An item in the news this week, which may have gone unnoticed by many, was the discussion about passing of the Physician Payment Sunshine Act. In summary, this act requires the full disclosure of money paid to physicians (and other medical providers) by the pharmaceutical industry. Until now, this information was hidden.
Why is this important? Because money can taint good medical care. As I discussed last time, that I am a supporter of Evidence Based Medicine. One rightful criticism of western medicine is that it has been corrupted by the money of people who make the drugs, which we prescribe. I can make the same argument about so-called natural medicine (who actually sells the products in their office) but that is not my point.
My point is, when you throw a lot of money at medical providers, it will influence them. The receivers of the money act insulted when someone suggest that they could be bought, or that they would allow money to influence their medical judgement, but we are all human.
Okay, let’s talk about headache treatment and the influence of money.
I’ve been around the headache treatment world for thirty years. I’ve witnessed first hand how money influences how patients are treated and what medical providers believe about good treatment. But this hasn’t always been true.
It is a long story but I remember the days when I was a receiver of this kind of money. When I was at Mayo Clinic, I was sought after as a national speaker on headache disorders. In those days, the drug company would pay my way to go cross country and then me about $1,000 to $2,000 per 1 hour talk. Easy money. What was so great about it was I had complete freedom to talk about what I wanted to. I made a point to be drug neutral. But then something extraordinary happened.
In 1996 a scientist Dr. David Franklin, who worked for Pfizer Corporation, turned and sued his own company (under the whistle blower’s act) because he himself was promoting gabapentin (Neurontin) for “off label” use, such as a migraine preventative. What this means is that the drug was not approved for the indications of migraine and bipolar, yet Dr. Franklin and others were telling physicians and other providers that it was useful for that. The settlement was for over $300,000,000. Dr. Franklin got a chunk of that.
Now, the problem wasn’t because it wasn’t true. Actually gabapentin is helpful for some migraine sufferers . . . but not that helpful. The problem was that gabapentin makers had not done the rigorous studies to prove that it helped migraine more than a placebo and receiving FDA approval.
In response to this lawsuit, the pharmaceutical industry created an industry-wide organization for guiding standards. This is called PhRAMA. PhRAMA decided that the best way to prevent speakers from saying things off-label was for the pharmaceutical companies to actually create the talks that the physicians or other providers give.
My relationship with the pharmaceutical industry started to change quickly. They started bringing me canned talks (usually a Power Point presentation), which little more than a infomercial for their product. I refused to do those talks. Some of the companies representatives whispered and told me that I really didn’t have to use their slides so I didn’t. Then one time I was speaking to a group of physicians in Oak Harbor about migraine comorbidites, which had nothing to do with the drug of the company who was sponsoring my talk. The night of the talk, the company rep showed up with a slide-set that was an endorsement for their drug. I refused to do it. The lady then said, “Remember who’s paying you. You better do what we say.” I didn’t mention their drug that night at all and retired from speaking.
However, there are many headache physicians who pad their pockets with drug company money. I’ve heard a famous headache doctor speak on the east coast one week promoting Imitrex as the best drug for aborting a migraine, then two weeks later, saying that Relpax was the best drug for aborting migraine. I felt angry. I also learned that he was paid over $200,000 that year just for speaking engagements (and he practices full time).
I was so outraged about that, I wrote an article in the Headache Journal, The Wrong War. (the link may not let you view the entire article because it is copyrighted).
So, I will bring the drug money even closer to home. When I first came to the Pacific Northwest, I was asked to do talks stating that Topamax was clearly the best drug for preventing headaches. I couldn’t do that because I didn’t believe that. I didn’t believe that because we, at Mayo Clinic, had done much of the research on Topamax. It is a fine drug for migraine prevention, but it has a lot of side effects to contend with. Plus, when it was branded only, there were far cheaper drugs that worked as well.
The makers of Topamax then (when I wouldn’t speak for them) brought in a headache specialist from Seattle who was glad to say that Topamax was the most superior drug for migraine prevention. The company also “blessed” him as THE headache specialist for NW Washington and wanted everyone to refer to him. This is how drug company money can buy influence. They are king makers and work to marginalize headache specialists who do not promote their products. Until this day, it is believed by virtually every neurologists in the NW that Topamax is superior for preventing migraines and drug money was able to buy that influence. The studies don’t say that.
Now my next close-to-home example wasn’t that long ago. I heard a regional headache specialist bragging about how they made a lot of money by talking all their patients into doing Botox on the first visit. The insurance companies pay about $300 for a provider to do a Botox treatment. If you do one the right way, taking about an hour to discuss things with the patient, you don’t really make money and barely cover your costs. But if you line up a large group of patients in the same morning and have a nurse help you, you could do twenty, earning yourself $6,000 for a morning’s work. But to do that, you have to push Botox on every patient that comes through the door, and this provider expressed no concern if the Botox was right for the patient, by only how much money they could make in a day, as if they were selling hot-dogs at a ballgame.
Now, I know that life is not fair and I accept that. But it is quite ironic that Group Health has refused to do business with us. However, they have sent out letters to their regional primary care physicians, urging them to send their headache patients to this provider, who is in just for the money. So here I am, not being in it to make money, but being totally devoted to helping my patients get better. I carefully give the patient the very best care for them, and making money has never entered the equation. But for some odd reason Group Health loves the other provider and hates us.
So, now that I’ve gotten off track and onto my bandwagon about Group Health, I will come back to my point. My point is that this forced disclosure about how much a provider is paid by the drug company is a good thing for the patient. If your headache doctor is pushing you to take Topamax or get Botox, and you can go on line and read that they got $60,000 last year for speaking for those companies, then the patient should beware. However, this full disclosure will not be available until 2013.
Here’s to more headache-free days.