The AMA, Going Reagan, Turns to Bean-Counting Again

It’s a “there you go again” moment for the American Medical Association.

We learn from CNN’s Elizabeth Cohen’s twitter page that the biggest standing ovation given to Obama by the AMA House of Delegates was in response to this line:

“You did not enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers – and that’s what our health care system should let you be.” (Here is the entire text of the president's speech.)

It is ironic that this sentiment in particular moved the AMA so, considering that the organization’s actions at the meeting so far indicate that bean counting—that is, counting their hard-earned money—is exactly why these doctors entered the profession.

First, they announced that they would not support an optional public insurance plan, because it might mean less money for doctors (though they appear now to be trying to recant that statement). They are basing their opposition on figures showing that Medicare pays doctors 20% less than private health plans, and therefore an expanded Medicare-like public insurance program might mean less money in their bank accounts.

A pay cut? Outrageous!

Here’s a news flash: all the players in the health care industry—doctors, hospitals, and insurance companies—are going to have to accept pay cuts if we want to bring health care spending under control. The AMA’s posture of knee-jerk opposition to anything that smacks of financial sacrifice gives it the look and feel of a reactionary organization, which is how they looked when they hired Ronald Reagan for "operation coffee cup" in its ill-fated effort to defeat Medicare in 1965.

Second, the AMA, yet again, has decided that its own ethics committee just doesn't understand medical ethics, at least when it comes to the topic of industry funding of continuing medical education. This is an issue I have covered here and here. One year ago, the first time the AMA read CEJA's report on CME (CEJA being the Council on Ethical and Judicial Affairs), the delegates rejected it because it announced the bad financial news that industry funding of education for doctors represents an unresolvable conflict of interest and therefore has to go.

Now, a year later, a new CEJA, under a new chair, introduced a new report, this time saying that industry funding of CME can continue, but it is still “ethically preferable” for doctors to pay for their own education. Apparently even this watered down version of medical ethics is unacceptable to the AMA, because defining industry-free CME as "preferable" might slow down the flow of industry cash, so they rejected it, referring it back to CEJA for more extreme dilutions. You can read the particulars on the Policy and Medicine blog.

Presumably, the next report will not dare to even mention ethics and industry funding in the same breath. I predict that the entire report will be brief and to the point: “Industry funding of CME is necessary for the public health.” Now that’s the kind of sentiment any bean-counting doctor can get behind!

Margaret Soltan on Zachary Stowe

The irrepressibly to-the-point Margaret Soltan has a nice post about the Zachary Stowe fiasco on her University Diaries blog. The commenters, too, are eloquent, subscribing to the dictum that brevity is the soul of wit. I suggest you surf on over to her site.

Other coverage of the affair can be read in the Fierce Pharma blog, the Chronicle of Higher Education blog, and the Atlanta Journal Constitution.

The Latest Conflict of Interest Poster Child: Dr. Zachary Stowe

The latest casualty of Charles Grassley’s investigations of conflict on interest is Zachary Stowe of Emory University.

Dr. Stowe is probably the most well known researcher in the risks of breastfeeding while taking antidepressants, and it is sad to see his reputation taking a nose-dive with these revelations.

The news originally broke in this article in the Wall Street Journal , but if you can’t stand the idea of actually paying for content you can find some of the same information for free on this post on the WSJ blog.

The bottom line is that Stowe has run into the same ethical problem as his boss Dr. Nemeroff—he was taking public NIH money to conduct research, while at the same time giving dozens of promotional talks for a company that stood to benefit from the results of that research.

Specifically, GlaxoSmithKline (makers of Paxil and Lamictal) paid Stowe $154,400 in 2007 and $99,300 during the first 10 months of 2008.

When I first saw this story I was rather unfazed and wasn’t even sure it was worth blogging about. Another academic using his NIH-supercharged credibility to make a bundle by hiring himself out to the highest bidders? Yawn, right?

But when I started to look through the publicly available documents, I realized there’s a bit more to this story than meets the eye.

