Is your physician receiving bribes from pharmaceutical or device companies to overprescribe their high-priced products?
Some people think it is really easy to find out. Anyone can simply go onto the , powered by the Center for Medicare and Medicaid Services, which lists financial payments from pharmaceutical companies to physicians. Type in the name of any physician and -- voila! Instantly, you can see how much money is listed for any given doctor.
Last year (2017), the ! Wow, that is a great deal of money. It is certainly tempting to conclude that physicians are selling their souls to industry and that patients suffer as a result.
But those payments went to 628,000 physicians and 1,158 teaching hospitals. A large proportion of the payments were for royalties and other intellectual property. A large chunk consisted of research payments for clinical trials. Another sizeable proportion was related to consulting fees, which are typically linked to new drug development. A major proportion of the listings are small sums of money, which reflect the costs of food consumed in connection with conferences and meetings. (Disclaimer: All of my payments are related to consulting fees connected to research on unapproved drugs or indications, which I do not prescribe in practice, and I do not give promotional talks.)
Where are the bribes?
There is an obvious place to look. If you sum the monies unrelated to royalties, research and consulting, in 2017, there were payments of about $630 million for either "services other than consulting" or "honoraria." This number reflects an average payment of about $1,000 to each physician in the database.
What are these "services" and "honoraria"? Some of these monies go to physicians to compensate them for giving promotional presentations to other physicians about approved drugs or devices, presumably to entice them to utilize the product more often.
Have you attended one of these promotional talks? I dropped in on one presentation at a recent cardiology conference, and it was awful. All of the slides that were shown were pre-approved through a lengthy medical and legal process, and the comments by the speaker were scripted and limited.
Why? If the company is sponsoring the presentation, its content is supposed to conform to approved labeling. So the sponsor is obligated to ensure that the meeting is compliant with regulations. The result: a talk that often has minimal evidence of an intellectual process. Why does the speaker even show up? The whole event could easily have been replaced by attendees watching a video.
Are these promotional presentations a form of bribe? They can be.
According to an , five doctors were recently charged with receiving kickbacks for prescribing a high-priced formulation of fentanyl. In exchange for increasing prescriptions of the drug to their patients, the manufacturer of fentanyl (Insys) paid the physicians to give "promotional talks" on the product. Apparently, the promotional talks never actually occurred, and the physicians are reported to have been paid upwards of $100,000 annually for merely showing up at social events. According to the article, these events were used to conceal kickbacks to them for increasing their fentanyl prescriptions.
Is this a bribe? If the description is accurate, the answer is unequivocally: Yes! This is a bribe! It is horrible and detestable. It represents exactly what the Open Payments website is supposed to reveal. In fact, if you look at the Open Payments website, the alleged kickbacks are included in the database, and they are clearly labeled as "Promotional Speaking/Other." Curiously, they appear at regular intervals.
Do you want to eliminate these payments? If you are inclined, you can propose a simple rule: If a physician prescribes a drug to patients in their medical practice, he/she should not be allowed to receive any payment from the manufacturer of that product for talking to other physicians about its benefits.
It is an intriguing (but draconian) proposal. More importantly, aside from its questionable legality, such a rule would not achieve its intended purpose. Most physicians who receive honoraria for giving promotional presentations are not being bribed. They are being paid for their expertise and time. And certainly, companies have the right to promote their products. Some might wonder about the virtues of such an activity, but the presentations provide both information and an opportunity for attendees to ask questions and interact with clinicians who have expertise and experience. And they are much better than television commercials!
More importantly, prohibiting promotional presentations won't eliminate bribes.
If industry wants to exert influence, it has countless ways of doing so. Few of them are revealed on the Open Payments website.
You don't believe me?
In 2016, Novartis paid $1.2 million to Trump's attorney Michael Cohen for some service. Many have validly wondered about the company's expectations at the time. But if you type in "Michael Cohen" and "New York" into the Open Payments website, you will not find any evidence of an exorbitant payment from Novartis. Michael Cohen is not a licensed physician, so the transaction never appears on the Open Payments website.
That is the whole point.
Thinking that the Open Payment website is a reliable way of revealing influence-peddling by the drug and device industry is akin to thinking that aspirin is a good treatment for malaria. It might occasionally help with the fever, but it doesn't get close to solving the problem.
Disclosures
Packer recently consulted for Actavis, Akcea, Amgen, AstraZeneca, Boehringer Ingelheim, Cardiorentis, Daiichi Sankyo, Gilead, Novo Nordisk, Pfizer, Sanofi, Synthetic Biologics, and Takeda. He chairs the EMPEROR Executive Committee for trials of empagliflozin for the treatment of heart failure. He was previously the co-PI of the PARADIGM-HF trial and serves on the Steering Committee of the PARAGON-HF trial, but has no financial relationship with Novartis.