Demystifying Medicine One Month at a Time

Tag: professional issues

Does Medical Marketing Work?

20140929-dollars-for-docs-300x200_1You bet it does.

In the ‘old days,’ doctors were taken on junkets to sunny destinations and indoctrinated with the latest and greatest in brand name medications. The trips were paid for by the pharmaceutical firms that manufactured these drugs.

Trips like this started to become unseemly, and the public began demanding more transparency in the relationships their doctors had with drug companies. A database was created to keep track of the monies flowing to docs from drug companies.

Docs can still get a meal (as long as it’s ‘educational,’ i.e. there’s a lecture along with it) and the traditional branded pens and pads of paper for the office. Sometimes drug reps (the sales people for the pharma firms, known in the trade as ‘detailers’) bring by bagels or doughnuts to woo the staff and steal a few minutes to tell us about their latest product.

The big money comes to the select few who become ‘thought leaders,’ i.e. spokespeople on behalf of certain drugs. This can range from five to six figures. Per year.

Docs have always been a little defensive about having these relationships explored or highlighted. “No drug company influences the way I prescribe,” is a common sentiment.

“I prescribe the best products that are on the market,” is another retort — not hard to defend, as the brand name drugs create the perception (at least) of being the best.

Conventional wisdom has always held that drug companies wouldn’t spend the billions that they do on marketing if it wasn’t beneficial. Proof of that has been hard to come by, though, as there wasn’t a way to clearly demonstrate a relationship between drug company payments and the rate of prescribing brand name (i.e. heavily marketed, more expensive) drugs.

Now there is.

In a beautifully conceived and executed investigative report, the non-profit news source ProPublica has linked the pharma payment database with the Medicare Part D (which since 2003 has paid for prescription drugs for seniors) database.

You know what?

There’s a perfectly linear correlation: Docs that receive payments (in one database) prescribe more brand name drugs (from the other database).

Nothing about this is illegal. There’s no doubt that some of the doctors receiving payments genuinely believe the brand-name products they prescribe are better. It’s just that no one can claim with a straight face any longer that payments to doctors don’t influence the way we prescribe.

(Mind you, the drug companies have known this all along, but have kept this information private as ‘proprietary’ information. Trade secrets, you know.)

If you like this kind of reporting, you can listen to a story about the investigation here:

Doctors on Labor Day

Happy Labor Day, GlassHospital readers!

Thought question: Who does your doctor work for?

You, right?

A Tulsa driller, perhaps...

But does your doc work for herself or is she an employee? If the latter, is she an owner/employee, or just a hired gun?

You may have read elsewhere that doctors who are in business for themselves, a proud bunch, are finding it harder to survive in the highly competitive, costly, and increasingly burdensome health care industry.

Flat/decreasing revenue + rising overhead equals burnout and/or business failure.

Due to this equation, as well as generational shifts in how doctors are choosing to structure their lives and practices, more doctors than ever (especially those in primary care fields like pediatrics and both internal and family medicine) are taking on the mantle of employee.

And given current unemployment numbers, we’re darn grateful to have jobs–and well paid ones at that.

Yet with the security of a job with salary and benefits comes a loss of autonomy.

Which is one thing if you work for a medical group or a hospital, which have the resources for marketing and infrastructure.

But what if the corporate boss is an insurance company?

United Health, among other market-based health insurers, is gobbling up doctors’ groups to in an effort to deliver more cost-effective care to its insured patients by ‘managing care on the front end.’

Optum, a United division, made a big splash last week by purchasing the biggest independent physicians’ group in Orange County, California, in the largest such deal to date.

“A price was not disclosed,” reads the Wall Street Journal article on the announcement.

I’m all for practicing the best possible medicine in the most cost-effective manner, but to me this gives too much leverage to the purse at the expense of the professional.

And where does the patient fit into all this wheeling and dealing?

What about choice? The freedom to choose where you go to the doctor? How can you be certain your doctor is working for you when there are corporate dicta to control costs?

Increasingly, I worry that doctors are simply a “means of production” in the world of corporate medicine. This must be why those yeoman docs holding out in private practice continue to buck the trend.

Ruckus over the RUC

An interesting legal case brewing in the medical world that’s worth sharing…

A legal challenge to specialty dominance.

