How effective will the physician payment national database be?

ProPublica.org did some interesting frontrunning on the physician payment national database that will become operable sometime around 2013 as part of health care reform.

In the first of a series of stories that has been picked up by several mainstream media outlets, the New York-based investigative journalism non-profit culled all the physician payments that have been publicly posted by seven drug companies to date. It aggregated the dollars to create a hierarchy of top industry buckrakers; and compared that database to physician sanction records in the states. Do yourself a favor and read their nifty, hard-hitting story, which already has some drug companies scrambling to double check the credentials of the shills they’ve put on their payrolls.

I was especially pleased to see they cross-checked the top buckrakers with their academic publishing record — a fair test of industry’s claim that they only hire “thought leaders” to spread the word about their products. As a New Yorker might say, fuhgeddaboudit. Typical thought leaders have resumes that go on for pages as they brag about publications counted in the hundreds. Most of industry’s top-paid guys (and the vast majority were men) had a handful of publications at best, and often in second- or third-tier publications, according to story.

I am a relatively knowledgeable observer of the health care scene. After perusing the list of 384 physicians earning over $100,000 from drug companies in 2009 and part of 2010, I can report back that I recognized less than ten of the names. These were not people quoted in the press, serving on Food and Drug Administration advisory committees, or publishing landmark studies in the New England Journal of Medicine, the Journal of the American Medical Association, or other top-ranked publications, whose table of contents I peruse weekly.

But here’s the rub. Now that we have this information, and will soon have more, what are we supposed to do with it? Will average patients search for their physician’s name to see if he or she is on a drug company payroll? If they do, will they act on this information? Should they?

This is an area of physician practice that cries out for regulatory oversight. Alas, no one is suggesting we ban the practice of physicians taking money from health care suppliers. But ask yourself these questions. Do you want engineers taking money from the companies that make the steel that goes into the bridges they build? It happens. Do you want judges taking money from the lawyers that practice in front of them? They’re called campaign contributions in states where judges are elected. Do you want politicians taking money from every interest group imaginable before they vote on legislation that affects those groups’ self-interest? Duh. Do we want economists taking money from investment banks to write studies that say derivatives sold on collateralized debt obligations do not pose a systemic threat to the U.S. financial system? Watch Charles Ferguson’s new film “Inside Job” if you want the lowdown on that one. The list goes on and on.

I have done a lot of railing against conflicts of interest in medicine over the past five years. I just gave an interview to a nice person from New Hampshire Public Radio, and she called me quite eloquent on the subject. But the truth of the matter is that right now, conflict of interest defines the American way of life, and not just in medicine. Journalistic exposes of such conflicts are the functional equivalent of the cock crowing when the sun comes up in the morning. The poor bird heralds the event, but he has no chance of changing its inevitability.

I sat through an FDA Cardiovascular and Renal Drugs Advisory Committee meeting yesterday where the assembled physicians refused to vote new restrictions on the use of Amgen’s Aranesp, an erythropoietin-stimulating agent for combating anemia in chronic kidney disease patients. The committee was presented with clearcut evidence that ESAs increase the risk of stroke in patients given enough drug to move their hemoglobin toward the top of the FDA-approved range.

At the outset of the meeting, the FDA made its ritual announcement about the conflicts of interest on the committee, which included six internal medicine physicians, four cardiologists, three nephrologists, a biostatitician and a pharmocologist (plus consumer and patient representatives, who had no scientific background). Not a single member had a reportable conflict of interest.

So what explains their vote? Long story short, the overwhelming sentiment of the non-conflicted physicians on the panel was that physician choice and patient preference must be preserved.

So here we have spread across this morning’s news two stories that when considered together reflect all the contradictions of modern medicine that lead to expensive and inappropriate care. ESAs clearly benefit some chronic kidney disease patients not yet on dialysis. It gives them more energy and helps them avoid transfusions. But for some, probably the sickest ones who often get the largest doses of the drug, it fails to end their anemia and carries a higher risk of stroke.

For decades, Amgen has funded studies that pointed only at the benefit. In fact, the trial that turned up the higher risk of stroke was aimed at raising red blood cell counts above the FDA-approved range. The company has convinced an entire profession — the Renal Physicians Association testified against limiting use of the drug — that “access” to these lifestyle benefits is more important than safety. It paid messengers, commissioned studies and underwrote clinical practice guidelines to spread the word. It funded patient advocacy organizations that endorsed its agenda.

This is how our health care system and its commercial suppliers interact. Printing doctors’ names on a website to see if he or she is “on the take” (to borrow the title of Jerome Kassirer’s 2005 definitive book on this subject) will do nothing to change the system.