No More Free (drug) Lunches or Pens

As part of the Affordable Care Act (ACA) health care reform, drug companies will soon be required to report payments and free lunches/dinners/cruises/vacations/gifts to physicians or payments to teaching hospitals. It includes any free ‘educational’ service for physicians or teaching hospitals. This is section 6002 of the ACA and is known as the Physician Payment Sunshine Act (sunshine, as in shedding light on or transparency). As part of the mandatory reporting, individual physicians and hospitals will be named, along with what items of monetary value they received and by which companies. This information will be publically available and easily searchable. Companies will be assessed hefty fines of up to $1 million for failing to report the information. This Sunshine Act was supposed to have already been implemented, but has been delayed while government officials at the Centers for Medicaid and Medicare sift through public comment and iron out final details.

I read through the proposed Physician Payment Sunshine Act (vol 76,no. 243/12-19-11 Federal Register), and found that they define “physician” as a doctor of medicine or osteopathy, dentists, podiatrists, optometrists and licensed chiropractors. Teaching hospitals are defined as hospitals having graduate medical education. And here is their rationale for the Sunshine Act:

“2. Transparency Overview

Collaboration among physicians, teaching hospitals, and industry manufacturers may contribute to the design and delivery of life-saving drugs and devices. However, while some collaboration is beneficial to the continued innovation and improvement of our health care system, payments from manufacturers to physicians and teaching hospitals can also introduce conflicts of interests that may influence research, education, and clinical decision-making in ways that compromise clinical integrity and patient care, and may lead to increased health care costs.” (p. 7)

(The NYT has a recent article on this, as does Kaiser Health News–older but good.)

Several states including Vermont have already implemented similar reporting requirements. Some physicians are complaining that drug companies are now wooing more nurse practitioners as a way around the reporting requirements. I saw that in action at this past fall’s regional nurse practitioner conference. It was overrun by aggressive pharmaceutical reps waiving tons of swag (including the ubiquitous drug pens), as well as signing NPs up for free lunches/dinners/talks, etc.

In the community health clinics where I’ve worked, most all of the family physicians were rabidly anti-drug company marketing and influence. One physician in particular would go on a tirade if she discovered one of her medical residents writing with a drug company pen. They—and everyone else in the building—would get a lecture in the evils of drug company influence on physician prescribing practices and health care costs. So I thought I had long ago purged myself of all drug company free stuff. While preparing to write this blog post I engaged in some late winter housecleaning searching for hidden drug company subliminal influences. I found six drug company pens, four of which were for drugs that have been pulled from the market as unsafe. I threw them all away. On a popular blog lamenting the Sunshine Act, one physician complained that he has to buy pens for the first time since he graduated from medical school in 1986.

The only drug company swag I found that I am keeping is a funky glass sun catcher given to me by a retired pharmacist who lives on my street. It has elemental alchemy symbols for strange things like lead and vinegar and talc—but is really an advertisement for a nasal decongestant hidden in small type at the bottom. See if you can find it on the attached photo—but don’t buy the stuff!

Complications/ September 28, 2010

Yesterday I started reading Atul Gawande‘s book Complications: A Surgeon’s Notes on an Imperfect Science. It is good and I briefly considered taking it with me to Virginia to read while I am caring for my Dad. The cover photograph is a bit disturbing to flash around in a hospital waiting room though. I decided to take something more soothing and distracting, so Dicken’s An Uncommercial Traveler is accompanying me instead. His chapter “Nurse’s Stories” has given me the idea to tell my father ghost stories when he’s in the hospital.
I have read all of Gawande’s recent New Yorker essay: “Letting go: what medicine should do when it can’t save your life” (available at Gawande’s website: http//gawande.com). His main point in this article is that US doctors–and US patients— just aren’t very good at “knowing when to stop” expensive treatments even when the benefits aren’t clear. What interested me the most was his reference to a study of Medicare patients with heart failure who I assume were randomized to either conventional or hospice care. The patents in hospice care lived on average 3 months longer than the conventional care patients (and I also assume with better quality of life). That study finding may come in handy this next week in discussions with my Dad and with his doctors. Gawande discusses how the tough ‘breakpoint discussions” (when to stop fighting for time/life) between patients and doctors aren’t done very often because the discussions take time and aren’t reimbursable/billable activities. I also think it is because doctors often view these discussions as failures because they are hard-wired for curing and not for caring. I am interested to find out how my Dad’s doctors handle this–and how my Dad and I will handle it. A difficult conversation or series of conversations. My Dad told me last night he’s getting tired more easily and he hopes the cardiac surgeon can fix that soon.

A Practical Man and Modern Medicine/ Sunday September 26th, 2010

My father hiking a year ago in the Cascades

Today on the phone, my 87-year-old father asked me to be his patient advocate. He is facing tough health care decisions over the condition of his heart, and is scheduled for surgery in a week. He is a practical man, bright, charming, and articulate, with no cognitive deficits that I can detect. He told me where his Living Will and Advanced Directives are, where he wants his body donated for medical research, and what to do when his CD matures (he’ll be in surgery) so that he can roll it over to a money market account. He says he needs access to the money for his after-hospital care, in case he survives surgery. I am thinking about the health policy issues within all of this: 1) heart failure accounts for the largest portion of Medicare expenditures, 2) none of his doctors have talked with him about what all is involved with this surgery, or what quality and quantity of life he can hope for afterward, and 3) home care provided by family members is not well supported (financially and otherwise) in our country. As his daughter and as a family member embedded in the health care system, what do I do with this information?

Perhaps there is a story here for possible future submission to Health Affair’s Narrative Matters (http://www.healthaffairs.org/NM.php). (Note: if you are interested in health policy and narrative and don’t know about this already, it is a wonderful non-technical resource). I even look up the submission guidelines. Coping comes in strange forms for someone like me who has always been a compulsive writer. I take some comfort in having read today that Roald Dahl did something similar when his favorite daughter Olivia died of complications from measles. He supposedly wrote out a very dispassionate account of the events surrounding her death. He wrote this in a school notebook and stored it in a desk drawer in his writer’s hut. (I do realize the important difference here between public and private musings, a topic for a future blog entry). Maybe this is a heavy topic to start out a blog on. But it is real and it is in line with the sorts of things I want to deal with in Medical Margins: the intersection of story/narrative and health care, and of people and topics that are marginalized. My Dad agrees to have parts of his story told here. As I said, he is a practical man.