Doctors Receiving Kickbacks

[Skipbidder]

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For more info on this topic, I highly recommend reading "Death by Prescription" as well as the widely debated Natural Cures book.

/Flame away

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Okay. I will take you up on that invitation for flaming. This is idiocy. It is the craziest thing I've heard today (and one of my patients had to be transferred to the locked psych floor--among other things...she refuses to sleep because she thinks that the nurses are trying to steal her dentures.)

The Natural Cures book is jam-packed with misinformation. It was written by well-known criminal Kevin Trudeau, a man who has been fined millions of dollars for his fraudulent medical advertisements (including a claim that coral calcium can cure cancer).

[Blarg]

Many doctors refer patients out for testing at testing facilities they own a part of or outright. This is extremely lucrative. Add in the fact that it's good to CYA against malpractice to order lots of tests, and that in some cases insurance or Medicaid covers them, and you have strong incentive.

Doctors also get inundated with free samples from drug companies. Some describe very intense courting by the companies, and huge amounts of profitable free drugs over a good period of time. Some doctors vigorously deny this, but I've read of many saying it's so common it's pretty ridiculous, and they get so many free samples of some drugs, even quite expensive ones, that they have to turn them away after a while because they couldn't possibly use any more.

Maybe there's some analogy to coke vs. pepsi there. You just want to land an outlet, and are willing to compete very very hard over a long period of time to sell just half a percentage more in a particular market. It's not just that you are making money, but it's absolutely essential that you take money out of the pocket of your competitors.

After all, once a doctor gets used to using a drug preferentially, and a patient gets used to using it, you can lock in profits for an incredibly long time. Think of someone who takes arthritis medication, as just a random example I pulled out of my butt, and uses it for 15 or 20 years. Establishing just one of those customers and the doctor who made her a customer, pays off a ton of money in the very long haul even if you take a loss at the beginning.

[jimmifli]

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After all, once a doctor gets used to using a drug preferentially, and a patient gets used to using it, you can lock in profits for an incredibly long time. Think of someone who takes arthritis medication, as just a random example I pulled out of my butt, and uses it for 15 or 20 years. Establishing just one of those customers and the doctor who made her a customer, pays off a ton of money in the very long haul even if you take a loss at the beginning.

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There is a big push currently with some companies to improve patient compliance. I just finished a patient educational video on Hypertension. The video promotes healthy lifestyle and stresses the importance of lifelong treatment with medication.

One study indicated over 70% of hypertensive patients stopped their medication with two years. This company was willing to devote huge resources to improving that stat.

[Skipbidder]

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So I'm in a routine arguement with my step-father. This time we're debating medicine and he says that all doctors make prescription decisions based upon potential kickbacks. Do doctors receive a kickback on prescriptions, diagnostic tests, braces, referrals, etc?

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"All" is of course going to mean that your step-father is automatically wrong. I've never had a dinner out on a drug rep. (The opportunities certainly exist, and many people do take them.) I don't have a single thing in or on my lab coat from a drug company. You will see docs walking around looking like billboards, however. Most doctors will tell you that accepting gifts does not alter their prescription habits. These doctors are for the most part lying to themselves. The psych literature is filled with study evidence that gifts of even trivial value (think pens) cause people to try to pay back the favor, often disproportionately. I personally believe that there ought to be zero-tolerance policy for gifts. I had no small part in getting an end to drug-company lunches at educational lectures in my residency program.

I make absolutely no money on any prescriptions that I write. Today, in fact, I changed medications on three patients to go from very high cost medications to much lower cost and more appropriate medications. (Nixed a Duragesic patch, Nexium, and nebulized Xopenex for those who are keeping score at home.)

I make absolutely no money on referrals either. I made two referrals today. I made one referral to a psychiatrist. This is my preferred psychiatrist because he sees patients relatively quickly after you call him and because after seeing the patient, he calls me back instead of just scribbling some BS in the chart. It doesn't hurt that I also happen to really like the guy. One of the first referrals I made to him, he called me back and said, in brogue, "I know you don't know me very well, but I just wanted you to know that your lady---she's [censored] nuts". I realize that this sounds disrespectful (mostly because it is), but he never acts that way in front of a patient, and they all love him.

I also called a GI consult today. One of the reasons I called the guy I did is because I've seen him refuse to put in PEG feeding tubes before. (GI docs in the US put in way too many feeding tubes in situations where they will not be helpful, and often when they will actually be harmful. It a bit of the situation where if your only tool is a hammer...all problems look like nails. This guy has the balls to refuse to do PEGs in some of those situations, even though it is costing him business. I respect that.)

