Sunday, July 26, 2015

Silence on Pro Publica's Recent Big Pharma Payment Disclosures

OK silence as far as psychiatry goes.

For the past ten years we have heard both individual psychiatrists and monolithic psychiatry maligned for accepting Big Pharma cash for presentations, expert consultations, or whatever.  The implications being twofold - that there were no legitimate reasons why a physician seeing patients should be in the employ of a pharmaceutical company and (courtesy of the Institute of Medicine) that since you can't really tell what is a real conflict of interest versus the appearance conflict of interest without some additional leg work that we should just consider any potential conflict of interest an actual conflict of interest.  At that point, the body in the US with the most real conflicts of interest that I can think of (Congress) decided that all payments from pharmaceutical companies and device makers should be catalogued in a data base for everyone to see.  When I accessed the database, it was a clear example of government information technology (IT) at its worst.  There are numerous examples of government IT projects being abandoned as unusable after an investment of hundreds of millions of dollars.  The recent hacks exposing the private information of millions of government employees and millions of classified documents are good examples of the lack of quality in government IT.  Why expect any higher bar with payment disclosures to physicians?

Rather than navigate the unnavigable, a better approach is to look at secondary data sources who have the time and staff required to translate the data like Pro Publica.  On their opening web page there is a small window half way down that asks:  "Has Your Health Professional Received Drug Company Money?"  I plugged in my name as a double check on the system and it returned 27 results with either a first or last name George or a last name Dawson.  None of them was me (which is accurate).  Only one of them was a psychiatrist and that physician had received a total of $88.  The remaining physicians had received anywhere from 0 to $18,450.  I would certainly not be very happy if I was included in this database for receiving zero dollars and wonder how often that mistake is made?

The bar graph of what types of fees were paid by the industry is instructive.  The largest single group of payments were for "Royalty or License" and number of current brand name chemotherapy and antiviral drugs were mentioned.  The next category was "Promotional Speaking".  I can't imagine that rheumatologists, endocrinologists, and cardiologists are not in demand to speak to primary care physicians about the latest developments in their fields.  I have spoken at Primary Care Updates in psychiatry for primary care physicians.  Are those presentations classified as "Promotional Speaking" if a pharmaceutical company sponsors it and the speaker does not mention one of their products by name?  I have similar questions about "Consulting Fee".  If a physician has a specific expertise and is paid by the private company for that expertise, in my opinion they are no different than any other University faculty in similar positions.  The idea that a physician's entire life is encompassed in relationship with patients and that this is somehow a sacred trust is a myth that is perpetrated by concerns who are quite willing to exploit all physicians on that basis.  They are all listed in various places on this blog.

One of their lead stories is A Pharma Payment A Day Keeps Docs’ Finances Okay.  In that article they focus on a neurologist who received $594,363 from 29 different pharmaceutical companies.  They looked at the top rated physician and concluded that she received payments from pharmaceutical companies on 286 days out of the year.  14,600 doctors received payments on at least 100 days per year.  A total of 606,000 doctors received payments, but then again there are people listed in my first search who apparently did not receive any money.  And then there was this excerpt:

"The nation's 3,900 rheumatologists in the data averaged 40 days of interactions with drug and device companies, more than doctors in any other large specialty. They were followed closely by endocrinologists, electrophysiologists and interventional cardiologists...."  In my home state of Minnesota they list the top 20 physicians receiving money from pharmaceutical and device companies and 19/20 are surgeons (orthopedic, spine, eye) and one is a cardiologist.

No psychiatrists?

That is a curious phenomenon considering how frequently psychiatrists are maligned for financial conflicts of interest in the popular media and blogosphere.  No Senate investigations of rheumatologists, endocrinologists, neurologists, or cardiologists?  No attacks on their professional organizations?  No suggestions that their diagnoses, interventions, prescriptions, publications or professional behavior are questionable based on their reimbursement from private industry?  Why is that exactly?  I certainly have plenty of good ideas.

In order to clarify the real picture here, I sent an e-mail to Charles Ornstein, the lead author of the  "A Pharma Payment A Day..." article.  I asked him to post the statistics by specialty including the percentages of physicians getting some payment, per capita payments or by whatever metric they chose.  Considering the scope of payments suggested by these tables, my speculation is that there will be several physicians in the tens of millions of dollars category and that none of them will be psychiatrists.   But I am content to wait to see if he posts those results.   

Until then, don't ever believe that what you read about psychiatrists is a random event free from the usual antipsychiatry biases.

No matter what happens with the Pro Publica data - don't believe that anyway.

George Dawson, MD, DFAPA  

1.  Charles Ornstein and Ryan Grochowski Jones.  A Pharma Payment A Day Keeps Docs’ Finances Okay.  ProPublica Web Site.

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