Who should she serve?
Compared to the tumultuous search for a new school system superintendent, the announcement of the appointment of a new Director of the Louisville Metro Department of Public Health and Wellness seemed to come out of nowhere. Since the departure of the previous Director, Dr. Adewale Troutman, the announcement in the Courier Journal on June 14 was the first indication of progress of which I was aware. Did I miss something– like a public hearing? Was there any public input into the process? Perhaps the search became invisible in the shadow of the school superintendent search. Yet both searches are equally critical for our future. As our failing private health system continues to eject middle income Americans (employed or otherwise), a new form of systemic health disparity is growing rapidly. The widening income gap in America is causing a pernicious denial of access to affordable health care within a system that is tailored for the well-employed and the wealthy. In a health system where even the “haves have not,” I predict that our public health departments will become increasingly important. They will likely be incubators for whatever our future system of health care looks like. As a society, we are only as healthy as the sickest among us.
Dr. LaQuandra S. Nesbitt, MD, our new Director, looks like a great catch. She has impeccable credentials of training and experience. She most recently held a senior public health role in the cauldron of Washington, DC. The challenges she faced there provide relevant experience for our needs. I wish her well. I hope I can help.
As far as I know, Dr. Nesbitt’s successful candidacy was without controversy. Therefore, let me introduce some! One sentence in the C-Js reporting positively gave me the shivers. It was reported that half her salary of $180,000 and half her benefits will be paid by the University of Louisville. I think this is a bad idea: a very bad idea. No doubt the fiscally-strained city was glad to have someone else pick up part of the tab, but I think this is bad public policy. This is not simply the customary gratis faculty appointment that honors Dr. Nesbitt, allows her to teach, and otherwise participate in the academic life of the University. Hundreds of other physicians in Louisville have such privileges. The current arrangement makes her an employee of the University of Louisville. By placing her in a position of having two very different employers, she will start on day one with conflicts of interest.
So what is my problem? Surely the University is interested in the public good– who is not? But as it was for General Bullmoose and for General Motors, the University’s vision of what is good for the public, is that which is good for the University– including its business interests and those of its faculty. If you have read some of the other entries on this site, you will not be surprised to learn that In my opinion, the University of Louisville has been captured by private business, and by the entertainment and hospital industries. It openly seeks to become a pharmaceutical company itself! The initial focus of its School of Public Health was how to perform commercial drug studies. An officer of the School of Public Health bragged to me of their intention to collect medical information from patient records in order to package and sell it to outside interests. Such information allows the University to identify candidates for its commercial drug studies, and for targeted marketing on behalf of commercial partners. The aim was to generate a stream of personal income in the way the University faculty scientists gain from patents and licenses. I am not making this stuff up! The University and its faculty practices already have experience with the privatization of public health functions and I have little doubt would like to acquire more.
The University has sadly, but badly, tarnished its reputation as a steward of the public good with its management the Passport Managed Medicaid program. This scandal led to the recent firing of the University’s highest ranking medical officer from that organization. You may have read about the extravagant meals and travel that were the focus of local reporting, but this was small potatoes. I am currently plowing through the 273 page Kentucky State Auditor’s report concerning Passport Health Plan and its affiliation with the University of Louisville. The report outlines staggering arrogance and mismanagement of public funds. The University treated the billion dollar state and federal program like a money tree, and it was shaken often and hard. Passport and its University management have placed the Kentucky’s Department of Medicaid Services in jeopardy of having to return money to the federal government. The Auditor’s office recommended review by both Kentucky’s Attorney General and the Federal Internal Revenue Service because of questionable compliance with state and federal regulations. I will report in further detail on the matter in the near future. (You can download the Auditor’s report (8.3 MB) from the KHPI site and read it for yourself. You will be stunned.) To further carry the analogy with the search for Superintendent of Schools, the University of Louisville wasn’t so hot in handling public educational monies either. People went to jail.
In the same day’s paper in which I learned of the appointment of Dr. Nesbitt, I learned that University Hospital and other University entities were going to announce a merger of the Jewish Hospital system and the Catholic Health Initiative system. At least one of the two downtown hospitals in this deal have not been doing very well lately and the merger was forced in largest measure by financial exigencies. There will be considerable pressure to generate income. There is concern that some services, especially those to the indigent and underinsured, will be dropped for financial or religious reasons. Who should the Director of Public Health represent as the new downtown academic medical center undergoes this radical reformation? The answer seems obvious to me. The new medical center will have plenty of other powerful people and organizations advocating for its wishes. The Director of Public Health and Safety must avoid even the appearance of conflict of interest, and that means not being on the payroll of the University of Louisville.
It should not be overlooked that the major provider of health care to our children is Kosair Children’s Hospital and its clinics. Kosair is the backbone of the medical safety net for the indigent children of our county and provides much more uncompensated care than its competitors, including University Hospital. Kosair is part of Norton Healthcare which is, and will be a fierce competitor of the new merged system. When I was a managed care medical director in Louisville some years ago, I watched firsthand the nature of hospital competition. It was nasty. (Much of the nastiness was directed against University Hospital, which was at that time run by Humana.) In the new system, I foresee much maneuvering to weaken the positions of Norton Healthcare and Kosair. I do not even think it farfetched to speculate that the new partners might establish a second children’s hospital. They would not need a certificate of need to do so. Such self-serving and wasteful duplication of this or other services would not be in the interest of the citizens of Jefferson county and its neighbors.
The Director of Public Health will have to deal with all these entities. Is it fair to anyone, including the public, that she be an employee of one of the major business competitors? Will she have to recuse herself whenever a decision is made that effects the University or its faculty, as I think she should? Better that she not be placed in this obvious conflict of interest. Her job is to protect the public health of Jefferson County– period. Her job is not to protect the University’s interests, nor those of its business partners, nor of its faculty. Is there any other public health director in the nation’s top metropolitan areas that is funded by a similar arrangement? If so, how is it working? What safeguards might have been put in place to protect against conflicts of interest? What safeguards, if any, were put in place at Dr. Nesbitt’s hiring?
What do you think? How far off are my opinions? I offer them in the nature of an open letter to Mayor Fischer and the Board of Public Health. I ask them to reconsider their funding plan. This city has seen controversy before when private and business interests have offered to supplement the salaries of public officials. It must not happen in our public health system, especially in a city that has designated health care as its highest priority for economic development. Business ethics are not medical ethics. Neither our veterans nor beneficiaries of public health deserve to be fodder for economic development.
Peter Hasselbacher, MD
June 18, 2011