Friday, March 6, 2009

Give a Drug Talk, Go to Jail?

Just as hired guns were getting used to the fact that their fees will soon be posted on the web for the world to see, federal prosecutors have made their lives a little more stressful. According to this recent article in the New York Times, they are planning to nab some of these consultants on kickback charges.

It’s illegal to prescribe treatments in return for payments from drug companies. Of course, no physician is going to admit that they do this. But anybody who has ever been involved in the unsavory business of speakers' bureaus knows that it happens all the time.

It can be rather subtle—call it “soft kickbacks.” When I was hawking Effexor for Wyeth in 2002, there was no explicit agreement that I would get more speaking gigs if I prescribed more of their drug. Not even a wink or a smile. But I knew that the company was keeping track of my prescribing history, and that it couldn’t hurt my relationship with them if I enriched by patient population with Effexor scripts. Add to this the fact that Effexor was not significantly different from several other antidepressants, and you have the right mix of ingredients for a kickback-esque situation.

I don’t recall consciously thinking, “I’m going to prescribe Effexor rather than Zoloft for Mr. Jones so that I can make my handlers happy.” It was more like breathing an atmosphere hypersaturated with Effexor money, Effexor thoughts, and Effexor rewards. Any doctor who chooses to put him or herself in such a situation ends up treading a line, and as the amount of money increases, the incentive to think actual kickback thoughts increases as well.

Thus, for example, when orthopedic surgeons are pulling in several million per year for consultation, immorality is highly likely to happen.

According to Lewis Morris, chief counsel to the inspector general of the Department of Health and Human Services
, big ticket surgeons are going to be the target of most of these investigations. But doctors prescribing the same drugs that they help to market can’t be far behind.

Imagine this scenario: Dr. X gives Seroquel talks for AstraZeneca. Dr. X also writes plenty of Seroquel prescriptions. Patient Y becomes obese after a year on Dr. X’s Seroquel. On the web, Pt. Y finds out that Dr. X made $50,000 from AstraZeneca over the past year. Pt. Y is not happy, and there are plenty of attorneys around looking for business. Dr. X could get into serious legal trouble.

This scenario, which may have sounded far-fetched only a few months ago, should now strike fear into the hired gun’s heart, and will hopefully lead to a gradual end of this dodgy marketing practice.


Anonymous said...

Effexor was 'similar' to other antidepressants- also on-patent and therefore more expensive. Therefore, you were basically paid to raise the cost of treating depression when generic meds would have worked just as well.

James M. La Rossa Jr. said...

A distinction should be made between surgeons who rely on implantable devices, and other fields of medicine, like psychiatry, where clinicians prescribe drugs. The NYT article references Michael J. Sullivan, the United States attorney for Massachusetts, who has been at the forefront of criminal investigations for many years, since numerous makers of cardiovascular and orthopedic implants are based in Mass. These implantables are enormously expensive, and surgeons tend to have strong preferences. If a surgeon's preferred device is made by a company he/she speaks for, the appearance of collusion -- whether credible or not -- is difficult to overcome. Most of the top psychiatric thoughtleaders speak for numerous pharmaceutical companies, so the possibility of inferring criminality by matching their industry honoraria with their prescribing habits would be impossible. (Though Sen. Grassley and his lot have never been stopped by ill-conceived prosecutions before.)

Personally, I would rather see Federal Prosecutors use their resources to combat terrorism, domestic violence, and illegal weapons, to name just a few, then to criminalize physician drug prescribing. Patients who believe they have been harmed have adequate remedies under civil tort law.

If there is a take-home message here it is this: If you are a physician who speaks for industry, make sure you speak for as many companies as possible. As the saying goes, it's harder to hit a moving target. Best wishes to all, j.

Anonymous said...

This is a very good description of how this insidious practice of influence happens. I know now that at the time of my daughter's death the atmosphere was saturated with Paxil money, Paxil thoughts, and Paxil rewards. And ads were running on television with the theme "Your life is waiting." It certainly was not saturated with Paxil warnings and risks which thankfully are much better known to the medical practitioner and the patient today.

Daniel Carlat said...

To All:

Supremacy Claus is hereby banned from this blog because of his profane language. I have removed his recent posts and will block any future ones.

Danny Carlat

Anonymous said...


There is good reason to go after these doctors. The kickbacks they are receiving are driving up medical costs because doctors then prescribe or implant products that are more expensive or that come with more side effects.

We are trying to change health care in this country, expand coverage to more people. The costs have to be controlled, because every company's biggest customer is the federal government through Medicare and Medicaid.

wetnurse said...

I think this is a problem that is not limited to those who earn really big bucks for speaking.

What about docs who aren't speakers, but who are wannabe speakers--and thus are very heavy prescribers of only 4 or 5 drugs? There's no way to prove that or find out if there is any financial reward since it doesn't add up to tens of thousands of dollars, but remains a major contributor of rising drug costs without the commensurate benefit.

James M. La Rossa Jr. said...

Anonymous makes some good points regarding health care costs. I question whether speakers are receiving "kickbacks" and, thus, the criminalization of their speaking engagements. I don't believe that psychiatrists who speak for industry are engaged in criminal practices, nor should the penal code be stretched to include these professional activities.

Should indictments be a thing of the future, one must ask: At what point do their actions become "criminal." After one talk, five, 10? And what if they speak for industry but don't see a lot of patients so don't prescribe much of the drug themselves? Does lecturing without prescribing still rise to the standard of "criminalization?" Conversely, wetnurse seems to suggest that it doesn't matter if they speak for industry or not -- if their prescribing is limited to a few agents, they are culpable. Don't most psychiatrists have four or five "favorite" agents at any given time? If those agents are brand name drugs and not generics, does wetnurse suggest that they have committed some sort of bribery? Don't physicians have enough on their plates already without worrying whether their prescribing pads could put them in jail? I would caution interested parties from going down this road.

Anonymous said...

From my point of view the most important thing is whether doctors who are speaking out about certain drugs are being wholly honest about the benefits and the risks and basing their presentations on good science. The problem of conflicts of interest extend to the science that's being done and the conclusions that are being drawn. There is a lot of corruption in the whole scientific process and that's where the real heart of the problem is, not as much with presentations that follow on after the fact.

Anonymous said...

While I think there are many good arguments here, I think most of you are missing the point. The crack-down is to protect the companies from the doctors. Corruption is a two-way street and companies have had to deal for years with doctors who have their hands out wanting more. Unscrupulous KOLs have no qualms about telling you exactly how their speaking engagement will go down - from the limo from the airport to the champagne in the room to the entertainment, etc.

Now I'm not saying this is always the case or crying innocence for the companies - just saying some doctors out there know what they want and aren't afraid to ask for it (or threaten). Those are the ones who will be targeted, I think.