Wednesday, June 27, 2007

I Still Prescribe Seroquel But I Don't Get Paid To Do It.

Chapter 10 remains up at Double Billing. Thanks to those who've commented!

And don't forget to check out the ClinkShrink fiction venture at Double Celling!


How this money may be influencing psychiatrists and other doctors has
become one of the most contentious issues in health care. For instance, the more
psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for
whom the drugs are especially risky and mostly unapproved.

Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state’s Medicaid program.

Wow! Or maybe Oy! That's a lot of money, they don't say How Many Vermont psychiatrists see that kind of moola. One, two, ninety percent of those maple-syrup, Birkenstock-wearing Shrinks, or all of them?

So, for the record, last year I earned $0.00 from pharmaceutical companies. Funny, it was the same amount that I earned the year before and the year before that and the year before that. What am I doing wrong? Where's my 45 grand?

Full disclosure: I work in two different settings that serve indigent, often uninsured, patients. Some of the people I see in private practice have no health insurance. Atypical antipsychotics cost a lot of money. If you don't have health insurance, they remain pretty much inaccessible to many many people. So I'm nice to the drug reps, I chat for a few minutes, I sign for samples, sometimes I even call and request samples, I use their pens, and if you show up needing an antipsychotic agent, you get the one that's in the closet. I used to run a clinic, and part of that work entailed educational programs for the staff and boosting morale: go straight for the stomach. Sometimes I asked the pharmaceutical reps to provide lunch and they'd bring a tray of sandwiches. This went over well with the staff.

Do the pens and sandwiches influence what I prescribe? I can't say no for sure, but it feels like they all come, so what's to say which I use more? Really, boils down to my anecdotal evidence more than anything else: if the first time I try a med, the patient returns saying it helped, I'm more likely to use it. If I have to slowly titrate up and it takes a lot of time and a lot of appointments, I'm less likely to use it. Sorry, Effexor. If the first patient who tries it comes back ranting it was horrible, I get a bit colored. I talk to my shrinky-friends: are they having the same experience? If not, I'll reassess and try again. Even if I don't use the drug myself, I still smile at the reps, sign on the dotted line, and throw the samples in the closet for whoever else wants it.

So why aren't they paying me? Really, that post I wrote on Why I Still Prescribe Seroquel, shouldn't that be worth a few bucks? Look, I'm cheap, never mind the 45 grand, I'd have done it for a mere $20,000.

Finally, I need to say a few words about media sensationalism. Villainizing psychotropics seems to be the thing to do, and hell, get those docs who prescribe them while you're at it. I really wish that atypical antipsychotic medications didn't cause weight gain, diabetes, and metabolic problems. And now that I know this, I tell people. Many people don't develop these side effects-- I've become more diligent about checking labs and warning people of the risks. Though I really wish I could say that it's rare for people to develop diabetes either on or off these meds-- the truth is it's a really common illness and a lot of my patients have it before they see me, a lot get it during the course of treatment, and some get it during the course of treatment with atypical antipsychotic medications. If there was something else I could prescribe, I would and often I do. From my perspective of the doc-in-the-office, there sometimes is just no option but to use these medications, they're what we've got. This isn't to defend the drug companies, I believe their goal is simple: to make money. Kind of like your health insurer runs ads with soft music telling how they care, but really they just want to make money. What surprises me is that anyone expects anything else from them. No answers, sorry.

My last word about media sensationalism: It's hard to get Medicaid, you have to be sick. An episode of depression treated with Prozac doesn't do it. To get Medicaid, at least in Maryland, you have to be chronically ill (and even that isn't always enough), so a bad psychiatric illness, chronically, probably one that you need a chronic, expensive, antipsychotic medication to get. No wonder antipsychotics are a high percent of the Medicaid budget.

Okay, send the check, I'll be waiting


NeoNurseChic said...

I'm talking without researching, so watch someone come through and blast me, but I don't think that PA medicaid works that way. I believe you just have to meet certain income requirements. When I worked in the ER, a lot of people had medicaid that had no health problems - except for the random thing or two that brought them to the ER.

Medicare in PA, on the other hand, requires that you meet the age requirement, or the chronic illness requirement. To get medicare coverage, you have to be on disability and have some sort of chronic disease, such as End Stage Renal Failure, or other variety of chronic illness. But that delves into the whole SSI/SSDI stuff that I don't really know a lot about, but other people may know more to comment on that than I do.

