How effective will the physician payment national database be?

ProPublica.org did some interesting frontrunning on the physician payment national database that will become operable sometime around 2013 as part of health care reform.

In the first of a series of stories that has been picked up by several mainstream media outlets, the New York-based investigative journalism non-profit culled all the physician payments that have been publicly posted by seven drug companies to date. It aggregated the dollars to create a hierarchy of top industry buckrakers; and compared that database to physician sanction records in the states. Do yourself a favor and read their nifty, hard-hitting story, which already has some drug companies scrambling to double check the credentials of the shills they’ve put on their payrolls.

I was especially pleased to see they cross-checked the top buckrakers with their academic publishing record — a fair test of industry’s claim that they only hire “thought leaders” to spread the word about their products. As a New Yorker might say, fuhgeddaboudit. Typical thought leaders have resumes that go on for pages as they brag about publications counted in the hundreds. Most of industry’s top-paid guys (and the vast majority were men) had a handful of publications at best, and often in second- or third-tier publications, according to story.

I am a relatively knowledgeable observer of the health care scene. After perusing the list of 384 physicians earning over $100,000 from drug companies in 2009 and part of 2010, I can report back that I recognized less than ten of the names. These were not people quoted in the press, serving on Food and Drug Administration advisory committees, or publishing landmark studies in the New England Journal of Medicine, the Journal of the American Medical Association, or other top-ranked publications, whose table of contents I peruse weekly.

But here’s the rub. Now that we have this information, and will soon have more, what are we supposed to do with it? Will average patients search for their physician’s name to see if he or she is on a drug company payroll? If they do, will they act on this information? Should they?

This is an area of physician practice that cries out for regulatory oversight. Alas, no one is suggesting we ban the practice of physicians taking money from health care suppliers. But ask yourself these questions. Do you want engineers taking money from the companies that make the steel that goes into the bridges they build? It happens. Do you want judges taking money from the lawyers that practice in front of them? They’re called campaign contributions in states where judges are elected. Do you want politicians taking money from every interest group imaginable before they vote on legislation that affects those groups’ self-interest? Duh. Do we want economists taking money from investment banks to write studies that say derivatives sold on collateralized debt obligations do not pose a systemic threat to the U.S. financial system? Watch Charles Ferguson’s new film “Inside Job” if you want the lowdown on that one. The list goes on and on.

I have done a lot of railing against conflicts of interest in medicine over the past five years. I just gave an interview to a nice person from New Hampshire Public Radio, and she called me quite eloquent on the subject. But the truth of the matter is that right now, conflict of interest defines the American way of life, and not just in medicine. Journalistic exposes of such conflicts are the functional equivalent of the cock crowing when the sun comes up in the morning. The poor bird heralds the event, but he has no chance of changing its inevitability.

I sat through an FDA Cardiovascular and Renal Drugs Advisory Committee meeting yesterday where the assembled physicians refused to vote new restrictions on the use of Amgen’s Aranesp, an erythropoietin-stimulating agent for combating anemia in chronic kidney disease patients. The committee was presented with clearcut evidence that ESAs increase the risk of stroke in patients given enough drug to move their hemoglobin toward the top of the FDA-approved range.

At the outset of the meeting, the FDA made its ritual announcement about the conflicts of interest on the committee, which included six internal medicine physicians, four cardiologists, three nephrologists, a biostatitician and a pharmocologist (plus consumer and patient representatives, who had no scientific background). Not a single member had a reportable conflict of interest.

So what explains their vote? Long story short, the overwhelming sentiment of the non-conflicted physicians on the panel was that physician choice and patient preference must be preserved.

So here we have spread across this morning’s news two stories that when considered together reflect all the contradictions of modern medicine that lead to expensive and inappropriate care. ESAs clearly benefit some chronic kidney disease patients not yet on dialysis. It gives them more energy and helps them avoid transfusions. But for some, probably the sickest ones who often get the largest doses of the drug, it fails to end their anemia and carries a higher risk of stroke.

For decades, Amgen has funded studies that pointed only at the benefit. In fact, the trial that turned up the higher risk of stroke was aimed at raising red blood cell counts above the FDA-approved range. The company has convinced an entire profession — the Renal Physicians Association testified against limiting use of the drug — that “access” to these lifestyle benefits is more important than safety. It paid messengers, commissioned studies and underwrote clinical practice guidelines to spread the word. It funded patient advocacy organizations that endorsed its agenda.

