Medicaid programs slow to act against system exploiters

At ProPublica, senior reporters Charles Ornstein and Tracy Weber have published the latest turn in their ongoing analysis of conflicts of interest, problem physicians and the disciplinary systems meant to reign them in. This time, they look at Medicaid in Florida and find at least three instances when the state “allowed physicians to keep treating and prescribing drugs to the poor amid clear signs of possible misconduct.”

Their piece revolves around those key examples – two of which were, in all seriousness, brought to their attention by a Scientologist-run watchdog website – and I strongly recommend you read the whole thing for the details. Below, I’ve just highlighted the bigger picture.

In general, Ornstein and Weber found, state Medicaid programs, as well as the federal Centers for Medicare and Medicaid Services, which doesn’t track relevant state data, have failed to act on information which seems to strongly indicate that certain physicians are abusing or exploiting state programs.

Medicaid programs across the country have long had evidence that physicians have been prescribing risky drugs in excess and perhaps to the wrong patients. These prescriptions also racked up huge bills for the programs.

But like Florida, many states did not act on that evidence. Last year, (Sen. Charles) Grassley demanded data from each state about its highest prescribers of pain pills and antipsychotics, and he asked state and federal officials to determine whether the prescriptions written by these doctors were legitimate.

Public hospitals, not nonprofits, shoulder burden of charity care

Writing in the Contra Costa Times, Sandy Kleffman reports that while nonprofit hospitals in the East Bay are given millions in tax breaks, “The responsibility of caring for the indigent falls largely on the region’s public hospitals.”

Kleffman’s findings are based on her analysis of publicly available California Office of Statewide Health Planning and Development reports, documents which she learned to access and process at a September webinar led by AHCJ board president and ProPublica senior reporter Charles Ornstein.

Her analysis revealed a substantial imbalance in the numbers, especially between public hospitals and nonprofits. For example, Contra Costa’s county hospital provided more than three quarters of the total amount of charity care given in the country in 2010, while the six nonprofits together accounted for just under 23 percent.

For their part, representatives of nonprofit hospitals protested that the numbers do not take into account the other community benefits they provide, nor are they adjusted to compensate for the differences in demographics across each institution’s patient pool.

For more on what went into Kleffman’s report, see her sidebar on “How we made comparisons.”

Pharma discloses free meals, ProPublica expands database

In his latest report, ProPublica senior reporter and AHCJ board president Charles Ornstein explains exactly how, since its founding last October, ProPublica’s Dollars for Docs database of pharma payments to physicians has mushroomed from 30,000 entries to more than half a million. They answer, he writes, has a lot to do with free meals and other perks that pharmaceutical companies are starting to publish ahead of strict federal disclosure regulations which will go into effect in 2013.

Pharmaceutical company representatives say the meals serve an important educational purpose, and they have adopted their own set of rules for such interactions.

A voluntary code of conduct adopted by the Pharmaceutical Researchers and Manufacturers of America says that “it is appropriate for occasional meals to be offered as a business courtesy” to doctors and members of their staffs attending information presentations by sales reps.

In such cases, the guidelines say, the presentations have to “provide scientific or educational value,” and the meals should be “modest” by local standards and not part of an entertainment or recreational event. Meals for spouses and take-out meals are not appropriate, the guide says.

To put it all into perspective, Ornstein demonstrates with numbers from Pfizer that, while the meal numbers have certainly increased the number of entries in their database, they haven’t had as significant an impact upon the overall dollar amounts in question.

Relatively, the meals didn’t add up to much money. Pfizer’s meals amounted to only $18 million last year, compared to $34 million for promotional speakers and $108 million for research.

As with previous installments, Ornstein, Tracy Weber and Dan Nguyen’s database work has spawned follow-up reports around the country. In fact, the response was such that Ornstein and Weber even took the step of re-nationalizing the localizations of their story, with the follow-up “News Reports Cite Drop in Physician Speaking Fees.” Below, I’ve linked to a few notable localizations and follow-up stories. If you’ve got another one to point out, add it in the comments.

