Today I’m off to a meeting on Pay for Performance, so I hope I’ll have something riveting for you all later. Meanwhile, as I’ve overblogged (and been over-exposed) in the past week or so, I thought that this morning I’d leave you all with the dulcet tones of The Industry Veteran. As the scandal of pharma and med device companies bribing doctors has got serious enough that even the New York Times has noticed, today the Veteran’s thoughts turn to the issue of how big Pharma might be made to keep to the letter and spirit of whatever new guidelines eventually get suggested to them regarding physician “incentives”—and not simply ignored as the previous many go-rounds have been. As you may have guessed, the Veteran’s suggestions are a little, shall we say, unusual:
I guess the symbiotic corruption of Big Pharma and physicians has become part of the conventional wisdom if the staid editorial column of the NYTimes issues an admonitory tsk-tsk. Well a dog does have four legs and the sun rises in the east, so in good Times-Democratic Party fashion, it’s worth deploring this state of affairs and mentioning that, together, we can do better. Meanwhile Billy Joe Tauzin and the AMA’s Babbitts will again confirm Lincoln Steffan’s opinion concerning muckraking’s futility by showing the crooks how to avoid getting caught next time.
Beyond exposing corruption and pointing out contradictions within the American system of political economy, Steffans, Ida Tarbell and their colleagues provided negligible help in showing a way out. Your note on HSAs in South Africa reminded me that it was Steffans who visited collective farms in the Soviet Union and returned to say, “I have seen the future and it works.” Upton Sinclair turned to health foods and crackpot schemes in California before running a feckless campaign for governor.
To avoid a perpetuation of same-old, same-old in health care, allow me to offer some guidelines for regulation and punishment meant to guide the life-diminishing hands of lawyers and legislators.
First, let’s deal with the manufacturers. Capitalism works by essentially outsourcing the regulatory oversight function to the same private concerns whose activity requires such monitoring. This is true even in a so-called “regulated” industry such as health care. That’s not necessarily bad because the latitude it permits businessmen and their hirelings in science, law and elsewhere facilitates innovation and attention to consumer demands. Unfortunately, since the pursuit of unconscionable profits also beats ethical constraint every time (and “twice on Sunday,” as my barber on Sixth Avenue used to say), this outsourcing usually becomes a license to steal, maim and kill.
Now despite the many shortcomings of the Sarbannes-Oxley law (it was, after all, intended to make up the revenue shortfalls of big accounting firms in the wake of the Enron/Arthur Andersen auditing scandal), I do admire the fact that it recognizes corporations are not shapeless forces of nature. To the contrary these institutions represent the lengthened shadows of a few greedy bastards at the top and, accordingly, the law requires that these officers sign to the veracity of Sarbannes-Oxley statements under liability for criminal penalties. It is thus in pharmaceuticals as well. The CEOs in that industry generally made their abbreviated, Bush-like journeys from birth on third base to home plate by functioning as the most effectively devious, unscrupulous, alpha-males within their various launching milieus. For that reason legislation prohibiting manufacturers from bribing, improperly inducing or influencing physicians should be directed principally toward the fiduciary officers rather than shareholders’ earnings. Any agreements between the companies and their officers related to indemnifying or otherwise reimbursing executives for these financial penalties should be construed as efforts to defeat the statutes and held for naught.
Legislation on this matter should also recognize that in cases of the culturally middle class, a little shame administered in front of the country club peers, the trophy wives and the compliant secretaries goes a long way. In other words degradation rituals should be made integral parts of regulatory penalties. We’re talking more than just mandatory perp walks here. The executives who derive enormous satisfaction from preening around as the dominant males within their respective companies should literally have their pants pulled down. This means mandatory Internet publication of their three-sided, nude photos: front view, side view (to show the paunch beneath the $2,000 suits) and rear bent-over view (to be advertised as previews for other inmates).
Legislation drafters must also deal with the greed and narcissistic egotism of physicians on this matter. I believe remediation here is a far more pedestrian matter. Physicians generally regard the advance of damnation as consisting of more work, less pay, less discretion in their professional decision making, more clerical duties and less deference from their support staffs. For this reason penalties should make even casual transgressors realize their Dantean fantasies. They must receive sentences that oblige them to practice medicine in circumstances that turn to ashes every reason that led them to medical school and their residencies.
Instead of providing scientific interest, the work of bribe-taking physicians must become mind-numbing drudgery. Their well-being must be placed into the hands of bulldog secretaries, each lacking the ability to add a column of four numbers. Far from receiving the fawning deference of women or the respect of men, they must be made to work in post office surroundings that all but brand large L’s on their foreheads.
Legislation can achieve a general deterrent effect from these punishments by requiring that once offenders are released, they must discuss their experiences with colleagues in detail after resuming private practice.
I offer the above suggestions in the interest of enlightened penology, which as it turns out, is equivalent in policy terms to better health care.