For its COVID-19 response, Utah leaned on business consultants to steer logistics

A group of business consultants is playing a behind-the-scenes role in Utah’s coronavirus response, advising the state budget and management heads who have at times supplanted health officials in decisions about fighting the disease.

Representatives of Goldratt Consulting, who have close ties to the state’s chief budget officer, have facilitated discussions about the creation of a $2.75 million mobile app meant to assist the state in contact tracing, email records show. They offered input about securing data gathered through the TestUtah survey, designed to screen people for possible coronavirus testing. Goldratt even built the economic model that spat out the numbers for the state’s COVID-19 testing targets, a high-ranking state public health official says.

And Democratic state lawmakers say they worry these consultants are wielding an outsized influence over critical decisions best left to public health experts.

“Decisions about how best to move Utah forward need to be based primarily on expert public health and medical recommendations, not recommendations from business management experts,” House Minority Leader Brian King, D-Salt Lake City, told The Salt Lake Tribune in an email. “Unless we put in place a better balance between public health versus financial considerations than we’ve seen, we’ll see higher levels of illness and death.”

The state has paid the Goldratt’s consultants hundreds of thousands for their guidance during the pandemic and has already contracted for an additional $200,000 in services, according to the Governor’s Office of Management and Budget.

GOMB says Goldratt has offered its services at a discounted rate during the pandemic and has contributed to myriad aspects of the state’s campaign against COVID-19, helping with testing strategies, creating an operational dashboard for officials, connecting them with subject matter experts on data analysis, and helping develop ideas for protecting long-term care facilities and other high-risk groups from the disease.

And this isn’t the only consulting firm the state has hired during the coronavirus, GOMB points out; the state has also paid nearly $340,000 to Leavitt Partners, a health care intelligence firm run by former Utah Gov. Mike Leavitt, who was also health and human services secretary under President George W. Bush. The agency has also sought guidance through a partnership with the University of Utah and from state health department experts, a medical panel and a data analytics panel.

A Goldratt representative said the company is “not providing any guidance on health care or public health policies” and has instead been assisting a short-staffed GOMB with metrics and data dashboards.

A March paper co-written by one of the lead Goldratt consultants, however, shows his thinking on COVID-19 hasn’t been limited to data crunching — in fact, he described a sweeping proposal for controlling the worldwide pandemic within just 90 days.

Dr. Robert Rolfs, former state epidemiologist for the Utah Department of Health, said he does see a potential role for business consultants such as Goldratt to help during a pandemic; for instance, they can mentor agencies in improving their workflow, he said.

And while public health science is essential in a pandemic, he said, “running the response appropriately requires expertise that goes beyond public health science and includes economics and an understanding of people’s values and preferences.”

But he did have a caveat.

“When they start becoming experts in things other people are already expert [in] and have done for a long time,” he said, “I’m not sure they’re as likely to help.”

The Goldratt philosophy

Goldratt Consulting, a firm that specializes in a management paradigm called the “theory of constraints,” is not a newcomer to Utah state government and over the years has forged a close relationship with Kristen Cox, a top member of Gov. Gary Herbert’s administration.

During her time as head of GOMB, Cox has garnered national attention as a practitioner of the theory of constraints, particularly for her innovations in applying the business-centric philosophy to state government.

Her endeavor has funneled millions in state taxpayer dollars toward Goldratt for consultation in everything from the construction of a new state prison to how officials decide what products to put on liquor store shelves. Cox and Goldratt co-host an annual “operational excellence” conference that cost the state upward of $200,000 in 2018, and she’s even co-written a book with one of the consulting firm’s executives.

Now, she and Goldratt are trusting that these principles will hold up in the state’s high-stakes fight against COVID-19.

Rachel Scheinkopf, a Goldratt representative, wrote in an email that the company is using “our expertise in operational improvement to help the State combat the pandemic” and is leaving public health policy guidance to the Leavitt group.

In a statement, GOMB noted that Utah has the nation’s lowest COVID-19 case fatality rate and among the nation’s lowest unemployment rates.

“Our goal throughout the entire COVID-19 response has been a balanced approach between protecting lives and livelihoods, and it will continue to be so,” the statement said. “A strong economy and a healthy public are inextricably linked. Those hit hardest by the economic fallout of the pandemic are also those hit hardest by this public health crisis.”

However, the state is grappling with a COVID-19 surge that began 12 days after Herbert loosened restrictions by moving nearly all of the state to “yellow” or low-risk status. Last week, Utah’s seven-day average of new positive cases hit an all-time high of 519, and the state epidemiologist warned in a recent memo that Utah is “quickly getting to a point where the only viable option to manage spread and deaths will be a complete shutdown.”

As the number of COVID-19 cases soars in Utah, state Rep. Jennifer Dailey-Provost worries top state officials are looking at the pandemic through the wrong lens.

“My ongoing frustration is that we need to stop thinking we can solve a public health crisis with a business plan and new technology,” the Salt Lake City Democrat said. “There’s always the opportunity to leverage new tools, but the failure of leadership to address this public health crisis as a public health crisis is, I think, contributing to what we’re seeing in these spikes right now.”

Chain of command

Dr. Robyn Atkinson-Dunn, who until recently led the state’s public laboratory, confirmed that state management and budget officials — not health experts — steered Utah’s COVID-19 response in the early days and have continued leading it to varying degrees since then.

