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Wednesday, July 23, 2008

The really, really dark side of P4P (maybe the only side)

Comments by an Hawaii physician,called to our attention by the prolific Sandy Suracz, should do more than raise a few eyebrows.I have characterized P4P as, among other things,bribing physicians for doing their job. It seems to be worse than that.There may be instances of docs being bribed to use certain medications.

Now we seem to have more reason to believe that some health plans are being bribed by drug companies to prescribe certain medications and then the health plans bribing and coercing the physicians in the plan to prescribe those medication under the feel-good facade of
quality care and guidelines.

Dr.Catey Shanahan from Hawaii is the whistle blower in this instance describing what went on in the plan for which she works and alleged comments from a management person in another plan where she interviewed for a position. Details can be found here in her letter to the editor of a newspaper. The guidelines that Dr.Shanahan found questionable involved the dictum that all type 2 diabetics should be treated with a statin medication to drive the LDL below some magic number.I hope the usual fate of whistle-blowers does not await Dr. Shanahan.

One can argue about the validity of the conclusion that all such patients be treated to that target with that class of medication and can question the robustness of the data that suggest that such treatment is both safe and efficacious, let alone effective. ( I'll admit I have/had firmly bought into that line of thinking but am rethinking that now) However, there is no argument, as far as any reasonable or even conceivable interpretation of medical ethics, about bribing physicians to prescribe certain medications. DrRich sent me (and everyone who reads his blog and book) the message that medical ethics and pride are in a downward spiral and if medical ethics is in a crisis, trust is next to fall.

Three years ago my brother-in-law received a prescription for simvastatin ( not the generic) because of his slightly elevated LDL. He was of the belief-without any specific supporting data- that the doctor was getting some type of "kick back" for using that medication. In my naivete,I told him in no uncertain terms that that sort of thing just does not happen.The conversation would have to be a bit different now.

This same general issue attracted a bit of attention when the "EPO" stories broke and the question of rebates for physicians and health care plans came to light at that time.I wrote about that here.

Fortunately the shattering of the trust in doctors which such activities will bring about will be mitigated by knowledge that no longer will pharma firms hand out the mind altering pens and mugs decorated by the names of medications. That should restore trust in physicians.

1 comment:

Anonymous said...

retired doc,

You need to catch up with the P4P times. I read your post and the links, this stuff has been going on and gathering momentum for some time now. Our P4P has had LDL goals of 100 for diabetics and CAD patients for a couple years now. Money paid to docs with more patients meeting goals. (meaning more money to aggressively push drugs on patients.) Same for BP in similar patients. Same for getting more
A1Cs less than 7. All, of course, encourages polypharmacy and blind adherence to guidelines.

fun stuff all around.