• A Dozen Pharmas Make Payments to Physicians Public, Kathlyn Stone, About.com
• Drug firms disclose spending on meals, Liz Kowalcyzk, Boston Globe
• How To Find Out If Your Doctor And Drugmakers Are In A Relationship, Scott Hensley, NPR

Data, AHCJ article lead reporter to story on possible cuts at local hospital

St. Louis Post-Dispatch reporter Blythe Bernhard followed up on suggestions offered in Charles Ornstein’s recent AHCJ article about updated CMS data to produce an article about looming potential cuts in Medicare payments to St. Louis’ Barnes-Jewish Hospital.

The hospital’s problem? As Bernhard writes, Barnes-Jewish “is one of just three hospitals in the country to perform significantly worse than the national average in readmissions within 30 days for three conditions — heart attacks, heart failure and pneumonia — for each of the last three years.”

Medicare … plans to penalize hospitals with higher-than-expected readmission rates. Under health care reform, Barnes-Jewish and other hospitals could face up to a 3 percent reduction in Medicare payments, meaning millions of dollars, starting next year.

Reducing readmissions nationwide could save $26 billion over a decade, the government estimates.

ProPublica investigates ties between doc groups, industry

With an assist from Sen. Chuck Grassley, ProPublica senior reporters Tracy Weber and Charles Ornstein, AHCJ’s board president, have published their latest data-heavy investigation (USA Today version). This time, their journey into the myriad avenues pharmaceutical companies pursue to influence physicians has taken them into the world of professional societies and annual conferences. The duo writes that despite the power of these groups, their dependence upon millions and millions of dollars in industry funding has often slipped under the radar.

Professional groups … are a logical target for the makers of drugs and medical devices. They set national guidelines for patient treatments, lobby Congress about Medicare reimbursement issues, research funding and disease awareness, and are important sources of treatment information for the public.

Their strongest anecdote comes from the Heart Rhythm Society, a group which, in 2010, pulled in about $8 million – half their total income – directly from manufacturers of the drugs and devices their members specialize in prescribing for, or implanting in, patients. The society has started to disclose these relationships, but perhaps not to limit them, the reporters write. “’This is our business,’ said Dr. Bruce Wilkoff, the incoming society president. ‘We either get out of the business or we manage these relationships. That’s what we’ve chosen to do.’”

The companies also pay two-thirds of the society’s board members speaking or consulting fees, a situation Weber and Ornstein found is far from unusual. In addition to these financial conflicts, the reporters gathered some fascinating examples of just how deep industry influence can run. My personal favorite comes from the conference of a well-known collection of cardiologists.

Last month, the American College of Cardiology attached tracking devices to doctors’ conference ID badges. Many physicians were unaware that exhibitors had paid to receive real-time data about who visited their booths, including names, job titles and how much time they spent.

For more examples, I recommend Robert Durrell’s photographs from the 2011 Heart Rhythm Society annual conference, which show dozens of industry-sponsored objects alongside the amount of money each company paid for that particular privilege. Dan Nguyen and Nicolas Rapp put together an infographic that expands upon a similar theme.

Much of the disclosure data the ProPublica team depended on for their reports was released in response to a request for informationGrassley sent out in late 2009. His investigation has started to yield some preliminary results.

There are fledgling efforts to push medical societies toward stricter limits on industry funding: 34 groups have signed a voluntary code of conduct calling for public disclosure of funding and limits on how many people on guideline-writing panels have industry ties.

“The general feeling is that the societies need to be independent of the influence of companies,” said Dr. Norman B. Kahn Jr., chief executive of the Council of Medical Specialty Societies, which helped draft the code.

Sponsored segments, hospital partnerships creep into news outlets

In the St. Louis Post-Dispatch, Blythe Bernhard takes a look at the fruits of the slow, steady advances hospitals and health providers have made into local television and print news. In recent years, sponsored segments and partnered content have insinuated themselves into broadcasts, columns and news-esque advertising spaces.

According to Stacey Woelfel, news director at KOMU-Columbia, Mo., partnership offers are more likely to come from medical institutions than from other sectors. There’s no denying that cash-strapped media outlets have welcomed the extra revenue, and the numbers show that providers have come out ahead as well.

Hospitals that promote their services during news broadcasts say the exposure is more effective than pure advertising. The Mayo Clinic in Minnesota launched its own news department a decade ago to distribute its “Medical Edge” stories to media outlets nationwide. A Mayo survey showed patients’ stated preference for the hospital increased about 60 percent within three years of the news service’s launch. Hospital executives said the business value of “Medical Edge” was more than 10 times the cost of producing it, according to the Columbia Journalism Review.

