An investigative outfit’s consolidation and analysis of payments that drug companies made to doctors has refocused attention on state efforts to shine light on the financial ties between doctors and drugmakers.

Currently three states—Minnesota, Massachusetts, and Vermont—require drug companies to disclose payments to prescribers and make some of that data public. While each of these states takes a different approach to collecting and making the payment data available to the public (more on that here), information from all three have been extremely valuable in demonstrating the dimensions and scope of these marketing relationships. And now a new value to the state data has emerged: demonstrating that pharma isn’t keeping very good track of who it’s been paying what.

The ProPublica report in Monday’s Minnesota Star Tribune and here online found a series of big discrepancies between what a company said it paid a doctor on its website and what it told the state of Minnesota it paid the same person. Right now, ProPublica can only crosscheck the seven companies that have posted payments on their own websites.

Big pharma has been caught off-guard again. Like the reports earlier this fall that hundreds of sanctioned doctors were still making cash on the side with speaking gigs, some companies seem not to know who they are paying what. Despite spending billions of dollars to develop and manufacture drugs, and spending other billions to market them to prescribers and armchair prescribers (i.e. consumers), the folks who brought you Lipitor, Effexor, Zyprexa and that one that will send this to your spam folder, don’t seem to know what they paid docs to give PowerPoint presentations.

The report also gave some doctors the opportunity to say strange things:

Dr. Randy Shapiro, one of the doctors whose take was under-reported to Minnesota told ProPublica that if anything, patients should want to see their physician among the speakers on these payment lists. “If their doctor is not on the list,” he said, “maybe they should look for a different doctor.”

That’s…an interesting take. We’re not aware of any links between participation on speakers bureaus and clinical excellence or bedside manner. Based on some earlier findings (we’re thinking of the Risperdal, Biederman, and all these folks) we’re not sure that would be our prescription. (In fact, based on the mounds of evidence about the influence of even small gifts, we tend to think finding a pharm-free physician or one who is engaged on clinical projects she’s happy to tell you about, and not just the PowerPoint circuit, is the way to go).

And the top-paid physician in Minnesota, Dr. Todd Hess, a pain specialist in St. Paul who made over $364,000 last year, told ProPublica that the media is unfairly lumping these educational talks with the old pharma ways.

“This is a mountain-molehill thing,” Hess told ProPublica. “I know the problems of the past. I know what pharma has done to change those. People just can’t get over the past.”

Maybe he knows something that we don’t know, but it might not be a problem of a press corps with a too-long memory. Recently, awkward chuckles went up through the pharma news sphere when word of Abbott’s celebratory pig roast for a Maryland doc who managed to implant 30 stents in one day showed up in a Senate Finance report.

That wasn’t back in the high-flying, anything-goes 90s depicted in the recent pharma-flick “Love and Other Drugs.” It was two years ago. Teachers are warned not to grade 30 papers in one day (and this blogger can vouch for that advice). We’re pretty sure, like the Senate Finance Committee, that 30 stent operations in a day is an even worse idea.

Despite what headlined docs and pharma spokespeople say, there is still a lot of money changing hands for things of questionable clinical value. The thing about the ProPublica data is: it’s current. The stories about hundreds of millions of dollars going to sanctioned docs, the Massachusetts reports that just came out–those payments are all from 2009-present. And now we see it isn’t being recorded very well. Maybe some of these companies really did believe no one would bother to look.

“If all the reports are true I’m outraged,” Maryland delegate and physician Dan Morhaim told the Baltimore Sun.

According to the Sun, “Maryland’s General Assembly has explored limiting financial relationships between doctors and drug or device makers, but no laws have come from it,” but Morhaim said ‘it’s a continuing topic of interest’ in the next legislative session.”

While there are real and beneficial relationships between academic medicine and industry, Pew Prescription Project Allan Coukell told a Memphis paper this week that “patients deserve to know if their doctors are receiving money from drug companies.”

And patients and state lawmakers are right to be concerned about what add up to significant financial exchanges between industry and doctors willing to pitch drugs to their colleagues. We wouldn’t be surprised to see more states explore ways to keep track of or limit the types of payments industry makes to doctors. Regardless, pharma should take this opportunity to get its house in order so everyone’s on the same—accurate—reporting page by the time Physician Payments Sunshine kicks in.