For one thing, Stowe appears to have been deceptive during a recent deposition, when he claimed that on top of his $232,000 Emory salary, he earned an additional 20 – 30% more doing work for pharmaceutical companies. But wait a minute--if he made $154,400 from GSK alone in 2007, by my calculation this is already 66% more salary than he got from Emory. And Stowe did work for lots of other companies as well. Here is his disclosure from a Medscape CME gig he did in March 2007:

Disclosure: Zachary N. Stowe, MD, has disclosed that he has received grants for clinical research, grants for educational activities, and has served as an advisor or consultant to GlaxoSmithKline, Wyeth, and Pfizer. Dr. Stowe has also disclosed that he has served as an advisor or consultant for Bristol-Myers Squibb. Dr. Stowe has also disclosed that he has served on the speaker's bureau for GlaxoSmithKline, Wyeth, Pfizer, and Eli Lilly.

Who knows how much money he was also getting from Wyeth, Pfizer, Bristol-Myers Squibb and Eli Lilly? He may very well have doubled his Emory salary, or more.

Furthermore, the $154,400 disclosed by GSK does not include all the cash they paid Stowe through laundered CME money. For example, here is a CME program Stowe did for Medscape that was funded by GSK. The program is entitled “Long-term health risks of antiepileptic drugs in women” and is essentially a commercial for using Lamictal in pregnant women with bipolar disorder. In it, Stowe begins by saying nasty things about Lamictal’s competitors, Depakote and Tegretol, and then minimizes a large study showing that Lamictal causes cleft palate. I’m sure he got paid a lot for this, and that he did plenty of other similar CME programs that are scattered somewhere throughout the internet.

But wait! There’s more!

We learn from a remarkable series of emails furnished by GSK to Grassley that Stowe gets pretty agitated when he doesn't get enough promotional money. Look at Attachment C of Grassley’s letter if you’d like to follow along here.

First, sometime in August of 2003, a GSK rep emails Stowe that he is “sincerely sorry” but that they have to cancel two scheduled talks (that would have been $2500 a pop, his usual rate) in Wisconsin because attendance was too low.

On 8/19/09, Stowe responds politely, but says that this late cancellation presents "two problems." As it turns out, Stowe schedules only 4 days per month to give talks for drug companies, and the cancellation meant that “others are denied speaking engagements.” He then asks, “What provisions do you propose for my compensation for my lost time?”.

Stowe's second problem is that he had apparently been coordinating this GSK gig with a meeting at the American College of Obstetrics and Gynecology and he would now have to arrange a new flight at the last minute. He believes, therefore, that GSK owes him: “Given the circumstances I think GSK should book and cover the costs of the trip up as well…”

I guess I can understand Stowe’s being upset about a last minute cancellation of a lucrative speaking gig. If he had already paid for a plane ticket for that, then of course GSK would owe him that money. But that’s not the case here. Stowe was apparently planning to mooch off some aspect of the GSK travel to defray some costs associated with a meeting he was planning to go to anyway. Without the GSK money, he now has to pay his own way entirely, and so he wants GSK to fund those costs, even though it has nothing to do with GSK!

You can imagine that whoever got this email was not very happy, and didn’t respond as quickly as Stowe wanted. So Stowe sends off another email on 8/27/03, again pretty polite, admitting that he had once rescheduled these talks, and that since maybe his recheduling affected the attendance, he would settle for getting paid only $2500 for a talk he never gave, rather than insisting on $5000 for two talks he never gave.

But still no reponse from GSK. Stowe fires off another missive on 9/13 saying he was sorry the programs “didn’t work out” and wants to make sure they have his address for a check.

Again, utter email silence from GSK—what lousy handlers they are! So on 9/18, Stowe lets it rip. Warning that he is “no longer in a compromising mood,” he is now demanding $4500, not just $2500, and points out that “you are still getting a $500 discount” because he usually gets $5000 for two talks.