This is how our health care system and its commercial suppliers interact. Printing doctors’ names on a website to see if he or she is “on the take” (to borrow the title of Jerome Kassirer’s 2005 definitive book on this subject) will do nothing to change the system.

Merrill Goozner is a freelance writer, independent researcher and consultant who blogs at Gooznews on Health.

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  • PAULMD

    You made some excellent points. Conflict of interest is the new pervasive reality that is a defining piece of American culture.

    I would not hang too much credibility on the presumed gravitas or lack thereof of some of the physicians that are paid by Pharma. It’s the integrity of the individual that matters. I am becoming more and more weary of the cozy relationships between physicians and the medical industry and how this effects the accuracy of medical information.

    I am more uncomfortable by the lack of detached autonomy of the premier academicians especially when they have skin in the game. It makes it difficult to know who to trust.

    On the other hand, if inovation and advancements are being made off of the sweat and intellectual work of physicians, why shouldn’t they be paid? Knowledge that can generate a profit has a new name. It is now called “intellectual property”. There are those docs that, like baseball players in MLB, want a piece of the action that they have helped in bringing to light. Is that so wrong?

    Personally, it has the power to taint and should be watched very closely for ALL of the reasons you mentioned. Going the industry route is your individual choice, just don’t don the cloak of truth and infalability of an ivory tower institution to peddle your wares.

    In the spirit of full diclosure, I have NO financial interest in my statements here or in any medical product or intellectual property.

  • http://www.stevebalt.com SteveBMD

    The system will only change when we doctors stop paying attention to the “thought leaders” in glossy throw-away journals or at fancy dinners, and instead evaluate the data from the REAL thought leaders in top peer-reviewed publications, texts, or (best of all) listen to the patients sitting right in front of us.

    We were trained to be critical thinkers and yet we’re ignoring that skill and proving ourselves to be as susceptible to marketing gimmicks as anyone else. (And potentially digging our profession’s grave in the process.)

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    Our peer journals, once devoid of advertising are filled to the brim with pharmaceutical advertising. Next to three glossy pages of advertising a new product is an editorial from an academic guru criticizing primary care physicians who have a in office blood laboratory ” ordering more tests” than physicians with no lab and calling it a conflict of interest. Its OK for our peer review journal to accept non critiqued advertising but the world will go to hell if a family practitioner orders too many blood sugars and cholesterols on his diabetic patients?
    If individuals are representing companies and presenting points of view and data that are untruthful then it is up to the profession to identify the individual and the mis information on a case by case basis and point it out. This is far better than treating the entire profession as criminals and creating more rules and regulations that support that position. If physicians are earning money from pharmaceutical companies , and are licensed and are in good standing with their licensing authority then point out where their position is wrong on a case by case basis rather than smear them as a group.
    Individuals who go to school and post graduate training for seven or more years and then practice successfully in their profession develop areas of interest within medicine as their careers progress often taking them out of direct patient care or direct teaching care. I personally do not represent any pharmaceutical companies but would not condemn an associate for voicing an honest opinion based on fact and research whether the research is his or someone elses if it is an honest opinion. If they get paid for their time and thought so much the better. Is it now a crime for physicians to get paid as well?

  • doctor

    You are correct to point out the conflicts of interest in all other walks of life. However, remember that even the venerated New England Journal takes advertising from big pharma quite gladly (to pay the salaries of all the “do gooders” on its staff) and allows industry sponsored cme/information topics in its august pages. Meanwhile, I’m supposed to feel guilty for accepting a bagel or cup of coffee. My auto mechanic was flown in a private jet to tour the factory of an auto parts supplier, but shame on me for getting reimbursed for my coach airfare to go to a surgical preceptorship. If I give a lecture at a University conference that has sponsors (all of them do to meet cost) should I feel ashamed, and turn down the speaking fee? Where do you draw the line? By announcing your disclosures, which IS taken very seriously by all doctors. Not by having a bunch of bureaucrats, convinced that they’re morally superior to all, running yet another data base at taxpayer’s expense. Do government employees disclose their conflicts? I don’t think so.

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