This article was published in the Dynamic Chiropractic newspaper in a two-part series:
Medical Payola Part 1 on May 1, 2013
Medical Payola Part 2

Medical Payola

 

By

JCS

 

In the 1960s radio disc jockeys were bribed to play particular records in a scandal known as “payola.” Although “pay to play” records on radio was merely a harmless scam, a recent Senate investigation found extensive corruption with most medical physicians who were generously paid by Big Pharma to use or promote their brand name drugs in a multi-million dollar bribery scheme.

Reminiscent of these old radio days, this medical payola, dubbed “pharmapayola,” is now widespread with 84% of doctors who admit to a financial relationship with the drug industry between 2004 and 2009.[1] In all, payments from drug companies to doctors totaled more than $760 million between 2009 and the second quarter of 2011.[2] Considering there were 985,375 physicians in the U.S. in 2010, this payola equates to nearly $1,000 per doctor.[3]

Although medical doctors are still among the best-compensated professionals in the US, apparently some feel remorse about their job choice because they see their peers in finance or business making far more than they do, says Howard Forman, a professor at the Yale School of Management. Only 54 percent of physicians say they’d pick medicine if they had the chance to choose their career path all over again.[4]

“Physicians have not gotten poorer over the last decade. But more and more you’re witnessing physicians who feel they could have done better if they had done something different,” says Forman.[5]

According to the Medical Group Management Association, primary care physicians received total median annual compensation of $202,392, and physicians practicing in medical specialties received total median annual compensation of $356,885 in 2010.[6]

Perhaps this “remorse” justifies in the minds of MDs to indulge in payola from Big Pharma. When they realize drug reps may make more money than many MDs, a sense of entitlement may motivate them to accept the payola from drug companies as “just reward.” Indeed, it’s a slippery slope when laced with tons of money.

This pharmapayola escalation of narcotics has gotten the attention of Thomas Frieden, MD, the director for the CDC, who recently commented about “the burden of dangerous drugs.” Considering one in 20 US adults is now addicted to prescription narcotics, he said physicians have supplanted “drug pushers on the street corners” as the most important suppliers of illicit narcotics.[7]

Prescription painkiller addiction is a problem that’s only getting worse, reports The Associated Press after analyzing a slew of DEA and pharmaceutical figures. The report focuses on sales of America’s leading two prescription painkillers: oxycodone (the key ingredient in OxyContin, Percocet, and Percodan) and hydrocodone (Vicodin, Norco, and Lortab). [8]

Among its more stunning findings:

• Between 2000 and 2010, oxycodone sales have jumped sixteenfold in some areas.
• There were 14,800 overdose deaths from opioid painkillers (that includes oxycodone and hydrocodone) in 2008; the CDC expects the toll to keep rising.
• In 2010, pharmacies doled out the equivalent of 69 tons of pure oxycodone and 42 tons of pure hydrocodone.
• That’s enough to give 40 5-mg Percocets and 24 5-mg Vicodins to every single US resident

According to one drug rep, “medical doctors have financially raped an entire nation with runaway health care fraud and deceptive money-funneling operations.”[9] Indeed, a dishonest disc jockey is nowhere near as dangerous as MDs who are “on the take” in this era of astonishing costs and rampant abuse of dangerous drugs.

Big Pharma bribing doctors has also gotten the attention of the Justice Department resulting in at least $10 billion in settlements with the federal government. The largest settlement occurred with GlaxoSmithKline’s $3 billion fine and guilty plea to committing felony crimes. Abbott Laboratories settled for $1.6 billion and an agreement with Johnson & Johnson could result in a fine of $2 billion.[10]

Despite the $3 billion settlement, it represents only a drop in the bucket of what GSK made on those drugs. Avandia, for example, racked up $10.4 billion in sales, Paxil brought in $11.6 billion, and Wellbutrin sales were $5.9 billion during the years covered by the settlement.

