California Physician Payment Data Shows Little Correlation between Prescribing and Consulting

One area that Senator Charles Grassley (R-IA) has focused on over the past several years has been investigating payments and prescribing rates of psychiatric and pain medications nationwide. This investigation led to an article last week covering payments to three San Diego County doctors who accepted five-figure payments from pharmaceutical companies.

The article, posted by California Watch, used the data from ProPublica. Continuing the trend of other local media sources that have gotten their hands on this data, the story portrays such payments in a biased manner. Although the article, like others, quotes physicians who received such payments, it paints physician-industry collaboration in a negative light.  

What makes this article particularly interesting is that “officials from Medi-Cal, the state program for the poor and disabled, provided a list of California’s top 10 prescribers to Senator Grassley. According to the article however, only three of the top ten accepted $20,000 or more in educational or speaking fees from the company that makes the drug they prescribe to Medi-Cal patients, company disclosures show. What about the other 7 prescribes in the top 10? Presumably, they were paid less than $20,000 or not at all.

California authorities specifically warned against viewing the data for this purpose because they did not want Grassley or media looking at payments as the “sole indicator of fraud or abuse.” Yet by including only 3 or the top 10 prescribers, California Watch did exactly that, without even considering the real benefits of industry-physician collaboration, or acknowledging the other 7 prescribers.

The story uses the same language from other local media sources who practically “cut and paste” their articles from the original stories from ProPublica, hardly investigative journalism. The article notes that “accepting drug company payments and then prescribing the products to patients is not illegal or even unethical, in and of itself.”

However, they distinguish this point my noting “critics” who are “concerned such marketing could induce over-prescription of drugs or otherwise corrupt the process.” First, where is the evidence that such payments will lead to this? Second, what about the supporters of industry-physician collaboration? Besides including quotes from the doctors themselves who received such payments, what about experts who recognize the importance of working with industry to improve patient outcomes and physician education and training? California Watch includes no quotes from them.

Nor do they acknowledge the significant and numerous breakthroughs that industry-physician collaboration has achieved (i.e. longer life, vaccines, lower death rates in cancer and heart disease, and numerous others).

Instead, they acknowledge drug companies who explain that “speaking fees help educate health care providers about the use, safety and benefits of their products.” Tony Jewell, AstraZeneca spokesman, told California Watch that “Physicians are selected to speak based on expertise in the area, and may not be nominated or retained as speakers in exchange for or as an inducement to any past, current or future prescribing or recommendation of the use of AstraZeneca medicines.”

Payments

What makes this article problematic is that the payments are low and merely represent the fair market value of payment for doctors who are losing money from being away from their practices. Moreover, the overwhelming majority of these payments are to educate other health workers and to lead educational forums.

John Allen, who was among the state’s top prescribers of Zyprexa, an antipsychotic drug, received payments from companies to educate other medical professionals about those drugs. He told California Watch that “he conducts speeches about Zyprexa for Lilly based on information contained in the literature that comes with doses of the drug.” He added that he speaks for a variety of drug makers only “if he has research and day-to-day experience using their medications.”

This point is very important for the public to recognize. Doctors who work for various companies that sell the same drug or similar drugs for similar diseases or conditions clearly do not have an allegiance to one company or another. Those who speak or consult with multiple companies are doing so to advance the science and medicine. They are speaking to educate doctors, and as Dr. Allen notes, because they have research and day-to-day experience using their medications.”

Dr. Allen noted that he “thinks it’s unfortunate that there’s an implication in articles that doctors are robots for drug companies.” He asserted that doctors “have to have their own experience with medications and find out what works best. They’re not 5-year-olds in front of TV watching cereal and toy commercials.” More importantly, Dr. Allen recognized that “he prescribes a wide variety of medications, new and old,” and choosing what works for the patient is most important.”

Conclusion

As Senator Grassley moves to the Judiciary Committee and continues his plans to investigate the health care industry, for now it seems like local media and news sources are able to use the database from ProPublica to sell their stories and papers in the meantime. The unfortunate consequence of this practice is that articles are still not objectively reporting these payments, and everything is being portrayed using a framing bias.

Readers can only come to but one conclusion when they see and read headlines such as “Top antipsychotic prescribers also drug promoters.” This sensationalist practice is unethical and misinformed. Journalists have a duty to report these payments fairly and objectively. Quoting critics of industry and not supporters or experts who work with industry is biased reporting. The benefits of the pharmaceutical and device industry have positively affected us all, and continuing to stigmatize them will lead to fewer jobs, less innovation, and worse health care.

Without education and information, physicians would not be able to treat the wide range of psychiatric conditions facing patients today, nor would they be able to closely monitor the side effects and risks these drugs present to patients. But we all know that keeping up with science, while treating patients every fifteen minutes, dealing with insurance companies and administrative burdens, and worrying about malpractice and other issues leaves little time for doctors to receive this information. While many believe interactions with drug reps or presentations have subtle forms of bias, these are not children being sold toys, as Dr. Allen noted.

Physicians are aware when they voluntarily choose to speak to a drug rep or attend a commercial speaking event. There is nothing “subtle” about it: doctors know they are being sold on a product, but they make that decision based on the science, and what is in the best interest of their patient. Why would a doctor put his career, his family, his practice, and his life on the line for a pen or free dinner or sample? The answer is they would not.

In the end, if critics really want physicians to stop seeing drug reps and attending commercial events, then show them why. If education, training, and information from the very industry who studies, researchers, and tests the products physicians uses are so bad and unethical, than 1) prove it and 2) provide another equal or better alternative. If patients can have better outcomes when their doctors do not interact with industry, and physicians can still be as up to date on the latest breakthroughs in medicine and treatments without information from companies, where is the evidence?

For now we have the evidence that people are living longer, healthier lives, in less pain and are happier. People survive deadly diseases longer and have better chances of beating and detecting such illnesses before they become unstoppable. This is all with doctors meeting with drug reps, attending speaking events, and through CME. As a patient, would you want all this to change because your doctor is being compensated for his time away from his office?