On the same day, he emails a colleague, apparently someone higher up in his department (a wild guess: Nemeroff?) to complain about the issue:

“REP NO RESPONSE – need your input or direction where to take this….I emailed the rep 3 times now with no response, because I had originally rescheduled this from an earlier date I told the rep that I would be okay with the 2,500 instead of the full 5,000 for the last minute cancellations (which I thought was very nice of me). She has failed to respond to 3 emails and I am getting slightly agitated, in fact to the point that she can just find the full 5,000 since my compromise has been ignored. I know that this has no business on your radar screen, but need a name of who to go to. Thanks for your help- talk to you soon. Any feedback on the Miami gig yet?”

I don’t know what the “Miami gig” meant, but I hope he got $5000 out of it!

Finally, on 9/19, somebody from the company responds, saying they will “take care of it.” According to Grassley, eventually Stowe received some compensation, but we don’t know exactly how much.

What to make of all this? It's a creepy insider's look at how entitled our key opinion leaders became at the height of the drug company gravy train in the early to mid 2000's. The only good news is that it is all coming to a screeching halt. According to the WSJ, Stowe has been formally reprimanded by Emory and ordered to cease his promotional talks. Of course, Emory recently announced a new policy that bans such practices anyway, so this may be a bit of overkill.

When Greed Happens to Good People: Atul Gawande's Solution to the Health Cost Crisis

You might have already seen Atul Gawande’s piece in the New Yorker called The Cost Conundrum. It has been covered in the excellent Century Foundation Blog, Taking Note.

In it, he tackles one of the problems at the core of our nation’s health care cost crisis: greedy doctors, or rather, greed-inducing incentives for good doctors. In this blog, I’ve looked at how greed has distorted the decisions doctors make when they are providing education to other doctors. It’s not that the key opinions leaders are bad people, but they are responding as rational human beings to perverse economic incentives. If you put yourself in a situation where you can make thousands of dollars for omitting certain points about a drug during a talk, chances are that you will, indeed, omit those points. The solution, in this case, is to remove the problem incentive (that is, stop accepting industry money for medical education), and the doctors will no longer be tempted to bend the truth.

Gawande looks at this same kind of greed from another perspective, and arguably a more important one. How does the allure of money actually affect the medical decisions doctors make about your care?

He starts his investigation by focusing on the small Texas city of McAllen, population about 130,000 . He finds that McAllen has the surprising distinction of being one of the most expensive health care markets in the country. In 2006, according to Gawande, Medicare spent $15000 per enrollee, more than twice the national average.

Gawande spends the rest of the article wondering why. Is it because people in McAllen are twice as sick as those in other cities? No—McAllen has lower than average rates of cardiovascular disease, cancer, asthma, HIV, infant mortality, and injury. McAllen has essentially the same demographics and health statistics as El Paso county, 800 miles to the north, but El Paso’s Medicare expenditures were only half that of McAllen's--$7504 per enrollee.

Perhaps doctors in McAllen are ordering more tests because they are more afraid of malpractice suits than other doctors? But that doesn’t make sense, because Texas has passed one of the toughest malpractice laws in the country, capping pain-and-suffering awards at $250,000. The number of lawsuits has plummeted, said one cardiologist interviewed by Gawande.

Finally, Gawande meets with a hospital administrator who is willing to speak frankly (though anonymously). It turns out that at some point over the last 15 years, doctors in McAllen developed a thirst for profit. Rather than seeing their practices as noble professions that also happened to provide them with a good income, they began to view their practices as income streams. Doctors began buying imaging centers and surgery centers, and found that they could profit greatly by referring patients to their own treatment centers for expensive tests. In some cases, Gawande heard stories of blatant corruption, such as doctors demanding huge fees from hospital executives for steering patients to their hospitals. One doctor, for example, reportedly asked for $500,000 per year as a kickback for sending the hospital his business.

A marketing rep for a home health agency told Gawande that doctors have requested kickbacks for sending patients to home health agencies as well:

“Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.”