But media critics, including AHCJ member Gary Schwitzer, say that providing all that valuable exposure may involve ethical compromises on the part of news organizations. After all, they’re ceding some control over the content they air.

“It looks prestigious, it looks clean, it looks expert, but this is information that is coming from and being bought by one medical center source,” said Gary Schwitzer, publisher of Health News Review. “Who has vetted that to say that is the best information, and when are we going to hear from other players in town?”

And, by forming these partnerships, news organizations are allowing hospitals to become the gatekeepers for medical news, and thus indirectly allowing financial concerns to dictate what is considered newsworthy. To illustrate the quandry, Bernhard mentions a 10-month cancer prevention series that was created through a partnership between a St. Louis local hospital and a TV news station. It includes weekly news segments, regular two-minute paid ads during commercial breaks and even monthly phone banks and online chats. Cancer prevention is certainly news, but AHCJ’s president told Bernhard there may be other reasons why it’s driving this particular news and advertising blitz.

Cancer is big business for hospitals competing in a “medical arms race” to attract patients with insurance to fund hospital investments in MRI scanners and robotic surgical instruments, said Charles Ornstein, president of the Association of Health Care Journalists and senior reporter at ProPublica, a non-profit investigative newsroom based in New York.
“There’s a reason they chose cancer instead of diabetes care for the uninsured population,” he said.
Even a medical topic as seemingly straightforward as cancer prevention generates differing viewpoints and requires health reporters to reach out to multiple sources, Ornstein said.

For disclosures of the Post-Dispatch’s own partnerships, see the final subheading, “Popular topic.”

Related

• Research: Local television encourages fatalistic view of cancer
• Ind. station runs ‘canned’ story about Fla. boy
• Hospital says it gives content to short-staffed media
• SF Bay Area station runs sponsored health ‘news’
• Tompkins: Don’t reward station for ethical breach
• State’s paid promotions appear to be newscasts

Carlat reviews Dollars for Docs, and the bleak picture it paints

Writing on KevinMD.com, psychiatrist and blogger Daniel Carlat reviews ProPublica’s Dollars for Docs database from the perspective of a medical professional, one who has taken a firm stand against drug company money and the conflicts of interest it brings. Carlat’s real focus is not the Dollars for Docs project, but rather the data available from drug companies. He does point out some limitations inherent in the data ProPublica is working with. And he writes about a slightly inverted use of the data, one which caused him to ask “How have we allowed this to happen to our once proud profession?”

There’s another way to use the Dollars for Docs database, although this is not spelled out on the website. If you want to browse for all the doctors in your city or state who are “on the take,” simply leave the “name” field blank, choose a state from the drop down menu, and click search. You’ll get a huge spreadsheet which is arranged alphabetically by last names of the doctors. By clicking on the various columns, you can sort the data by city, drug company, amount of money, or time period of the payments. This is a nice feature that is absent from most of the drug company databases.

Carlat’s data trick is a simple one, and one which local reporters should take a minute to replicate if they haven’t already. After reviewing the mountain of local data revealed by his sorting and the vast armies of conflicted doctors it implies, Carlat reminds us of the power of pharma money then drives home the sheer magnitude of the issue.

The true malfeasance here is in the aggregated effect. The companies are using these legions of doctors to artificially manipulate medical discourse. Any doctor who participates in the enterprise knows exactly how they are being used. You decide whether this is “immoral” or not.

ProPublica finds academic physicians violating schools’ conflict rules

While journalists have been finding innovative ways to use ProPublica’s Dollars for Docs database, the database’s founders, Tracy Weber and AHCJ President Charles Ornstein remain ahead of the curve when it comes to using the freely available data for fresh stories.

This time around, the duo looked for medical schools with strict conflict-of-interest policies and ran their faculty lists through the database. They found dozens of matches, even at elite research institutions. It’s an idea so effective that it’s a wonder nobody thought of it sooner – and apparently the institutions involved feel the same way.

“For God’s sake, if the media can look at these websites, why can’t we?” said David Rothman, president of the Institute on Medicine as a Profession at Columbia University. “Why trust if you can verify?”

