两篇关于美国医疗体制的文章

Prosecutors Plan Crackdown on Doctors Who Accept Kickbacks

(医药企业很欢迎这样的做法呀！看来，谁都想fairplay，特别是对自己产品有信心的企业.看来，也可以利用政府达到一些营销的目的。)



By GARDINER HARRIS



Published: March 3, 2009
WASHINGTON — Federal health officials and prosecutors, frustrated that they have been unable to stop illegal kickbacks to doctors from drug and device companies, are investigating doctors who take money for using these products.
Skip to next paragraph 

Darron Cummings/Associated Press
In January, Eli Lilly agreed to pay a $1.4 billion fine to settle federal criminal charges that it illegally marketed Zyprexa.


For years, prosecutors rarely pursued doctors because they believed that juries would sympathize with respected clinicians. But within a few months, officials plan to file civil and criminal charges against a number of surgeons who they say demanded profitable consulting agreements from device makers in exchange for using their products.
“What we need to do is make examples of a couple of doctors so that their colleagues see that this isn’t worth it,” said Lewis Morris, chief counsel to the inspector general of the Department of Health and Human Services. “We want to send the message to the physician community — particularly surgeons — that you can’t do this.”
The move against doctors is part of a diverse campaign to curb industry marketing tactics that enrich doctors but increase health care costs and sometimes endanger patients. Taken together, the new measures are likely to transform the relationship between medicine and industry.
Over the past year, for instance, prosecutors have greatly increased fines that are collected as part of plea agreements with drug and device companies charged with illegal marketing tactics. In January, Eli Lilly announced it would pay a record fine of $1.4 billion to settle federal criminal charges that it illegally marketed Zyprexa, an antipsychotic medicine. Two weeks later, Pfizer announced that it had set aside $2.3 billion to pay an expected fine over charges that it illegally marketed Bextra, a painkiller that has been withdrawn from the market.
Michael J. Sullivan, the United States attorney for Massachusetts, said that prosecutors — after winning record fines from a record number of companies — realized that they needed to expand the scope of their targets.
“The strategy of looking at the companies alone was not completely successful in terms of our objective to deter health care fraud,” Mr. Sullivan said. “So it’s fair to say that the government is looking at evidence of criminal wrongdoing even by doctors.”
Besides jail time and fines, doctors convicted in the cases could lose their licenses for a time and be excluded from the federal Medicare and Medicaid programs, severely limiting their potential pool of patients.
Dr. Charles D. Rosen, an orthopedic surgeon and president of the Association for Medical Ethics, predicted that the pending cases would tarnish the entire profession. “The abuse of the public trust by the few will hurt the many,” Dr. Rosen said.
Also, as part of plea bargains, federal health officials are forcing a growing number of drug and device makers to post publicly all payments made to doctors who serve as consultants or speakers. Manufacturers have repeatedly used consulting payments in illegal schemes to persuade doctors to prescribe drugs or devices in inappropriate and unapproved ways, according to federal charges.
Prosecutors are hoping that public disclosures of the details of these agreements will make criminal conduct more difficult to conduct and easier to spot, and that they will discourage doctors from taking money and gifts from manufacturers at all.
“The rules of the game have changed,” said Dr. David Rothman, president of the Institute on Medicine as a Profession at Columbia University. “You’ve got to presume that anything you take from a drug or device company is going to be on a Web site. Your colleagues will know; your patients will know. That’s going to stop a lot of doctors from pocketing their gifts and funds.”
Since a substantial share of doctors accept money from drug or device makers, the public postings could have considerable effects.
In Minnesota, the state’s unique payment disclosure and gift limit law has led a growing number of academic and private medical centers to impose severe restrictions on industry marketing practices. Park Nicollet Health Services, one of the largest health systems in the state, banned all industry gifts and nearly all free drug samples and has made public all doctor consulting payments.
The Department of Health and Human Services inspector general’s power to require payment disclosures extends only to companies charged with wrongdoing. A bill sponsored by Senator Charles E. Grassley, Republican of Iowa, and Senator Herb Kohl, Democrat of Wisconsin, would mandate that all drug and device makers disclose such payments.
Companies that have announced their intentions to disclose payments to doctors even before the legislation is passed have won plaudits from ethicists and industry critics.
“Being more transparent by opening up our business to the public is an important step to building trust and confidence,” John C. Lechleiter, the chief executive of Eli Lilly, said in a speech to the Economic Club of Indiana in September.
On Feb. 9, the chief executive of Pfizer, Jeffrey B. Kindler, said the disclosures were part of the company’s commitment to increased transparency and would “earn the trust of patients and the public.”
Neither executive mentioned that prosecutors would soon require them to make such disclosures anyway. In addition to Eli Lilly and Pfizer, companies that have agreed to disclose payments to doctors include Merck, Cephalon, GlaxoSmithKline and Medtronic. Some executives contend that the disclosures will increase public support for the payments.
“Through greater transparency about the nature of these relationships, we will help people better understand how important they are to developing life-saving and enhancing products for patients who need them,” Bill Hawkins, chairman and chief executive of Medtronic, said Tuesday.
But doctors who have seen details of their consulting deals made public say they have been tarred.
Dr. Richard Grimm, a Minnesota researcher, twice served on government-sponsored hypertension panels that create guidelines about when to prescribe blood pressure pills. But when state records revealed that he had earned more than $798,000 from drug companies from 1997 to 2005, invitations to serve on such panels dried up, he said.
“There’s this automatic assumption that if you make money from a drug company, you must be corrupt,” Dr. Grimm said.
Prosecutors are hoping the new measures will finally stop drug and device companies from repeatedly breaking the law.
Eli Lilly, for instance, pleaded guilty to illegal marketing charges in 1985 related to its arthritis drug Oraflex, in 2006 related to its osteoporosis drug Evista, and in January related to Zyprexa. In 2004, Pfizer paid a $430 million fine and pleaded guilty to criminal charges that it illegally marketed the epilepsy drug Neurontin, and it now faces similar charges over its marketing of Bextra.
A common problem in illegal drug and device marketing cases is doctors’ willingness to delude themselves into thinking that cash, lucrative trips and other kickbacks do not affect them, said Mr. Morris, the chief counsel.
“Somehow physicians think they’re different from the rest of us,” Mr. Morris said. “But money works on them just like everybody else.”
Mr. Sullivan, the United States attorney, said officials hoped to send a strong message to doctors. “I have been shocked at what appears to be willful blindness by folks in the physician community to the criminal conduct that corrupts the patient-physician relationship,” he said
Duff Wilson contributed reporting.