A good source of information about the effect of drug companies on prescription habits is available at
www.nofreelunch.org

[jimmifli]

Excellent response sb,

A few questions for you (if you are willing), that hopefully don't hijack this thread:

Is the majority of continuing education available to doctors provided by pharmaceutical companies?

and

Do you find the education provided by pharmaceutical companies to be questionable?

[Skipbidder]

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Many doctors refer patients out for testing at testing facilities they own a part of or outright.

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They very much need to be careful about this. In my state, it is illegal to do this under many circumstances.

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Doctors also get inundated with free samples from drug companies.

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Many offices are now turning toward having a policy of accepting no samples. My office takes no samples, and I am proud of this. I think that it is undeniable that sampling is a huge factor in prescription habits of docs who take them.

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Some describe very intense courting by the companies, and huge amounts of profitable free drugs over a good period of time.

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Drug reps are usually quite attractive too, by the way. Carry on.

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Some doctors vigorously deny this, but I've read of many saying it's so common it's pretty ridiculous, and they get so many free samples of some drugs, even quite expensive ones, that they have to turn them away after a while because they couldn't possibly use any more.

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I'm vigorously denying that I take any samples myself. I'm wholeheartedly agreeing that this has been and continues to be a problem in many offices. There is mounting pressure against sampling. The profession will be improved when this practice is banned.

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After all, once a doctor gets used to using a drug preferentially, and a patient gets used to using it, you can lock in profits for an incredibly long time. Think of someone who takes arthritis medication, as just a random example I pulled out of my butt, and uses it for 15 or 20 years. Establishing just one of those customers and the doctor who made her a customer, pays off a ton of money in the very long haul even if you take a loss at the beginning.

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Ding, ding, ding. We have a winner.

[Skipbidder]

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Excellent response sb,

A few questions for you (if you are willing), that hopefully don't hijack this thread:

Is the majority of continuing education available to doctors provided by pharmaceutical companies?

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I don't know about "majority", but "much" would certainly be true.

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Do you find the education provided by pharmaceutical companies to be questionable?

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I find the idea to be questionable in the abstract. In particular, I have certainly seen misleading information presented.

[renodoc]

meh. if dropping a few pens off at the office and maybe buying lunch for my staff once in awile is a kickback then I am guilty. there are opportunities for docs to whore themselves out as a "consultant" but it doesnt really come down to how many scripts you write, at least in my business.

[Baxter]

So I shawdowed in a private ortho/sports med office and they had a Breg rep on site. When a patient needed a xxxx brace, they called in the Breg rep, he fitted them right then and there, and the patient walked out of the office with a custom fit brace (sometimes it would have to be made off-site, and then mailed to the patient). What are your thoughts on this?

90-95% of the patients received x-rays from the x-ray machine that was part of the private practice before they were even seen by the doctor. I know this speeds up the consult, but a little much?

The private office also had a physical therapy office that was off-site. Although they didn't "require" their patients to go to this office, it was printed in huge letters and in bold at the top of the sheet a patient was given with other local offices. Some of the other physical therapy offices had wrong addresses or weren't updated. When someone asked the doctor about a different physical therapy office (it was closer to their house, a friend went there, etc) the doctor usually said they were "too big" and the therapists wouldn't give them individual attention. Then he'd strongly encourage the patient to go to their office. This seemed very sketchy (especially since I was working for a physical therapy clinic that wasn't even listed on this sheet).

[posnera]

I had lunch today brought by a drug rep. Lunch cost about $10. She told me about a drug I had never heard of (recently approved). I told her that in my practice I would have no use for it and thanked her for her time. The other drug reps that I have a "relationship" with have never given me anything more valuable that a pen or some cheap food. I would have no problem ending all contact, but I am the newest to the practice, and I can't veto them outright.

Far too much of what masquerades as "continuing medical education" - which is a requirement in order to maintain hospital priveleges - is actually advertising by drug companies. I think this sucks. I continue to read journals and get my information from legitimate sources, but many do not.

As for direct kickbacks, there have been some publicized issues with surgeons and surgical devices, but in medicine itself, there probably isn't that big an issue. Noone is going to pay me a real amount of money under the table to choose one drug over another.

There are certainly individual physicians who pad the check by referring patients for specialist consultations they do not need. There could definitely be kickbacks involved here, either in the form of direct payments, or by referring back other patients.