Interesting the way it works state by state. At our hosp, we are no longer accepting one form of medicaid, so everyone who has that now has to switch to the next type. I think at one point there were 3 different types in PA.

I'm curious what they mean about getting paid by drug companies! I know that the one psychiatrist I saw was really into prescribing concerta, which he put me on, and I'm still on it. When I'd talk to other patients who also saw him, they were all also on concerta. We had our moments of wondering if he was getting kickbacks of some sort from prescribing concerta! I don't really believe that, but I guess it just seemed weird that all of us had some sort of treatable ADD/ADHD.

So does income from drug companies mean actual dollars written from one person to another? Or does it mean the cost of pens, gadgets, food, tickets to sporting events, and so on that often goes on.

Great post, as usual!!
Take care,
Carrie :)

Gerbil said...

1) I have an impressive collection of pharmaceutical office products, but none of it influences my practice--lack of prescriptive privileges for psychologists (outside New Mexico) and all.

2) my former psychiatrist once wrote me a letter on Abilify notepaper. In it he apologized for the cheesy stationery, adding, "I don't even rx Abilify!"

Gerbil said...

Oh, and I just have to share my most creative use ever of pharma-swag (if I do say so myself)... at the American Psychological Assn. convention a few years ago, Pfizer was handing out little foam stress toys in the shape of the Zoloft bean. I tried really hard to get the cat to play with it. However, she wasn't interested in least.

So I poked a hole in the top of it with a screwdriver and pushed some catnip inside. The cat shows minor interest in the Lobotomized Zoloft Head, but mostly she just lets it sit around and stare at the floor.

Anonymous said...

I have a drawer full of Seroquel, Zyprexa etc. I am renting a hot air balloon and going to drop them from the sky. Tomorrow.

Medicoglia, RN said...

I have to agree with the media hysteria about atypical antipsychotics. I was on one for a little less than 1 year. Yes, I was diagnosed diabetic. Now...I have a very strong family history of diabetes, both types I and II. So did the med cause it? I would have to say I don't think so, maybe it contributed to my developing it at a younger age than I would have anyway, but it didn't cause it. And let's be real...I would much rather eat well, exercise and check my bgl a couple times a day than to be cowering in a corner while trying to convince my partner to call animal control for the 4 ft spider on the ceiling that I just KNOW is going to eat me!! It's all about weighing the benefits and risks...just like any other med.

By the way...the spider thing really did happen...not just a silly example. :P

Anonymous said...

Maybe I'm missing something in my own reading of the Times article, but it looks to me like the Times made a serious error in reporting on this story. The $45,000 figure described as the average payment to psychiatrists represents only the average among the top 11 (psychiatrists) recipients in the state. It is not a statewide average, as the Times article leads one to believe.

I did my own quick and dirty analysis based upon the report issued by the State of Vermont and it looks to me like gifts, education and payments totaling an average of $1000 per psychiatrist are probably typical for the average psychiatrist in Vermont. That’s definitely more consistent with the experience you report in your own practice.

Anonymous said...

Total nonsequitar...

( OK not total...where I work the drug reps would offer a "Drug Lunch" every month or two , telling us what study from 5 to 10 years ago supported the efficacy of their drugs. But MD's never went to these, and the nurses hardly had time. It was usually Social Workers in our state system that found time for these Veal Parmesan extravaganzas.

The nursing staff sometimes scored wilted leftovers, no inservice, and a pen made in the Pacific Rim slaveholds.

Compensation hardly worth subjecting anyone to at the losing end of a cost benefit analysis, much less anyone we are professionally obligated to protect like our own)

What's your take on the benefits of Abilify? I've seen miraculous cures, and a preponderance of increased delirium and hypothalmic effects including hypothermia in the patients where I work. Haldol makes them dystonic. Zyprexa makes them diabetic. Lithium slows them down and destroys their thyroids and kidneys. All these drugs throw their livers into an altered state. Age makes all the side effects worse.

Benefits vs costs ( in all it's measures). These drugs allow certain people to have decent lives before they cause organ failures and early death. There's a significant minority who remain sick with pychiatric symptoms, and then get more more sick, both mentally and physically)as more meds are added.

When is it enough? Whe is it ok, and an accepted part of life,to temporarily or chronically be impaired with voices and irrational thoughts?

Why aren't we giving the side effects more attention as a professional body?

Some things are incurable, and some things cannot be medicated away with our present resources.

Why do we persist in making some people sicker with the available meds when their psychiatric symptoms do not resolve?

What ever happened to "Asylums"