“So a $3 billion settlement for half a dozen drugs over 10 years can be rationalized as the cost of doing business,” according to Patrick Burns, spokesman for the whistle-blower advocacy group Taxpayers Against Fraud. [11]

Doling for Dollars

Not only has drug money tempted doctors to over-prescribe expensive name-brand medications, 28% of physicians reported that they received “honorariums” up to $6,000 a day from a drug company to serve on a speaker’s board, as a consultant, or on an advisory board.[12] GlaxoSmithKline alone had a speaker’s bureau network of 49,000 paid speakers who knowingly accepted kickbacks and bribes to push GSK products in the form of “medical education.”[13]

“The notion that this is all for physician education is nonsense,” says Dr. Jerome P. Kassirer, a professor at Tufts University School of Medicine. “One important question: why would the drug industry spend so much money on advertising if they didn’t think they were influencing physicians?”[14]

Drug companies spent at least $220 million last year on speaking fees to doctors who endorsed their products.[15] Other gifts doled out by drug companies included free tickets to sporting events, spa treatments, hunting excursions, meals at five-star restaurants, and all-expenses paid trips to medical meetings in exotic locations in Jamaica and Bermuda.[16]

Original Sin: Tobacco

This pharmapayola scandal is not the first time the medical profession has been linked to corruption. Long before Big Pharma lured physicians into their web of drugs, the origins of medical payola began in 1930 when the AMA accepted advertisements from the tobacco industry.

Yes, you heard me right—the medical profession jumped in bed with the biggest killer mankind has ever seen since the medieval plagues or the Spanish flu epidemics.

In 1930 under the leadership of Morris Fishbein, MD, executive director and senior editor of the prestigious Journal of the AMA, the AMA partnered with the tobacco industry to finance its war chest against chiropractors/competitors and to influence politicians and the media.

This illicit marriage made the AMA rich beyond imagination as a trade association, making it the most powerful lobby in the world. Harper’s Magazine described in 1949 that tobacco money initially transformed the AMA from a “panty waist” organization that promoted education and research into “the most terrifying trade association on earth.”[17]

Under Fishbein’s reign, AMA allowed the image of physicians in cigarette ads in the Journal as well as in public advertisements.[18] In 1948 the Journal netted a non-taxable $1,400,000 from total revenue of $5,166,000 that included $4,858,000 from tobacco advertising.[19]

Imagine the millions of Americans—especially the Greatest Generation of WWII—who became addicted to tobacco and afflicted with lung cancer and heart disease, all at the

encouragement of the AMA. After all, if your favorite doctor smokes, it must be okay for you, too.

The AMA continued to mislead Americans about the danger of tobacco until 1986 when public pressure forced the AMA to divest itself from all ties with tobacco due to the growing evidence of diseases caused by tobacco smoking. However, the AMA didn’t blink an eye at this loss of revenue since it turned to Big Pharma to replace Big Tobacco as its primary payola advertiser.

Capitol Handouts

Considering the monies at stake in the US healthcare system, influencing Congressmen has been foremost among the medical cartel. Of all places, money speaks loudest on Capitol Hill.

One obvious example of medical payola was the absence of medical executives on Capitol Hill when the Obama healthcare reform began. Unlike the Detroit auto executives and Wall Street bankers whose feet were held to the fire during Congressional hearings to explain why their industries failed, not one member of the medical cartel—the AMA, Big Insurance, Big Pharma, and Big Hospitalists—was called to explain why America has the most expensive healthcare system on earth, yet Americans lead the world in every category of disease.

In reality, medical payola extends deeply into Capitol Hill with the same quid pro quo arrangement. The following information obtained from OpenSecrets.org shows the huge amount of money spent on lobbying over a ten-year period of 1999-2008.

 

This decade of payola by these four members of the medical cartel equated to $656,437,716. Considering there are 535 members of Congress with 100 Senators and 435 Representatives, this equates to $1,226,986 per member, another example of a “just reward” for doing legislation.

In 2011, consider these figures: the American Hospital Assn spent $20,812,147 and the American Medical Assn spent $21,500,000, which equates to $79,088 per Congressman. The obvious question is: how does a trade association generate so much money? Of course, the medical cartel’s pharmapayola funds their war chest and enables them to maintain its quid pro quo with influential Congressmen.