What in God’s name has happened to the doctors of McAllen, Texas? Somehow, they have embraced the culture of money, just as the key opinion leaders in psychiatry and other fields jumped onto the gravy train of industry-funded medical education. Gawande interviews Woody Powell, a Stanford sociologist who has studied the “anchor tenant” theory of economic development. Just as an anchor tenant store will dictate the character of an entire mall, so will an anchor tenant university or hospital or physician foreshadow the culture of a community. To quote Gawande:

“About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.”

Dr. Lester Dyke, a cardiac surgeon in McAllen, and one of the few doctors to publicly criticize its health care system, tells Gawande that “Medicine has become a pig trough here….We took a wrong turn when doctors stopped being doctors and became businessmen.”

In the last part of his article, Gawande outlines some solutions, highlighting organizations and communities that have kept health costs below the national average while achieving some of the highest quality-of-care scores in the country. These include the Mayo Clinic in Minnesota, the community of Grand Junction, Colorado, Kaiser Permanente in Northern California, the Geisinger Health System of Pennsylvania, the Marshfield Clinic of Wisconsin, and Intermountain Healthcare of Salt Lake City.

The key to all these systems is creating financial incentives to coordinate care, rather than to simply order as many tests and procedures as possible. Such a system, he believes, is possible in the context of either a single payer system or a mixed private and public insurance system, as is more likely to be the outcome of Obama’s health care reform efforts. More important than the specifics of health care reform, concludes Gawande, is “whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.”

Spurred by Nemeroff Debacle, Emory Reforms Ethics

According to the Atlanta Journal-Constitution, Emory University School of Medicine has announced a new ethics policy that, among other things, forbids any Emory faculty from speaking for drug companies and bans gifts from industry.

You can read the updated ethics policy here.

Regarding industry-funded CME, the report makes the intriguing statement that:

"Revisions in national and School of Medicine guidelines and policies on continuing medical education are underway. Therefore, this policy currently contains only limited revisions at this time."

I assume this is an oblique reference to the recent hard-hitting report from the Institute of Medicine, which has recommended that a new system of CME funding be developed within two years that will prevent direct industry funding of courses.

At any rate, Emory's updated ethics code still allows its faculty to speak at industry-supported CME events, but does not allow such courses to occur in any Emory-affiliated buildings. In addition, the policy states that:

"Preferably the event will have more than one industry sponsor, and possibly an institutional cohost."

Behold the Pri-Med Empire

Oddly enough, the day after I posted an article about the scandal involving Partners, Harvard, Jack Connors, and Pri-Med, I received the postcard below inviting me to attend Pri-Med's Boston event in November. As you can see, the affiliation between Harvard and Pri-Med is prominently displayed. However, what is not mentioned is that most of the conference consists of industry-supported symposia. In fact, not a single drug company name is printed on the brochure, although in small print on the back of the card is the following statement, buried in the middle of the program's overall description: "Learn in a smaller setting and earn additional AMA PRA Category I Credit on the Pre-Conference Symposia Day and at the Industry-Supported Symposia. Separate registration and ticket are required."

It makes it sound like the industry symposia are a small part of the conference. Nothing could be further from the truth. According to this study of the Pri-Med courses published in the Journal of Continuing Education in the Health Professions, the conference consists of 27.5 hours of non-sponsored lectures by Harvard faculty, versus 43.5 total hours of industry supported lectures, which also give the attendees free meals. Furthermore, according to the study, the industry-funded courses focused almost exclusively on a small subset of medical topics for which the sponsoring companies market a new product. Durng the 2000-2001 academic year (soon after Jack Connors bought the company), the 103 industry symposia covered 30 different topics (primarily related to diabetes and arthritis), while the Harvard courses covered 133 topics.

The industry symposia ignored rather important topics such as: preventive screening, pediatrics, cancer, child abuse, problem drinking, skin problems, and technology resources for clinicians. Sorry, but there's just no money in these topics.