Stanford, the University of Pennsylvania, the University of Colorado Denver and the University of Pittsburgh drew particularly heavy attention. (On the other side of the coin, UMass Memorial Health Care was singled out as an example of a robust conflict policy.)

Pizzo, Stanford’s dean, said physicians who appear to have violated the policy will be investigated and referred for discipline if necessary. He compared some of their explanations to what a cop might hear after catching a motorist running a late-night stop sign.
“You can give 1,000 reasons: There was nobody around. It’s safe. I looked and didn’t harm anyone,” he said. “The reality is, it’s still a stop sign.”

Watch the full episode. See more Nightly Business Report.

And this isn’t just a database story. Weber and Ornstein also found time for a review of various academic conflict of interest policies and point out how policies are weakened through inaction, loopholes and a reliance on self-policing.

Prolific antipsychotic prescribers have industry ties

California Watch’s Christina Jewett compares a list of that state’s top antipsychotic prescribers reimbursed by state Medicaid (obtained through Sen. Charles Grassley, R-Iowa) to ProPublica’s database of educational and speaking fees pharmaceutical companies have paid to doctors.

Not surprisingly, she finds matches. Of the top 10 prescribers, Jewett writes, “Three of them accepted $20,000 or more in educational or speaking fees from the company that makes the drug they prescribe to Medi-Cal patients.” Of those, the most remarkable are a duo who share an office near San Diego:

Samuel Etchie prescribed Seroquel more than 1,000 times in 2009 at a cost of $449,000 to the state, according to Medi-Cal records collected by the ProPublica news organization and provided to California Watch. The drug’s maker paid him $25,350 this year to speak to health professionals.

Etchie did not return two calls to his office.

John Allen, who shares an office with Etchie, was among the state’s top prescribers of Zyprexa, also an antipsychotic drug. Allen dispensed 418 prescriptions at a cost to the state of $346,569. This year and last, the drug’s maker, Eli Lilly and Co., paid him about $27,000 to educate other medical professionals.

The icing on the cake? A quote from Allen:

“I think it’s unfortunate that there’s an implication in articles that we’re robots for drug companies,” Allen said. “We have to have our own experience with medications and find out what works best. We’re not 5-year-olds in front of TV watching cereal and toy commercials.”

Lieberman, Ornstein on health as a top 5 beat

Earlier this month, Online Journalism Review’s Robert Niles stirred things up with his lively post on the five most important beats for a local newspaper or website. As you might have heard, health didn’t make the cut (though the related “food” beat is at the top of the list).

Under pressure from commenters and tweeters, Niles conceded that health would be a contender for any “top 6″ list. He elaborated on his health take in the comments, essentially arguing that local health coverage would fall under “Top 5″ categories like labor, business and food.

Angilee Shah, who writes the Career GPS feature over at Reporting on Health, took Niles’ bait and defended health journalism with the help of AHCJ President Charles Ornstein and AHCJ Immediate Past President Trudy Lieberman.

Ornstein’s take:

Even if you factor in the health stories that can be written by the wires, think of all the local health institutions that consumers rely on—doctors, hospitals, nursing homes, hospices, assisted living centers, other health professionals. Do you really expect the reporter who covers the local bank or the local shopping scene to parachute in and cover these institutions well? A reporter covering health understands the difference between Medicare and Medicaid, assisted living and nursing homes, etc. To ask a local government reporter or education reporter to thoroughly cover food deserts in their community or childhood obesity in their schools is too big of a stretch.

And, Shah describes Lieberman’s take:

Lieberman takes an equally adamant stance. “I argue strenuously that this should be a beat, and it should be a dedicated beat with a well-trained reporter,” she said in a phone conversation. Dwindling local health coverage has increased the gap between Washington policy makers and the communities their policies affect. Local journalists should be explaining the effects of complicated health care laws on specific communities. She points to “bright spots” in local health news, such as a Las Vegas Sun series about hospital safety in Nevada.

“I think reporters need to know what’s allowed and how that should translate into what people are seeing, and whether or not they’re being deceived at a local level,” Lieberman said. “It’s a Washington story but it’s not a Washington story. It’s a local story.”

Your take?

There are plenty of small-town reporters in AHCJ, many of whom have more than just health care on their plates. What do you folks think? How many reporters does a newspaper or website need to have before it can dedicate one of them to health care journalism?

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