Paid to Get Screwed

According to Mark Schoene, the editor of ^The BACKLETTER^®, “Spinal medicine in the US is a poster child for inefficient spine care.”[20]

He might have added the queen of corruption, too, as another investigation by the Senate Committee on Finance showed:

1. How the practice of spine medicine has been further corrupted by conflicts of interest involving doctors tempted by surgical device companies and
2. How medical journals were complicit with this latest scam by publishing articles edited by medical researchers on the take.

Medtronic Inc. is the biggest maker of spinal implants —screws, rods, and clamps—and last year generated world-wide sales of $3.5 billion, accounting for half of the roughly $7 billion spinal-implant market.[21] Among other surgical devices, Medtronic manufactures pedicle screws required for spine fusions that sell for $1,000 to $2,000 apiece, but cost less than $100 to make.

“You can easily put $30,000 worth of hardware in a person during a fusion surgery,” said Charles Rosen, a spine surgeon who created a group called the Association for Medical Ethics to combat what it sees as conflicts of interest in spine surgery.[22]

According to The Wall Street Journal’s analysis of Medicare claims, spinal fusion procedures cost Medicare $343 million in 1997, escalating to $2.24 billion in 2008—nearly a 400% increase.[23] The most complex type of back surgery among Medicare beneficiaries with spinal stenosis increased dramatically with a 15-fold increase from 2002 to 2007.[24]

These device companies entered into partnerships with surgeons and paid them “dividends” based on the number of surgeries they performed. Dividends is the industry term for kickbacks.

For example, the WSJ article revealed Dr. Kevin Foley at Memphis’s Methodist University Hospital has had royalty agreements with Medtronic since 1996. The company paid him more than $27 million from 2001 to 2006, according to internal Medtronic documents reviewed by the Journal. On its website, the company discloses paying him another $13 million in royalties in the first three quarters of 2011 alone.[25]

Payola Journalism

Not only has Medtronic made billions selling expensive screws and hardware for highly controversial spine fusions, the Senate investigation found Medtronic felt compelled to write and edit medical journal articles attributed to outside physicians that downplayed the risks of the company’s best-selling bone graft, InFuse.[26]

Instead of using bone from a patient’s own body to insert in the disc space, Infuse is a powerful biological agent that stimulates the growth of new bone and can sell for more than $5,000 a pack, depending on the size.[27]

The Senate Finance Committee said that the world’s largest device maker did not disclose its role in shaping thirteen key studies of InFuse, which helped turn the bone graft into an $800-million a year product. Infuse has been used to treat more than 500,000 patients, but one huge problem was they cannot control the growth of new bone.

 One clinical trial of Infuse was halted because of excessive bone growth in the spinal canals of 70% of the patients.[28] This complication was the subject of a 2004 paper written by doctors who had received millions of dollars from Medtronic. However, the studies failed to mention serious risks of InFuse including male sterility, infection, bone growth, and increased back and leg pain.

Inexplicably, the surgeons who wrote the article said that patients weren’t harmed by the excess bone growth. But that claim was refuted by another surgeon who admitted he had patients who developed pain from excessive bone growth that required additional surgeries.

Senate investigators also reported over the course of fifteen years, Medtronic paid $210 million to a group of thirteen doctors who co-authored the series of now-repudiated papers about the product. Between 1997 and 2003, two of the “independent” authors had received $8.5 million from Medtronic. [29]

Another example is Dr. Thomas A. Zdeblick of the University of Wisconsin who claimed he did not have a “direct financial interest in the success of Infuse or Medtronic.” Over the years, however, Dr. Zdeblick has received over $20 million in royalty payments from Medtronic in connection with patents on devices, including one that is used with Infuse. [30]

Such “ghostwriting” has been condemned as a breach of integrity because doctors rely on information in those articles to make medical decisions, not knowing that the papers may contain biased, inaccurate, or potentially harmful information.

