Later this year, the federal government plans to release a website to expose payments made by pharmaceutical companies to doctors, ProPublica reported. While checking its site, the government found--I know it's hard to believe--several glitches. The most interesting one is this: Doctors entering their names on the site to verify information get error messages if they haven't received money from drug manufacturers, ProPublica noted. That speaks volumes.
Financial ties between doctors and pharmaceutical companies are worth noting. Patients have a right to know if drug recommendations they receive are objective or biased. When do relationships between doctors and drug manufacturers improve healthcare and when do they compromise it? When do methods of marketing pharmaceuticals become a problem? This much is certain: When drug companies cross the line into unethical conduct, there are doctors waiting to meet them.
There are no easy answers to these questions; but wrestling with the issues shows the connections between compliance programs and fraud.
Prescription drugs are a big business, with global pharmaceutical companies posting billions of dollars in profits. Drug companies can afford to cultivate relationships with prescribers. This may involve providing free meals, travel, drug samples, tickets to entertainment events, rounds of golf and consulting fees for professional services.
And it's not only providers that drug companies woo. They've offered to fund health insurers' projects, for example, or supply payers with researched-based customer literature for use in care coordination.
We need to keep tabs on all this, since accepting freebies can skew the integrity of work. If doctors in the pockets of pharmaceutical companies prescribe their drugs instead of cheaper, more effective alternatives, patients and insurance programs may suffer for it. And how do payers ensure that drugs made by pharmaceutical benefactors don't get more favorable placement on tiered formularies?
The University of Pittsburg Medical Center--an insurer, employer and healthcare provider--tackled some of these questions by banning affiliated medical practices from having lunch in their offices with drug companies. UPMC also implemented a virtual drug sample closet, which is a web-based technology doctors use to order medication samples. This replaced industry representatives' distribution of samples at doctors' offices, which critics say helps drug companies access and influence practitioners.
Looking at these issues, it becomes clear that we need comprehensive compliance programs to fight fraud and abuse. Not paper tiger programs paying lip service to buzzwords of the day, but actively implemented programs that drive behavior from the top down. We need these programs not only within insurance companies, but also in offices of other healthcare stakeholders including providers and drug manufacturers. Effective compliance programs monitor and resolve conflicts of interest.
Think about it: Fraud has a cohort of shady companions. On the front end, for example, there's medical identity theft leading to fraudulent billing. One the back end, there's money laundering to hide the illegal proceeds of fraud. And in the middle, there are conflicts of interest that--if unchecked--create opportunities for corruption. We need to watch for these and view them as near occasions of fraud.
It's a mistake to draw a villain's mustache on all drug companies, though, since they face their own pressures to be both ethical and competitive.There are tremendous costs to research and develop a new drug, get it approved for use, and generate sales before another manufacturer debuts a better, cheaper product to treat the same problem. And drug companies also have been victimized by fraud.
Consider the case of Boston anesthesiologist Scott S. Reuben, M.D. An eminent researcher, his work reportedly changed how doctors treat surgical patients for pain. But Reuben admitted that he never conducted the clinical trials on which he based his published findings. For this, he was dubbed the medical equivalent of Bernie Madoff. Reuben was sent to prison for healthcare fraud and ordered to pay restitution to pharmaceutical companies, including Pfizer, Merck and Wyeth.
"This case does nothing but make it even more difficult to perform clinical research," Paul F. White, M.D., Ph.D., distinguished chair of anesthesiology at the University of Texas Southwestern Medical Center, told Anesthesiology News.
Large-scale insurance fraud can have similar constricting effects. And since some fraud and abuse problems are rooted in conflicts of interest, we need to clear these. Because while conflicts of interest are inevitable, the damage that flows from them is not. - Jane (@HealthPayer)