a month ago, they had a very interesting speaker by the name of Atul Gawande. He is an author and surgeon and his talk was about the many issues that plague the medical community, particularly the occurrences of incomplete and inadequate care. He discusses the attitudes amongst the physician community and how certain ideals of perfection can impact behaviors.

I thought that his talk echoed some of the same concepts discussed in the medical errors chapter (pp. 160- 161) of Managing Ethically. In this chapter Dr. Morreim discusses the legal and ethical imperatives in dealing with medical errors. He notes that the healthcare culture views doctors as error-proof gods and this is similar to Gawande’s perspective in the TedTalk. Gawande also acknowledges that the physician community places in emphasis on being a “cowboy”—kind of like the “answering to no one” mentality—and how this attitude belittles the importance of rules and structure.

What I find to be very interesting is how this attitude can prevent physicians and medical staff in general from taking the ethical high road in situations. If doctors are held up to a standard of perfection, I would think that they would be much more likely to hide their errors or downplay them so that they save face in front of their superiors and colleagues. This is damaging not only to the patient who may be harmed as a result, but it also does not allow for the improvement in systems due to fear of judgment or repercussions.  

Perhaps these attitudes are the reason why public records of physician errors are so controversial. In a culture where perfection is the standard, any doctor would be fearful of losing patients because of this information going public.

I think that there are several ways to help deal with this problem. Firstly, healthcare managers need to be intentional about creating a culture of teamwork. Doctors do not do their jobs alone. They rely on nurses, other physicians and a full staff of people to help them succeed in caring for patients. The healthcare environment should place more emphasis on teams and less on individuals. Certainly, there are times when individuals need to be praised or held accountable for their actions, but all around a culture that focuses more on teamwork could be helpful.

Additionally, managers need to create a safe environment for error reporting.  The staff should feel comfortable reporting errors without fear of being punished or judged. The more employees share in this area the more a hospital can improve in their systems.

Finally, I like the suggestion that Gawande makes in his TedTalk video: checklists. There are a variety of strategies that can be used for reducing medical errors, but Gawande notes that even in surgery using checklists decreased complication rates by 35% and death rates by 47% in hospitals that implemented the technique. He agrees that overcoming physician attitudes around checklists will be a challenge, but the outcomes of this idea appear to be promising.

I’m sure that there are many more ways to reduce errors in hospitals, but a key aspect of that is to create a culture where people feel comfortable admitting that they made a mistake.

The Ted Talk Video is below.

Ethics--A Not So Black and White Topic

I never took an ethics or philosophy course in school so these concepts are all new to me which is exciting. When I think of the word ethics, typically I associate that with examples of unethical behavior as opposed to positive examples of ethical behavior. This is most likely because the negative examples get all the media attention (Enron, Wall Street, etc.).

I worked for a major pharmaceutical company for a little over two years and I would have to say that in my role as a sales rep I have never experienced more ethical challenges. Every day I was faced with decisions about whether or not to skew the truth a bit, over exaggerate or sometimes even outright lie. It was a very interesting situation. I was working for an organization that prided themselves on being “transparent”’ and honest in the midst of many other (pharmaceutical) companies that were being flamed by the press for hiding life or death clinical information from the FDA.

It was a cynical environment to work in and pretty much the entire 2 years that I was there the morale of the company was very low. I remember when rumors started leaking that my company had (illegally) tested vaccines on indigenous tribes in Africa. I remember one drug scandal after another that broke out and the reports of reps selling drugs “off label.” I remember the scowls on patients’ faces as I brought in big bags of catered lunch to offices along with lots of pens, notepads and other drug company paraphernalia.  Looking back, I don’t blame them.

As I read over the Basic Ethical Terms and Normative Theories I couldn’t help but think about my days as a drug rep. I find that some of history’s greatest transgressions have been justified by the “greater good of the people.” There are so many ways to argue what may be right or wrong or what makes something “good.” To me, the greater question is whose perspective is deemed to be most important which the writer of the website points out. This is a key point in differentiating the three Theories of the Good (utilitarianism, care ethics and ethical egoism).

For example, a drug company could justify illegally testing vaccines in humans because even though some may die or suffer terrible consequences, the greater good is that much more people will benefit from the “advancement” vaccines bring to medicine. This is utilitarianism.