–Kate Petersen, PostScript blogger

A review by the Sunlight Foundation found that important safety and other clinical data on more than one-third of the top-prescribed drugs in the U.S. is  not readily available to prescribers, researchers and patients. The transparency watchdog group found that nine of the 25 top-prescribed drugs, including Lipitor, Effexor, and Plavix, lack this online information–meaning most prescribers have an incomplete picture of safety and efficacy on commonly-written scrips.

The data, required by the FDA for approval but often left unpublished in medical journals and other venues, is only online for drugs approved after 1998. Even then, Sunlight reports, the online info may be heavily redacted and is published in manually-created PDFs that “are not hyper-linked or text searchable, and therefore are hard to navigate.” Information on drugs approved before 1998 has to be obtained by the characteristically slow and cumbersome Freedom of Information Act request, a process most physicians don’t use to inform prescribing decisions.

The Foundation says its unclear whether such data will be included as part of the Obama administration’s Open Government Directive, a plan to have each government agency publish previously undisclosed data sets to the public, but drug safety advocates like Dr. Steven Nissen of the Cleveland Clinic say that such drug info should “absolutely” be included.

For more on the review, including a list of the top-prescribed drugs and which data remains inaccessible, read the story here.

–Kate Petersen, PostScript blogger

Right now, Dr. Daniel Carlat’s article, “Dr. Drug Rep,” is sitting atop the vaunted Most E-mailed list on nytimes.com.  Featured in Sunday’s New York Times Magazine, Dr. Carlat’s narrative recounts his year as a paid speaker for Wyeth Pharmaceuticals and its depression drug, Effexor.  Carlat, a psychiatrist with a practice in Newburyport, MA and author of a great blog, spins an intriguing tale complete with dialogue, disillusionment, and Broadway glitz in four parts.  If you haven’t already read it, chances are someone has sent it to your inbox.

No doubt: We are a list-crazed culture. From the fatalistic travel book series 1000 Places to See Before You Die to the Seven Habits of Highly Effective People to Casey Kasem’s American Top 40, we are a people in love with the list.  And “Most E-mailed” at nytimes is no exception, showing a real-time ranking of the stories being sent (and to extrapolate, being read) most frequently from the New York Times website.  “Most E-mailed” has been elbowed as an echo-chamber metric, perhaps most charmingly by The Onion, which reported in April that the coveted top-ten was tearing the New York Times newsroom apart.

But despite this and other “real news” criticisms, nytimes.com “Most E-mailed” has become the sidebar to watch for what people are talking about around the web-based water-cooler.

And what they are talking about today is Carlat’s “Dr. Drug Rep.”  Over every other Times news story.  We read this as a really good sign that pharmaceutical influence on doctors—the economics of it, the tactics, the pervasiveness (Carlat cites a report that estimates about 25 percent of U.S. physicians receive money for speaking about or helping to market drugs)—is at the top of readers’ minds.  And though we’re biased, we think that’s where it should be.

The blogosphere is also a-flutter with Carlat’s confessional (the story is currently at #8 on the Times Most-Blogged tab), and is yielding some interesting side stories, including a comment on Pharmalot from an ex drug rep who says that some pharmaceutical reps just go through the motions of setting up speaking engagements and ‘ghost-dinners’ under pressure to spend their speaking budgets. More blogs here, here, and here.

All of this buzz comes along as more and more legislation is being introduced at the city, state, and federal level to alter the way drug companies court and co-opt doctors.  Recent headliners include the Physician Payments Sunshine Act, similar legislation slated to be introduced in the House, Maine’s data-mining restriction bill, and the Safe Rx Act being considered by the D.C City Council.  It’s a natural feedback loop, and the volume is growing. 

Does all this add up to our nation taking stock, just as Carlat did, about the ethics and consequences of our relationship with medicine and the pharmaceutical industry, and the relationship we permit between the two?  Perhaps.  Or perhaps it’s too a big leap to see the patchwork of moves by individual, corporate, academic, and public healthcare stakeholders as the actions of a united, albeit clumsy, moral agent.  Either way, it seems we can read the growing policy and media attention—measured in bills and newspaper inches and airtime—like a loudening macro version of the silent internal dialogue Carlat describes having with his conscience after each Wyeth talk he gave. 

It will be interesting to follow this story and see whether this interplay among policymakers, press and the public concludes, as Carlat’s tale did, in a collective, incremental “No Thanks.”