Dear Health Care Lobbyists

Over the last 14 years, as i worked in city, state, and federal government, we met at least 1,000 times. Without fail, I thanked you and your clients for coming by to see me. Now, a few months after leaving public service for academia, I am ready to tell you what I really think. On good days, while representing health professionals, insurers, hospitals, drug and device manufacturers, patients, or consumer advocates, you put the right information in the right place at the right time to make health policy more effective. Our meetings have led to improvements that benefited children, families, individuals with chronic illness, and the environment. On bad days, well, let's just agree that we spoke past one another. In a few cases, there really was no common ground. More than once, you asked for financial commitments that my agency just could not make. During a few particularly agonizing meetings, I daydreamed about developing a questionnaire to distinguish among the good, the bad, and the ugly in health care lobbying. Let's call it the first Milbank Health Care Lobbyist Quiz. Ready to begin? Give yourself 1 point for every time you answer yes to the following questions: 1. Can you rally your clients to help a public agency in an emergency? As Baltimore's health commissioner in late 2005, I asked the representatives of city pharmacy groups to help me design an emergency response program for anticipated bumps in the implementation of Medicare Part D. Together we developed and implemented a 24-hour on-call system to provide emergency medications to vulnerable city residents who had trouble accessing their prescription coverage. As a result, hundreds of people were able to maintain access to essential therapies. (The effort also won city pharmacies positive media attention.) 2. Do you seek out partnerships to advance the public's health? Lobbyists for ophthalmologists called me to combat unregulated contact lenses. Advocates for dermatologists asked me to publicize the risks of indoor tanning devices. Representatives of dietary supplement companies reached out to join forces in warning the public about spiked products. The relationships created by these partnerships work in both ways. I get the chance to educate health professionals and companies about the challenges facing my agency. They know how to reach me when their concerns arise. 3. Can you think creatively in a crisis? When I was serving as acting FDA commissioner, the agency announced a national recall of pistachios out of concern for Salmonella infection. The industry's lobbyists came to meet me, looking ashen. I asked them to create a website of unaffected products that we could link to the agency's updates on the recall. This unusual arrangement allowed the agency to broaden the reach of its communications about which products actually posed a risk. It also allowed the industry to sell more pistachios during a challenging time. 4. Can you accept no for an answer? One year ago, I bumped into one of my favorite lobbyists in Annapolis during a debate over widening access to the opioid overdose reversal agent naloxone. The lobbyist was representing a group of physicians opposed to the expansion. She pulled me aside and whispered that my side was going to win. Her half smile meant that either she secretly was happy for public health or, more likely, that I would be hearing from her soon about something else. 5. Can you lead your clients into the future? Recently, Maryland adopted an innovative payment model with the Centers for Medicare & Medicaid Services that essentially establishes a global budget for all hospital services for state residents. While initially wary, the leadership of the Maryland Hospital Association came to play a critical role in educating hospital executives about a unique opportunity to achieve better outcomes at lower costs. In the end, every Maryland hospital endorsed the final agreement. Now deduct a point for every time you answer yes to the following questions: 1. Are you a name-dropper? Some lobbyists loved to drop the first name of the mayor, governor, HHS secretary, or a senior White House official. But I knew that if there were really such a close relationship, the mayor, governor, HHS secretary, or senior White House official would already have called me. 2. Are you afraid to keep your clients on track? Before meetings with government officials, lobbyists should educate their clients about what is and is not possible, thereby allowing meetings to be focused and productive. Yet in my experience, some lobbyists just watched silently as meetings digressed into long discussions about why health insurance even exists or why the FDA sets any standards for safety and effectiveness. 3. Are you storming the wrong barricades? Some progressive lobbyists conflate formal regulatory authority and actual power. When an agency has the legal ability to take a specific action, the lobbyist's simplistic strategy is to pressure the agency into doing so. One flaw in this approach is that no agency is an island. Controversial actions often require understanding and support from other agencies, the chief executive, and the public. A second flaw is that the advocates can wind up attacking the credibility of the one agency interested in and capable of addressing their issue. In my experience, a better strategy is to create the understanding and space for an agency to act. Such was the case when attorneys general and consumer advocates called the nation's attention to the dangers of caffeinated alcoholic beverages in advance of decisive action by the FDA. 4. Do you do your homework? Somewhere inside the Beltway, there is a lobbyist who tried to sell me on the idea of Nicotine Water, a product made from the simple recipe of bottled water and a whopping dose of nicotine. He claimed the product was a “homeopathic remedy” and thus not subject to the FDA's usual drug approval process. I asked him to explain how Nicotine Water fit within homeopathy, a field with a preference for minute quantities of active ingredients. He said he had no idea. I once met with a senior lobbyist who insisted, on behalf of a candy manufacturer, that a particular contaminated product was no longer on store shelves and could not be found anywhere in the nation. He then said it again. And a third time. Finally, I responded that I had walked into a local store and bought some of the suspect candy that morning. I reached into my pocket and put the container on the table. I then watched the lobbyist throw a complete temper tantrum in front of his clients. 5. Do you wish you could help, but … ? Are you, of course, totally supportive of what the agency is trying to do and would love to be of assistance, but you know there are committees that need to weigh in, and the annual meeting isn't until June, so thanks for asking and maybe next time? If only I could have used this answer for any of the pressing tasks facing me. How to score: +5 points, you have a successful, proud career ahead as a health care lobbyist; 0 points, keep working at it; −5, points, it's time to consider choosing another profession. Didn't your parents always want you to become a doctor?