Monday, October 6, 2014

How Health Care Went Tabloid

Physicians, whether practicing medicine or not, should not be involved in clinical research. They should never be consulted on development of new drugs and medical devices. Doctors should not invent new treatments, and should never supervise clinical trials. They should not travel to or speak at conferences either, and they should banish all entrepreneurial notions out of their heads. If they insist on engaging in these activities, they should do it all for free, out of the goodness of their Hippocratic heart. A medical degree should immediately disqualify you from making money in the health care industry, which is a privilege reserved for technocrats, business executives and garden variety ex-political appointees.

Matt Bai, a veteran political journalist, wrote a new book titled “All The Truth Is Out: The Week Politics Went Tabloid”, where he is attempting to pinpoint the demise of serious political journalism to the Gary Hart scandal of 1987. If you recall, Mr. Hart, the all but certain Democratic candidate for President of the United States at that time, was railroaded out of politics by a romantic dalliance with, of all people, a very pretty pharmaceutical saleswoman. Matt Bai goes on to assert that since the Gary Hart affair “the entire ethos of political journalism has really changed. Because all the attention, all the kudos, is in taking someone down, is in finding hypocrisy”. Political journalism is arguably the heart of journalism, and as the heart goes, so goes the lesser journalistic body, health care reporting included.

This week, the CMS released a new "trove" of information about payments made by pharmaceutical companies and medical devices manufacturers to physicians and hospitals. The dataset includes millions of records ranging from payments of $0.00 (?) to millions of dollars. Some of the records specify the recipient while others do not, and most list the reason for payment. The data is preliminary at best and lots of cleanup activities are to be expected, since various recipients of funds have discovered errors large and small. A database like this one could eventually be useful for example for cross checking disclosures for published papers and education materials, or for people who are studying the financials of life science sectors of the economy. As expected though, the health care media saw things differently, because these data present ample opportunity to find hypocrisy and take someone down.

To put things in perspective, here is a brief summary of the data from an angle nobody saw fit to print. Below is a breakdown of amounts received by named physicians for the largest category of general payments, which includes food, travel, honoraria, consulting, royalties, licensing fees, and a host of other frivolous activities. In addition to this dataset, there are two smaller sets, one for research payments and one for ownership, or equity, in life science companies. And then there are three parallel datasets where the CMS decided to withhold the names of recipients due to uncertainties regarding data validity. We will disregard the list of payments made to unidentified entities, and concentrate on the largest dataset of payments to doctors. There are 358,686 named physicians in this dataset, and this is how total payments are distributed.

It looks like the median payment value is approximately $100, and 9 out of 10 docs who received anything, received less than $1,000 worth of goods, services and sometimes even cash. The big money went to a fraction of a percent at the top, mostly for royalties and licensing of things they designed or invented. I randomly picked a couple of these folks and looked them up on Google. The first one turned out to be a world famous vascular surgeon who invented multiple devices to fix aneurysms, pioneered various types of surgeries, and even got himself a Medal from the Society for Vascular Surgery. The second fellow is an orthopedic surgeon, also world famous who specializes in acute trauma and posttraumatic reconstruction of feet and ankles, and is the inventor of all sorts of plating and nailing systems for his specialty. He has more credentials than you can count and some very prestigious awards to go with that. At this point I stopped searching.

Now let’s look at how the New York Times reported this data release. The first article came one day before the data was published, giving us a heads up on the impending release, educating us on already existing resources, such as the subtly titled Dollars for Docs database, and plainly stating that “most physicians that are in private practice are touched in some way” by the industry. Yes, only private practice docs are “touched” by the scourge. The next article was just a kneejerk litany of complaints about the CMS database functionality, which by the way, I found to be surprisingly nice.

The third New York Times article was cleverly titled “Detailing Financial Links of Doctors and Drug Makers”, a title as innocent as the 1987 Miami Herald story “Miami woman is linked to Hart”. Linkage implies secretive impropriety about to be exposed. You don’t often see headlines saying “Fireman linked to saving baby from burning building”. The article itself is fraught with equally innocent language such as “doctors reaping over half a million dollars each”, “murky financial ties between physicians and the health care industry”, “lucrative arrangements are just some of the findings”, and in a surreal tale of the doomed, a righteous Cleveland Clinic physician is contesting his own listing because “he had spoken at the event but deliberately skipped the lunch”.

The most recent New York Times article is titled “Financial Ties Between Doctors and Health Care Firms Are Detailed”, just in case you missed the “detailing” pun the first time around. This article opens with a series of dramatic one sentence paragraphs. “For some doctors, treating patients isn’t the only way to make money”. You can pretty much hear the thriller music in your head. “A Michigan plastic surgeon was paid more than $300,000 to travel the world teaching doctors about new cosmetic products like a breast implant”. Impropriety is best served with female body parts. “The retired chief executive of the Mayo Clinic, who once helped write its conflict of interest policy, received more than $237,000 in compensation for serving on multiple corporate boards”. Wow, a retired doctor sits on corporate boards. Even the venerable Mayo Clinic has no ethics.

Following the boilerplate “murky financial ties between physicians and the health care industry”, we are informed that “the typical doctor earned only about $1,750 from August to December 2013”. Actually, the “typical” doctor barely eked out a hundred bucks worth of crappy conference food, unless he or she skipped lunch altogether, or maybe just refused the fake ├ęclairs at the end, but math is a very flexible thing.  And on and on goes the litany of naming names, like a bad Seinfeld take on the McCarthy era.

The rationale for this abject witch hunt is that physicians who ingest pharmaceutically sponsored food are likely to return the favor and prescribe expensive brand name drugs instead of cheap generics. According to an IMS report from April 2014, generic medicines are now representing 86% of prescriptions, and have been steadily increasing over recent years. I seriously doubt that the numbers can get much better, and either way during these days of high deductibles and narrow formularies, doctors are rarely at liberty to prescribe brand name drugs when generics are available. Not to mention that as physicians are increasingly losing their independence, pharmaceutical companies are turning their efforts to hospitals, which are much better at financial wheeling and dealing. And yet, all the headlines and all the articles are about doctors, because taking down a person with a name and a face, using innuendos and baseless allegations, is so much easier than picking on a lawyered up corporation, and it is equally fulfilling, it seems.