“This sounds eerily familiar to many of the transgressions we’ve read about from the pharmaceutical industry,” said Harlan Krumholz, MD, a professor of medicine at Yale University, when told of the Senate report. “It paints a picture of a company very heavily involved in the science, marketing contaminating the science, and the medical profession and researchers being complicit.[31]

“Medtronic’s actions violate the trust patients have in their medical care,” said Sen. Max Baucus, D-Mont, in a statement. “Medical journal articles should convey an accurate picture of the risks and benefits of drugs and medical devices, but patients are at serious risk when companies distort the facts the way Medtronic has.”[32]

Medtronic’s payola is not new nor is Medtronic the only device company doing this. What made this case unique was the “massive corruption and the towering sums” paid out to greedy MDs who put their profit above their patients or their own integrity.

Science & Chiropractic

“The incentives are all out of whack,” said Justin W. Timbie, a health policy researcher at the RAND Corporation. “The current system favors treatments that are well paid, not necessarily those that are most effective.”[33]

Not only have Big Pharma and Big Device Manufacturers paid doctors millions to compromise their ethics, their refusal to follow new research guidelines has been rampant in the medical profession, especially in regards to spine care.

This pattern resembles “zombie science,” according to Bruce Charlton, MD, who defines it as “a sinister consequence of evaluating scientific theories purely on the basis of enlightened self-interest…In the real world, it looks more like most scientists are quite willing to pursue wrong ideas so long as they are rewarded with a better chance of achieving more grants, publications and status,” or making great livelihoods.[34]

No doubt the best example of zombie science rests with medical spine care. After a century of libeling chiropractic as an “unscientific cult” by the AMA,[35] the present era of evidence-based healthcare has been a blessing to chiropractors.

Over twenty years ago research showed that the medical treatments for low back pain—drugs, shots, and surgery—were ineffective and inappropriate in many cases. Indeed, this cat was first let out of the medical black bag in 1989 when orthopedist/author, Gordon Waddell, admitted that  “Low back pain has been a 20th century health care disaster…back surgery has been accused of leaving more tragic human wreckage in its wake than any other operation in history.”[36]

The paradigm shift in spine care essentially began in 1990 when research by Scott Boden, MD, now director of the Spine Center at Emory University, found no clear correlation between disc abnormalities and back pain.[37] Richard Deyo, MD, MPH, noted this misleading disc theory has led to “false positive” misdiagnosis, suggesting that “many of these abnormalities are trivial, harmless, and irrelevant, so they have been dubbed incidentalomas,”  and “they are likely to lead to more tests and perhaps even unnecessary surgery.”[38]

^The BACKLETTER^®, a newsletter from the Department of Orthopedic Surgery at Georgetown Medical Center in Washington, DC, spoke of the “growing frustration” with the medical approach. “The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate…there is little evidence that patient outcomes have improved.[39],[40]

The turning point occurred following an extensive, two-year seminal study released in 1994 by the US Public Health Services’ Agency for Health Care Policy and Research[41] (AHCPR) that listed spinal manipulation as a “proven treatment,” as did studies from Canada[42] and the UK[43] that also recommended hands-on conservative care over medical care for this problem.

What angered spine medicine the most about the AHCPR study was its finding that confirmed the rare need—estimated to be only one in 100 cases—for back surgery except in the most severe cases of cancer, fractures, infections, cauda equina, or those cases that did not respond after four weeks of conservative care. [44]  

Another study in 1994 compared international rates of back surgeries and found the rate of back surgery in the United States was at least 40% higher than any other country and was more than five-times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopedic and neurosurgeons.[45]

Today there are more random controlled trials on spinal manipulative therapy for low back pain than any other treatment.[46] Researchers now vindicate chiropractic treatments over medical care for the majority of “mechanical” back pain cases that comprise the majority (~85%) of all back pain cases, a fascinating yet untold story never revealed by medical journalists on cable news.[47]

By 2006, the Dartmouth Institute of Health Policy also admitted 30-40% of spinal fusion surgeries were unnecessary.[48] This is a low-ball figure, but still alarming.