Pri-med Brochure p 1

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Pri-Med Brochure p2

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Harvard Med School, Jack Connors, and the Manipulation of Power

Sunday’s Boston Globe reported yet another conflict of interest problem in medicine. This one, however, is on a scale that will astonish even the most jaded observers of recent events.

According to two-time Pulitzer Prize winning journalist Steve Kurkjian, Jack Connors, the chairman of the board of Partners Healthcare, never bothered to inform the board that he was the major owner of a drug industry funded CME empire. The company, M/C Communications, runs the lucrative Pri-Med courses, a series of industry-funded symposia that reach 35,000 doctors per year.

According to the article, Connors bought the company (with an investment group) for $13 million in 2000, and sold it for a whopping $450 million in 2004, personally making $250 million in profit from the deal.

So what? Jack Connors is a successful businessman and entrepreneur. There’s nothing wrong with flipping a company and making a tidy sum in the process, right?

Generally speaking, that’s true. In this case, however, there was a web of undisclosed relationships that enabled Connors to make that kind of money. Connors is neither a physician nor an educator. But he knows advertising, having co-founded Hill Holiday, the main advertising firm for Partners. The way advertisers become rich is by finding rich companies and promising them a lucrative market for their products. In the world of industry-funded CME (which is merely a deceptive form of promoting industry products), that lucrative market consists of doctors. The more doctors you can attract to your courses, the more you can charge the drug companies that fund those courses. The best way to attract doctors is to promise them gold-plated medical education, and nowhere does this gold shine more brightly than at Harvard Medical School.

By being chairman of the board at Partners, Connors had access to the key decision makers at Harvard Medical School, access that would have easily allowed him to negotiate deals on behalf of his company, M/C Communications. According to the Globe article, M/C has an “exclusive commercial relationship” with Harvard Medical School. The Pri-Med website is quick to make drug companies aware of this fact:

“Because of our relationship with Harvard Medical School, clinicians are drawn to our conferences and the opportunity to engage with peers and learn about the latest advancements in the medical community.”

Did Connors actually exploit his position with Partners to hawk medicine’s equivalent of Boardwalk and Park Place to drug companies? He denies it, saying that he was only a “passive investor” and that he never spoke to Harvard’s dean about his company. Maybe he is telling the truth here...but then again, maybe not. Connors certainly damages his own credibility when he defends his decision not to disclose his ownership of M/C Communications to the Board:

“Connors said he was under no obligation to disclose his ownership of M/C Communications to the Partners board. He said that while there is an "affiliation" between Harvard Medical School and the two Partners hospitals, there is no formal contract between them.”

This is like saying that when two people marry there is not really a contract between them, only an “affiliation.”

Apparently, Connors has studied the Bill Clinton playbook of wordsmithing . Partners was literally founded in 1994 by Harvard’s two main teaching hospitals, Mass General and Brigham and Womens. There may be no “formal contract” between Partners and Harvard, but without the Partners hospitals, Harvard Medical School would have all the power, money, and prestige of a local community college.

Former Partner’s board members interviewed by Kurkjian were dismayed to learn about Connors’ odd opinion about appropriate disclosure—unfortunately, they opted to remain anonymous, perhaps fearing repercussions from Connors.

W. Micheal Hoffman, who is a specialist in corporate conflict of interest policies, explained to the Globe why this is a major PR problem for Partners:

"That's not good governance," said Hoffman, noting that M/C's relationships with Harvard Medical School and the pharmaceutical industry were close enough that Partners trustees should have discussed it. He said the board could have placed restrictions on Connors's private ventures or even demanded that he choose between his for-profit enterprises and his nonprofit chairmanship. Or, he said, after vetting the issue, the board could have decided to take no action.
"People are going to think that the trustees have either a laissez-faire or old-boy network attitude toward conflicts of interest," Hoffman said. "And Partners can only lose with that attitude out there."

All in all, this is a remarkable--if nauseating--example of the manipulation of power at the highest level of American medicine. Kudos to Kurkjian and the Globe for printing it. This is the kind of investigative journalism that we will lose if our newspapers go under—so keep up your subscriptions!