If I were a person that was being subjected to that testing, I could talk about my rights as an individual and the unfairness of being forced into a potentially dangerous situation. I would be arguing for my own self-interest and this is ethical egoism.

In these two situations few people would argue against the fact that the pharmaceutical company is wrong and the individual is right. But what happens in situations that are not life or death?

For example, Iet’s say a colleague conveys in confidence that they are cheating the company in a way that is putting the organization in serious financial risk in order to pay for his five year-olds leukemia treatment. And let’s say that this should be covered by the company insurance, but due to budget cuts the company has had to scale back on insurance plans.

Should you tell your supervisor what’s happening? You know that your colleague will be fired and then how will their child’s treatment be paid? Are you being unethical by not sharing this? Should you tell? You know they’ll be after you if they find out that you knew and didn’t tell someone. So many things to consider!

It seems that ethics is this big conundrum of trying to balance all of the different perspectives involved in any given scenario. It is inevitable that the outcomes are not always fair. There is no clear right or wrong in many situations and it takes a lot of good judgment to be able to decipher what is appropriate for each circumstance. As a leader, I hope that this course gives me insight into how to discern ethical dilemmas in an appropriate way. 

The Government as HR Manager

The Government as HR Manager

I never thought about the government as a Human Resources Manager until I started reading Chapter 11 of the textbook: Compensation Practices, Planning and Challenges. In particular, compensation is of interest in relation to the Medicare program. Fried and Fottler discuss compensation strategy and how to reward employees for performance in a way that is meaningful to them. As I thought about the ideas presented about compensation and how doctors might perceive their roles and positions, I began to wonder what their perspective is on the government as an HR Manager. Fried and Fottler state that, “organizations earn a reputation for the amount they pay employees.” Well, what type of reputation has the federal government earned in regard to Medicare reimbursement for physicians?

In my experiences of working with physicians overall, I can say that my perception is that doctors (especially primary care physicians) aren’t very fond of the Medicare reimbursement system. A common complaint of physicians participating in the program is that the reimbursement rates are way too low. And who can blame them? According to the Washington Post, doctors have been paid below market rates for DECADES. Current reimbursement rates are at 25 to 35% below commercial insurance. In fact, reimbursement has become such a sore point for physicians that 31% of primary care practitioners have chosen to limit Medicare patients within their practice. These doctors are fearful of more cuts—which they can pretty much count on because it happens nearly every year. Another 60% of doctors are at least entertaining the idea of removing Medicare from their practice entirely (Newman, 2010).

One of the biggest problems with the payment system is the fact that the way costs are calculated has not been updated in several years. Congress is very fearful of promising not to make cuts due to the huge financial costs. Apparently, freezing Medicare reimbursements for the next ten years (meaning no slashes to payments) would cost $276 billion. But, that’s just FREEZING costs…who knows what would happen if physicians actually started to be paid market value for services.

These reimbursement issues are a pretty big deal. More and more medical school graduates are choosing higher paying specialties—i.e. anything but primary care where reimbursement is often the lowest. The younger generation of physicians has caught on to the mess that is Medicare reimbursement. Patients that are privately insured are much more profitable, and young doctors will be opening practices right out of school that restrict heavy Medicare so not to get themselves involved with the conundrum that older physicians are in. It’s particularly difficult for older doctors to hire younger replacements if their practice is heavy with Medicare. Considering the fact that in Florida alone 60% of physicians are 50 or older, this could be a serious problem if younger physicians are unwilling to replace them (Fritz, 2002).

This issue is also pretty far-reaching into the future as practitioners speculate about what might happen once the nation goes to the new healthcare program in 2014. What kind of reimbursement can clinicians expect from the new system if Medicare is treating them so poorly? If enough doctors opt out of this new program access could end up being a huge problem—and the program was designed to improve access, right?

The bottom line is this: Nobody wants to work for free, including doctors. The government needs to figure out how to “reward employee performance” and “attract and retain high-performing employees” without breaking the bank (Fried & Fottler, 2008). But is that possible? Maybe the entire Medicare program needs a complete and total overhaul. In the future it’s not hard to see why doctors would “quit” Medicare and government programs altogether. Hopefully, the government will give our physicians more incentive to see Medicare patients. There’s nothing wrong with a little bit of optimism, but let’s just say I’m not holding my breath.