Finally this research has led to substantial changes. Both the North American Spine Society and American Society of Spine Radiology now admit the term ‘bulging disc’ should only be used as a descriptive term, not a diagnostic term.[49]

In 2010 the North American Spine Society also admitted spine fusion should be a last resort and recommended spinal manipulation—5 to 10 sessions over 2 to 4 weeks—should be considered before surgery.[50] In 2011, North Carolina Blue Cross/Blue Shield announced it will no longer pay for spine fusion if the sole criterion is an abnormal disc.[51]

Ironically, many spine experts now suggest chiropractors should be considered America’s primary spine care providers by virtue of their superior educational training and clinical effectiveness.[52]

This is a growing concern since 80-90% of all adults will suffer from an acute low back pain in their lifetime, and many mistakenly seek initial help from their medical primary care providers who are untrained in this area of musculoskeletal disorders.

Dr. Scott Boden admitted this inadequacy. “Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders.”[53] Many other researchers also confess medical primary care physicians are typically inept in their training on musculoskeletal disorders,[54] prone to ignore recent guidelines,[55] and more likely to suggest spine surgery than surgeons themselves.[56]

Rick Deyo, MD, MPH, noted the frustration in medical spine care: “People say, ‘I’m not going to put up with it,’ and we in the medical profession have turned to ever more aggressive medication, narcotic medication, and more invasive surgery.”[57]

Not only is payola an unethical motivator, the medical profession is also steeped in stubbornness. Researchers have found that today it takes 15 years for a new treatment to be incorporated into mainstream medical practice and, more shocking, it takes 44 years for a method proven to be ineffective, dangerous, or outmoded to be removed from practices.[58]

Considering the initial discogenic theory was debunked 22 years ago in 1990, perhaps this foretells it may take another 22 years before the paradigm shift from drugs, shots, and spine surgery moves to the chiropractic model.

This growing denunciation of the medical spine care treatments has led researchers to the chiropractic model, but this shift has gone unnoticed by the media and the naïve public who continue to believe in the “bad disc” concept kept alive by unscrupulous spine surgeons and a medical-media that refuses to tell the truth about this paradigm shift in spine care.

Obviously the medical model has had its day with less than stellar results. According to Mark Schoene, the editor of ^The BACKLETTER^®, “Given the unsustainable growth in medical spending, there is a need to cut back on unnecessary, ineffective, and costly treatment services.”[59]

Judgment Day

Now that the tide has turned due to the plethora of evidence, a judgment day may be at hand according to Christopher Bono, MD, in his keynote address at the International Society for the Study of the Lumbar Spine:

“In the US, we have decreasing reimbursement for everything we do in spine. Why? It is the years of overbilling and overtreatment that have led to the current situation. In the end, I hope we can come up with a better solution ourselves before the government or some other entity solves this situation for us.”[60]

That “better solution” has been clear on this issue, but now we find a bigger problem—the corruption that keeps this medical approach alive despite the critics, cost, and ineffectiveness.

Imagine the millions of patients harmed financially and physically by “the years of overbilling and overtreatment” as well as the billions of dollars wasted on “zombie science” methods with this abuse of drugs, epidural shots, MRIs looking for incidentalomas, and spine surgery based on an outdated discogenic theory.

“It’s no wonder the public has lost confidence in the drug and device industries,” noted Harlan Krumholz, MD.[61]

He might have added the lost trust in the entire medical spine field. With the many skeletons in the medical closet—from tobacco to pharmapayola to surgical corruption—it is hard to understand how anyone can trust their MD knowing the bias, bribery, and greed that permeates the medical profession.

Perhaps the answer is patients simply do not know the history of these events because the medical professionals and the medical media like Sanjay Gupta are not telling them.

Medical payola is so ubiquitous it will require more than merely a few lawsuits to fix this problem that is certainly bad to the bone in medicine.

 

JC Smith, MA, DC, is the author of The Medical War Against Chiropractors.