A group of six physician plaintiffs from Georgia are suing the government (the Secretary of Health and Human Services) in a federal district court claiming damages from the fact that Medicare, the massive program that covers the elderly and disabled, fails to execute due diligence by rubber-stamping a reimbursement structure that overvalues procedural medicine over cognitive services.

Huh?

Some background is in order.

It’s no secret that specialists (e.g. radiologists, cardiologists, dermatologists, urologists, etc.) make higher incomes than primary care doctors (family doctors, internists, and pediatricians). Obvious reasons include more training, differentiated skill, and an ability to handle specific technical and/or surgical procedures that generalists aren’t able or authorized to provide.

But the non-obvious reason is a poorly publicized and shadowy body known as the Relative Value Scale Update Committee, or RUC. The RUC is a committee convened by the American Medical Association (AMA) and about two dozen medical specialty societies.

The RUC promulgates an annual report to CMS, the government’s Medicare and Medicaid arm. The update advises CMS on the ‘relative value’ of an extraordinarily lengthy list of medical services, including both procedures (things ‘done’ to patients) and cognitive services (those done for patients with a doctor’s hands, stethoscope, and brain).

The RUC has twenty-nine members, twenty-three of whom come from medical specialty societies. The list is publicly available.

Critics of the RUC point out that it’s a little like the Senate, in that smaller specialties gain outsized importance since representation is not proportional. This has in effect, so the argument goes, perpetuated the overvaluation of procedural skill over cognitive service. The downstream effect of this is twofold: a disparity in doctor incomes between generalists and specialists, but more importantly, ever-increasing cost of delivering health care as the premium on procedures incentivizes them.

Early commenters seem to suggest that the case will have meritorious legal standing. It certainly will be interesting to see what happens as the case wends its way through the judicial system.

There’s an excellent synopsis of the suit and the issues surrounding it on the Health Affiairs blog by Brian Klepper and David Kibbe, which I recommend to anyone with further interest. Here’s a key paragraph that may inspire you to click over:

The policy community should keep a close eye on this case, because its target is the beating heart of the American health care cost crisis. Aside from the primary care community, the plaintiffs are unlikely to have many organized supporters within a health care industry that has benefited so handsomely from the current payment regime. But the employer community as well as anyone who cares about the larger economic issues facing America should see the opportunity to largely correct a tremendous wrong in our system.

Docs & Politics

There was a fascinating piece in the NY Times suggesting that on the whole, the medical profession is moving leftward politically.

Here were the main reasons cited:

Definitely need some weathermen to know which way the winds blow.

  1. The demise of private practice in favor of salaried work. [For an analysis of this phenomenon, read here.]
  2. The hassles of administration [i.e. paperwork and bureaucracy] leading to a preference for a more idealized, streamlined form of “care for all.”
  3. Moral outrage at a patchwork system of health coverage the currently excludes ~50 million Americans.
  4. More women (and part-timers) in the profession.

What do you think?

If you’re a doctor, have you felt your politics changing or standing more resolute in the face of the passage of health care reform?

If you’re a patient, do you ever talk politics and/or health care reform in the U.S. with any of your doctors? What’s your take on their positions?

Rather than give you more of my spin, I’ll just excerpt the last four paragraphs of the article here to save you some clickage:

Even in Texas, where three-quarters of doctors said last year that they opposed the new health law, doctors who did not have their own practices were twice as likely as those who owned a practice to support the overhaul, as were female doctors.

Dr. Cecil B. Wilson, the president of the A.M.A., said that changes in doctors’ practice-ownership status do not necessarily lead to changes in their politics. And some leaders of state medical associations predicted that the changes would be fleeting.

Dr. Kevin S. Flanigan, a former president of the Maine Medical Association, described himself as “very conservative” and said he was fighting to bring the group “back to where I think it belongs.” Dr. Flanigan was recently forced to close his own practice, and he now works for a company with hundreds of urgent-care centers. He said that in his experience, conservatives prefer owning their own businesses.

“People who are conservative by nature are not going to go into the profession,” he said, “because medicine is not about running your own shop anymore.”

Not about running your own shop anymore…

Does he mean that the folks choosing medicine as a career nowadays are less entrepreneurial? Or simply less interested in controlling the means of ‘production’?

These are excitin’ times in the world of doctoring.

If you don’t believe me, just read ol’ Dr. Gawande’s commencement address at Harvard Med, courtesy of the New Yorker.

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