References

Fried, B.J. & Fottler, M.D. (2008). Human Resources in Healthcare: Managing for Success (3rd Ed.). Chicago: Health Administration Press.

Fritz, S. (7 October 2002). Young doctors may avoid Florida. Saint Petersburg Times, p. 3A.

Newman, M.A. (19 June 2010). A fix for the ‘doc fix.’ The Washington Post, p. A17.

Pay for Performance

Health reform discussions over the past couple of years (centered on the Obama/McCain election) have shed light on the state of healthcare in the U.S. for the American public. As policymakers and elected officials have attempted to rectify our somewhat broken healthcare system (it depends on who you ask) a topic that often comes up is healthcare quality. What can we do about quality and the fact that we spend so many dollars on healthcare for below average outcomes? The question has sparked plenty of debate. One suggestion for the quality problem relating specifically to physicians is pay for performance (P4P). This is highly controversial and criticized—especially among primary care physicians. A New York Times article addresses some of the key points of the discussion and a recent study related to P4P published in The Journal of the American Medical Association (JAMA).

The article opens with a primary care physician expressing his dissatisfaction of a letter from an insurance company that notified him of his “quality ranking.” The quality ranking is essentially a way for the insurance company to objectively and uniformly measure their physician partners. This doesn’t seem like a bad idea, actually. However, even though the doctor maintained a high quality ranking he was still unhappy with the system. His argument was that the insurance company shouldn’t assume that the way he practices medicine has any direct connection to patient outcomes. I’ll be completely honest. At first glance it sounds to me as though the doctor wants to make an excuse or “have an out” when quality in his office falls below average. The second thought I had is that doctors in general don’t typically like to be held accountable to anyone because the very nature of their profession offers a high level of autonomy. But it doesn’t make sense that outcomes aren’t correlated to physician care.

The doctor then went on to talk about a patient with high blood pressure that he’d been dealing with for several years. This particular patient couldn’t afford to take time off work for appointments and his argument was that he should not be accountable for her poor health because of her job situation. Okay, I can understand that. However, I believe that for most doctors situations like that are the exception and not the norm. I believe that most people want to obey the doctor’s orders—especially if they have a pretty severe condition. On some level I can understand why this doctor is irritated, but I don’t think the solution is to let all doctors “off the hook.” Performance management measures need to be in place for all employees including doctors.

The JAMA study discussed in The New York Times article reveals that WHO doctors are actually treating makes a difference in P4P rankings. For example, doctors that treat more minorities and non-English speaking or underinsured patients typically have lower quality scores when rankings are not adjusted for these factors. However, after adjusting for the type of patient that the doctor is typically treating, many of the lower ranking doctors increased their scores up to 10 points.

According to Fried and Fottler, performance management is essential because “you can’t manage what you can’t measure.” Physicians can be difficult to work with and they can definitely be difficult to manage—but even they need to be held accountable to some set standards. The goal of performance management is to create goals and an action plan to achieve them. Progress must be monitored to ensure that employees are on target, so set standards must be in place and enforced—even for doctors (Fried, 2008).

I realize that P4P is controversial and many healthcare practitioners believe that it should be done away with. However, I don’t think the solution is to throw the baby out with the bath water. P4P can work, there simply need to be adjustments in place to account for extreme differences in physician patient populations. It will be interesting to see if P4P effectively motivates physicians over time.

References

Chen, P.W. (1 October 2010). Paying doctors for patient performance. The New York Times. Retrieved October 25, 2010 from LEXIS-NEXIS Academic Database.

Fried, B.J. & Fottler, M.D. (2008). Human Resources in Healthcare: Managing for Success (3rd Ed.). Chicago: Health Administration Press.

Healthcare Performance Managment

Performance management is an area of confusion among most executives throughout the United States. Most organizations struggle to define how to measure their employees, often sticking to strict metrics as opposed to measuring performance based on a variety of behaviors and day to day tasks. According to Fried and Fottler, “Performance management is a set of tools and practices that comprises setting performance goals with employees, designing strategies with employees to make and sustain improvement…(2008). From this definition it is clear that performance management should be a coordinated effort that includes the input of the employee along with that of the manager and involves a plan to help the individual achieve success within the organization.