“It seemed strange to me,” she said, “for a public health response to be directed by GOMB and not the health department.”

GOMB has managed no-bid contracts for a couple of the state’s largest coronavirus initiatives — the statewide testing and screening project called TestUtah and the creation and rollout of a contact tracing app, both of which have been entangled in controversy.

GOMB is also overseeing a $2.8 million contract with the University of Utah David Eccles School of Business for a large-scale, randomized testing effort that has the goal of helping “Utah’s citizens and economy return to normal in a safe and informed way.”

Email records suggest the Utah Department of Health wasn’t always in the loop as these initiatives unfolded. When a state lawmaker in early May asked which department had oversight for TestUtah, state epidemiologist Dr. Angela Dunn responded that she was “not sure of the chain of command.”

Also in the email, the health department’s deputy director wrote that he “wasn’t involved in developing the contract with TestUtah,” while Dunn said she didn’t have access to a copy of the contract with the involved tech company.

But in its role as advisers to GOMB, Goldratt was engaged in the internal talks about TestUtah, records show. Atkinson-Dunn can personally attest that the consultants helped set the state’s goal of conducting 7,000 coronavirus tests each day.

Officials cited that target number as part of their rationale for inking the contracts for TestUtah. The group of tech companies involved in the initiative has since expanded the model in several other states, despite being dogged by questions about the accuracy of the COVID-19 tests and its lab’s failure to meet federal certification guidelines.

Atkinson-Dunn first learned about the 7,000 daily tests target during a late March or early April conference call with other state officials and Goldratt representatives, she said. The business consultants explained that they’d derived this number from their economic model — so named because its focus was on what the state should do to get the economy back open, Atkinson-Dunn said.

Utah never reached the 7,000-daily test goal.

State health officials removed Atkinson-Dunn from her position at the head of the public health lab in early June and reassigned her to work in the epidemiology bureau. She says her bosses demoted her because she was unwilling to send coronavirus test samples to TestUtah’s hospital lab.

The health department declined to comment on the transfer, saying it doesn’t make public statements on personnel decisions.

Scheinkopf, a Goldratt representative, confirmed that the company built a “constraint-based simulation model” to help with coronavirus planning but said all the epidemiological assumptions came from state health experts.

“Utilizing the input, the simulator shows the impact of different operational efforts, like the number of tests, speed of testing, effectiveness of contract tracing, and the ability to protect hospitals to combat the spread of COVID 19,” she wrote.

A state health department spokesman confirmed that agency experts helped develop the models.

Email records show that Ajai Kapoor, a Goldratt partner, also offered suggestions about the data collected by TestUtah, adding that the state’s contract with the lead tech company in the initiative should specify that the information would be destroyed except for research purposes. The contract should also include “strict penalties” for anyone who misuses the data, Kapoor wrote in an April 1 email.

And, on March 29, Kapoor facilitated an email conversation about the development of the state’s contact tracing app, assigning tasks both to Utah officials and representatives of Twenty, the tech company building Healthy Together.

“If any of these conversations is not moving fast enough, please involve me,” Kapoor wrote at the end of the message. “I will do my best to be the ‘bulldozer’ over here.”

A 90-day plan

Kapoor spelled out his plan for confronting the pandemic in a mid-March paper titled “Stopping COVID-19,” a piece that began with an acknowledgment to Cox for her feedback.

The paper, co-written with two supply chain management experts, outlines a plan for containing the disease within 90 days by halting international and domestic air travel and local bus and train service, drawing zones of about a million people each and stopping people from traveling between regions except to transport goods.

After reviewing the paper, Rolfs said it largely described traditional public health practices but restated them in the language of a business analyst.

The suggestion to carve the world up into zones of a million people is unusual, he said, and he was doubtful of its practicability. He also disagreed that any containment plan could completely eradicate the virus within 90 days — calling the idea “beyond naive.”

The paper also highlights the potential advantages of deploying mobile technologies to track people’s movements and pinpoint COVID-19 hot spots, a tactic later adopted by Utah officials with the Healthy Together contact tracing app.

“These technologies with their ease-of-access to (historical and real-time) location capabilities provide a way to simplify tracing and investigation steps,” the paper states.

To encourage public buy-in, it continues, the government should stress that the app would offer users valuable information about the possibility of exposure to the virus and offer “early-warning, hot-spot visibility.” Officials should also reassure people that their personal information would be secure and that they could purge their data by opting out at any time.

As suggested in Kapoor’s paper, the contract with Twenty mentions hot spot updates as a perk for those who download Healthy Together. And in unveiling the app, Herbert tried to quell concerns over “Big Brother” by emphasizing that users can delete their data at any time and that information about location and symptoms would be purged automatically every 30 days.

In his paper, Kapoor predicted that many people would be willing to relinquish some of their personal privacy in exchange for better information about their risk.

“Given the value proposition and firm legal assurances,” the paper says,”we expect a high degree of participation of citizens in the face of this unprecedented crisis.”

Although the app is now fully functional, according to the health department, it failed early on to accomplish what it was contracted to do, and the platform took longer than expected to ramp up. A Twenty representative said that as of late June, 87,000 people had joined Healthy Together and taken more than 494,000 symptom assessments. About 14,000 users have been referred to get tested and received results.