By MICHEL ACCAD, MD

In his recent article “Feed Me, Pharma,” ProPublica’s Charles Ornstein has been calling attention to studies showing that the prescribing decisions of doctors are linked to to the amount of money that drug companies can bestow on them, usually in the form of meals, travel expenses, tuition support to attend courses, and so on.

I find nothing surprising about that, and Ornstein need not be so scrupulous when he clarifies that “the researchers did not determine if there was a cause-and-effect relationship between payments and prescribing.” To deny that perks have a causal effect on physician behavior invites improbable considerations.

In fact, the data suggests that doctors are particularly easy to manipulate. One of the researchers interviewed by Ornstein was “surprised that it took so little of a signal and such a low value meal [to influence doctors]” A Chick-fil-A is all that it takes!

On the other hand, Ornstein clarified,

…the researchers don’t think the meals themselves cause doctors to prescribe more of a drug, but rather the time they spend interacting with drug reps when they drop off those meals.

In other words, doctors are cheap dates for pharma. In response, “patients [should] talk to their doctors and ask ‘Is there a generic that’s just as good?’”

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By DAVID SHAYWITZ, MD

I was thrilled to learn that Stephen Friend, co-founder and CEO of the nonprofit open data platform Sage Bionetworks, has accepted a role at Apple and is stepping away from day-to-day operations at Sage (he will continue to serve as chair of the board).

I’ve known Friend for over decade, starting when I was at Merck (he led cancer research), and continuing through his cofounding of Sage with Eric Schadt (I was at the Boston Consulting Group by then and served as a founding advisor).

(Disclosure/reminder: I am chief medical officer of DNAnexus, a cloud-based health data management platform based in Silicon Valley.)

Under Friend’s leadership, Sage pursued a powerful vision of open science, where data are richly shared and scientists (and citizen-scientists) collaborate to accelerate knowledge turns–a point Josh Sommer (later a Forbes 30 Under 30 awardee) made at the First Sage Commons Congress in 2010, as I described in an early Forbes post, here.

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By JIM PURCELL

On June 11, 2016, James Madara, MD., addressed the American Medical Association’s Annual Meeting with some wonderful hyperbole. Dr. Madara is the CEO of the AMA, and he likely felt some pressure to rally the troops (a/k/a physicians) and show that the AMA is advocating for their “side.” And it got attention, with articles trumpeting that Dr. Madara called digital products “modern-day ‘snake oil’.” He indeed did.

We do need to give Dr. Madara a little leeway here.  The role of the AMA is to represent physicians, and he’s the CEO.  That being said, consider for the moment that one of the major points Dr. Madara made was to tout how the AMA’s predecessors over 100 years ago outed snake oil for the fraud it was, thereby protecting the consuming public.  While it was a while ago, the AMA should be rightly proud of that accomplishment.

However, what Dr. Madara did at the June AMA meeting, entertaining as it was, does not deserve equal accolades.

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By STEVEN FINDLAY

This year’s release of the annual Medicare Trustee’s report on June 22—261 pages of mind-numbing healthcare and budget minutiae—coincided with the release of the House Republican’s long-awaited alternative to Obamacare.   

Coincided, but not coincidence.  Republicans’ sought to leverage the annual report’s hand-wringing about Medicare’s fiscal unsustainability—to draw attention to their proposals.     

Indeed, the GOP plan garnered the news spotlight.  But it’s the Trustee’s report that deserves closer attention and has more long-term import.   

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By SAURABH JHA, MD

A petition to the British Medical Journal (BMJ) asking for Makary’s paper on medical errors to be retracted has received over 100 signatures. I, amongst others, criticized Makary’s analysis. But I shall not be signing the petition.

I applaud the editor of the BMJ, and the section editor, for publishing Makary’s analysis. The analysis was in the right journal in the right section. To be clear, I believe the editors did nothing wrong publishing the paper. The role of medical journals is not to tell us how to think, but what to think about, which the BMJ achieved.

Makary’s analysis was provocative. I almost developed laryngeal edema reading it. The analysis advanced the discourse about medical errors. The analysis made doctors think, think beyond dull platitudes. The analysis broke the taboo of questioning the number of deaths from medical errors. Whether or not this was the intention of the authors is immaterial. The BMJ achieved a vigorous debate about medical errors. Not since the NEJM series on physician relationship with industry has any publication led to such intense discourse.

