- Machiavelli's Laboratory is a free ebook that I published on April 13, 2010. It is a satiric discourse on scientific ethics, from the perspective of an unethical scientist. Please don't take any of the advice and opinions in the book (or the excerpts featured in this blog) seriously.
This blog entry continue's yesterday's blog, "Psychiatry: slow care getting faster".
To summarize yesterday's blog, modern pharmaceuticals allow psychiatrists to treat more patients, in less time. Consequently, psychiatrists have been prescribing more and more drugs, thus bringing billions of dollars of annual sales for the big drug companies. This has helped make drug companies the most profitable of all the big industries in the U.S.
The problem for the psychiatrists is that they don't get any revenue from those prescriptions. Since 1987, the Antikickback Statute has restrained the drug companies from paying physicians for the prescriptions they write (1). Specifically, Section 1320a-7b(b) makes it a felony to solicit or receive remuneration (in the form of a kickback, bribe or rebate (directly or indirectly, overtly or covertly, in cash or in kind) for arranging an individual to receive an item (such as a prescription drug) or service for which payment may be made in whole or in part under [Medicare] or a State health care program (1).
The AntiKickback Statute may have enhanced the level of trust between patient and physician, but it has nearly destroyed the mutually beneficial relationship between physicians and drug companies. If psychiatrists couldn't receive any remuneration for their prescriptions, might they not revert to their formerly standard practice of listening to patients?
The stakes are high. When an antipsychotic medication sells well, much of the credit should go to the psychiatrists who write the prescriptions. Just two anti-psychotic medications: Zyprexa and Risperdol, each provided sales exceeding $4 billion dollars, in 2006. If psychiatrists were to engage in pharmaceutical-free psychotherapy sessions, the drug companies would lose many billions of dollars.
For drug companies, psychiatry is a chemical industry, and mental illnesses are chemical deficiencies. For example, schizophrenia can be thought of as a Quetiapine deficiency, and depression can be thought of as an Escitalopram deficiency. The chemicals that nature failed to provide are now available in convenient gel-cap or tablet form, courtesy of the American pharmaceutical industry. To sell their chemicals, the pharmaceutical companies must convince psychiatrists of the following:
- Every sanity-challenged patient can benefit from pharmaceuticals.
- Patients deserve the very best pharmaceuticals available, and the best pharmaceuticals are the newest pharmaceuticals (i.e., still under patent protection).
- Mental illness cannot be treated overnight. Patients must be treated indefinitely, or at the very least, until their health benefits and their personal savings, are exhausted.
If hefty kickbacks cannot clarify these three self-evident principles, then some other method of persuasion is necessary. The pharmaceutical industry, resourceful to a fault, developed the marketing concept of the "physician thought leader" (2). It works something like this:
- A pharmaceutical company representative seeks the "expert assistance" of a local psychiatrist. The representative explains that his company, which employs thousands of professionals and earns billions of dollars each year, is woefully lacking in the kind of "hands-on" expertise wielded by the local doctor.
- The doctor is asked to serve as a thought leader for his local colleagues.
- A dinner seminar is arranged wherein the local doctor presents a powerpoint demonstration (prepared by the drug company) highlighting their products. As the thought leader, he moderates a discussion in which his colleagues ask quesions and discuss their own experiences prescribing the company's drugs.
- The doctor receives a generous check; the first of many.
Doctors love being consultants for the drug companies. Besides the money, it's a highly valued ego boost. Psychiatrists seem to be particularly susceptible to this kind of manipulation. Knowing very little about clinical medicine, psychiatrists are seldom taken seriously by other members of the medical profession. Few psychiatrists have the ego strength to rebuff the advances of a pharmaceutical representative who values their clinical knowledge.
It's hard to find an academic psychiatrist who has not received money from the pharmaceutical industry (examples are easily found (3)). The payouts can exceed a million dollars. A Harvard psychiatrist received $1.6 million from a pharmaceutical company but did not report much of the income to Harvard University. The payments were absolutely legal. The psychiatrist got into some trouble only because he failed to report the income to his employer, Harvard (4).
In a recent review of authors who write clinical practice guidelines, it was found that the vast majority had financial ties to pharmaceutical companies (5). It was rare for any of these conflicted authors to disclose their drug company affiliations. A survey of physicians has shown most payments received by doctors, for collaborations with pharmaceutical companies and with the medical devices industry, are deemed appropriate by their colleagues (6).
The American medical-industrial complex is profoundly mercantile. Physicians, much like pharmaceuticals, are up for sale.
REFERENCES
[1] The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. 1320a-7b (the "Antikickback Statute"), P.L. 100-93, January 23, 1989.
[2] Spiegel A. How To Win Doctors And Influence Prescriptions. National Public Radio October 21, 2010.
[3] Expert Interviews. Disclosures. American Academy of Child and Adolescent Psychiatry. 2010. http://www.aacap.org/cs/
expert_interviews/disclosures]phych_pharm_consultants.pdf
[4] Harris G, Carey B. Researchers fail to reveal full drug pay. The New York Times June 8, 2008.
[5] Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA 287:612-617, 2002.
[6] Ross JS, Keyhani S, Korenstein D. Appropriateness of Collaborations between Industry and the Medical Profession: Physicians' Perceptions. AJM 122:955-960, October 2009.
- © 2010 Jules Berman
key words: medical-industrial complex, American healthcare, physician reimbursement