I worked for a large pharmaceutical company as a sales rep and one of the greatest complaints among the reps was how ridiculous the performance measurements were. The organization often focused on metrics like sales calls per day, the number of lunch appointments scheduled during a given week, or the number of doctors that attended dinner programs. These metrics were constantly emphasized, but none of these directly added any value to our customers or increased the bottom line. By focusing on tasks as opposed to customer satisfaction or sales, reps often became disillusioned with “busy work” without moving any real revenues.

Hospitals and other healthcare organizations call fall into the same trap by putting too much focus on things like the number of patients seen in an hour rather than focusing on the quality of care provided to those patients. Some metrics evaluations can be useful when they are not emphasized at the expense of other more important factors. Fried and Fottler provide guidelines that should be followed in determining the actual criteria to be used in performance management.

First, performance measurements should add value to the organization’s corporate goals. When I was working as a pharmaceutical rep, the company constantly stated that their goals were to add value to physicians and grow sales. However, their performance criteria usually highlighted metrics that did not necessarily enhance customer value or increase sales. For example, I remember one coworker in my area that was praised repeatedly for a high sales call average per day. This same sales rep was consistently ranked in the bottom in regard to actual revenue performance. This is a great example of focusing on performance measures that don’t necessarily add value to the company’s overarching goals.

This example also fits the second guideline from Fried and Fottler, which states that performance measurements should not focus solely on any given task or behavior. Criteria selection should take a multifaceted view of the employee’s total job description.

Finally, any measurements need to be within the realm of control of the employee. This means that external factors that staff members cannot influence should not negatively affect their performance evaluations. When I worked as a rep, there were always several offices that would not allow reps to come in due to physician time constraints. Regardless of how inaccessible these doctors were, we were still responsible for sales whether positive or negative, that came out of these physician offices.

Overall, every organization wants productive people. Executives want people that are committed to their work and add value to the bottom line. In order to set the team up for success, organizations have to get employee buy-in regarding how they are measured. Employees that feel they are unfairly evaluated may harbor anger and bitterness towards the company and their performance will decrease. If organizations want to get the most out of their people they need to involve them in the performance management process and work together towards a common goal.

References
Fried, B.J. & Fottler, M.D. (2008). Human Resources in Healthcare: Managing for Success. Chicago: Health Administration Press.

Culture is the Key

At nearly every company I have ever been employed, Human Resources (HR) was considered a four-letter word. Nobody wanted to have any interaction with HR. You didn’t want phone calls from them, you didn’t want any e-mails from them, you just wanted to stay off their radar. Typically, when people were contacted by the HR department they weren’t receiving good news.

I believe that most people view HR as a part of the organization that only looks for personnel that are breaking the rules. We all know that part of their job is to ensure that employees are compliant with the rules and regulations of the organization. However, I think in most companies more emphasis can and needs to be placed on some of the more enriching aspects of human resources.

HR should be the primary entity that focuses on the establishment and cultivation of company culture. This extends far beyond a thorough discussion on values during new employee training and orientation. Culture is ongoing and I believe that the responsibility for building a solid culture is often left up to the employees to execute on their own without much encouragement from anyone. The values of the organization serve as a guide for each individual and determine how they conduct themselves in regard to customers and other employees in the organization. HR executives should create programs that bring the values to life on a daily basis. That first starts with the leadership team, who should be modeling these behaviors each day.

I can’t tell you how many times I went to one boring corporate meeting after another only to watch the big wig executives “grand stand” on a stage about how important company values were. But if you asked any of the employees the majority would say that they didn’t feel valued at all and they didn’t feel like the company was representing its values well either. Most hadn’t received merit increases in over a few years. That wasn’t due to poor performance, it was due to the company’s lofty goals that were unrealistic for the economic environment we were all up against. It was just another meeting where we all pretended that we felt “empowered and valued” or whatever the new catch phrase was, but those qualities rarely described the environment we worked in on a daily basis.

HR should be constantly working to create a company culture that truly embodies the values that the organization seeks to represent. If that isn’t possible then either the leadership or the values themselves need to change. People don’t like working in environments that breed a culture of “say one thing and do another.” It’s dishonest, and I like to believe that most people are honest, they want to do what’s right and they want to work for people that also want to do what’s right.