Some say that the paper should be retracted because it was a scientific paper, not an opinion, and as science it is even more dubious. This is not true. The paper was an “analysis.” Look up the definition of “analysis.” But were it research, so what? Methodology for this this type of research is flawed. If all research with fallible methods are retracted, that’ll end medical research.

Some say that the paper should be retracted because the media runs with the story amplifying the error. The media is fickle. The media runs like decerebrate pigeons every time a nutritional study is published. The media doesn’t know its posterior from elbow and I, for one, find this state of affairs comical. I find it hilarious when someone, who follows nutritional advice as punctiliously as a celibate nun listens to her pastor, is later told that it is all rubbish. Nothing gives me more pleasure than seeing mirthless optimizers taken down the garden path.

It is true that the media will be quoting “medical errors are the third leading cause of death” for years. However, the root cause of this chicanery is not Makary’s analysis but the Institute of Medicine (IOM) report: To Err is Human, which stated that jumbo jets of hapless patients were crashing daily. The report created a new science and a professional empire. Should the IOM retract that report?

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By HANS DUVEFELT, MD

One of the things that can cause physician burnout is the arcane way information flows in medical offices. In essence, due to EMRs we are the recipients of increasing amounts of unfiltered data without context.

Pre-EMR, team members sorted incoming data, which allowed us to deal with it more efficiently. We would have piles of things that needed a signature just as a formality, other piles for normal reports, smaller piles for abnormal reports, or whatever system worked best for us and our practices.

Because EMRs were created by people who never imagined that doctors themselves knew anything about how to maximize their own efficiency, results and reports now fill our inboxes in random order and demand our attention and our electronic signatures more or less immediately.

There is a better way. It is standard practice in manufacturing. They call it “Just in Time”.

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By CRAIG KONNOTH

After the horrific shooting in in Orlando, the conversation has turned to homophobia—specifically, the homophobia of a man who sees two men kissing, buys an AR-15, goes to a gay nightclub, and killed 49 individuals.  But homophobia does not always come with a high capacity rifle—sometimes it comes with lab coats and syringes.  As the 53 individuals who were critically injured in the shooting receive medical care, we must come to terms with the anti-gay discrimination that pervades our medical system.

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By JOE FLOWER

Can’t. Won’t work. We’re stuck with this. We have to fix it.

But “Brexit” was a great logo/hashtag/campaign meme, with echoes of “Britain, break it, exit” all in one. Falls right off the tongue, it does. And it described fairly exactly the mood behind it, one of breaking, getting out.

So in healthcare? Time to FFSexit — exit the fee for service business model. Nah, doesn’t trip off the tongue. And it has echoes of “sex” and even “sexist.” Next!

Time to ITexit — exit the non-interoprative, non-communicative garbled EHRs and other information systems we have ended up with. Nope, nope. Sounds too much like inviting Texas to re-think this whole annexation thing.

Time to Vexit — exit the volume-based business model. Hmmm, no. Sounds vexatious, vexed.

Time to exit the fragmented, opaque, partial, byzantine, and outright cruel healthcare financing system we have now —FragOpParByzOutCrexit! Sigh.

Wait. Wait. Here’s the core problem of this meme-pondering: We don’t want to “exit” healthcare in any way.

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By JIM PURCELL

A message to health insurance CEOs, COOs, and CFOs.  I believe there to be a fundamental disconnect between typical health insurer provider reimbursement strategies and the long term good of our healthcare delivery system and its financing.

Let me give you some examples which I know, as a former health insurer COO and CEO, to be true.

• Insurers still pay primary care physicians far less than most specialists.  That perhaps was a function of the RBRVS system adopted by Medicare to “measure” the demands of specific physician activities and pay accordingly.  Specialist activities were rated higher than primary care activities.  They were deemed more complex, often involving surgery and fancy equipment with more training needed, etc.  The gap between primary care and specialist reimbursement grew and grew.  And what happened?  Predictably, the best and brightest are avoiding low paying primary care.  Consequences?

• Shortage and aging of primary care physicians who are needed to keep us from requiring the much more expensive specialist and hospital care

• Oversupply of specialists resulting in overuse, because if you build it they will come

• Keeping the focus on sick care, which is what most specialists specialize in, rather than well care

• Devaluing E&M (evaluative and maintenance) activity, which is the heart and soul of the practice of medicine, requiring observation, patient knowledge, and perception

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