看看美国的医疗保障和医改，还是有所感慨。

A Hurdle for Health Reform: Patients and Their Doctors 
Stuart Bradford


Published: March 2, 2009
Recently, I went to the drugstore to fill a prescription. Instead, I left with a costly lesson in health care economics.
At the checkout, I was surprised when the clerk billed me for $100 instead of my usual small co-payment. It was only then that I realized my doctor had traded me up to a costly branded migraine drug, even though the old drug had worked just fine. And I had allowed it.



As a conversation about health care reform intensifies in Washington, much of the focus is on the role the government and insurance companies will play in a revamped health system. But surprisingly little attention has been paid to the role that patients and their doctors have played in shaping the way medical care is delivered.
Ultimately, for any reform to work, patients will have to change their behavior. Of course, everyone should continue to demand the best possible care. But we will have to accept that “best” doesn’t always mean the newest drug or the latest treatment. The looming question is whether patients are ready to embrace the realities of reform.
“You can make policy changes till you’re blue in the face, but if patients and doctors don’t change the way they think about medicine, we’ll never change medicine,” said Dr. David Newman, an emergency medicine physician at St. Luke’s-Roosevelt Hospital Center in New York and the author of “Hippocrates’ Shadow: Secrets From the House of Medicine” (Simon & Schuster, 2008). “If everybody at the ground level believes that prescriptions and procedures are the things we need to make us healthy and well, then it doesn’t matter what kind of policy you draft or what kind of system you build. It’s never going to get better.”
Americans spend $2.5 trillion a year on health care, or about $8,160 per person, more than twice as much as many countries in Europe. But we clearly aren’t getting our money’s worth. Today, 46 million Americans aren’t covered, and measures like life expectancy and maternal and childhood health lag far behind those of many developed nations and even less-developed ones.
At the heart of reform is a plan to cut costs, in part by trying to discern which treatments really work. President Obama’s economic stimulus plan includes $1.1 billion for studies that will ask basic questions about the comparative effectiveness of expensive procedures versus less expensive ones. For instance, with certain kinds of injuries, does surgery work better than physical therapy? Are costly new drugs any more effective than their generic predecessors?
Dr. Harold Varmus, the president of Memorial Sloan-Kettering Cancer Center in New York and a former director of the National Institutes of Health, said increasing public access to the findings of medical research would be important for health care reform to succeed.
“One obvious goal is getting information out to health care practitioners about effectiveness experiments,” said Dr. Varmus, a Nobel Prize-winning cancer biologist and the author of the new book “The Art and Politics of Science” (Norton). “This is going to be crucial, because if the government’s going to spend $1.1. billion from the stimulus bill on comparative effectiveness research, you want that stuff to be in the public domain.”
But when it comes to comparative effectiveness, the track record of the American public and their doctors is not encouraging. Even when such comparisons are available, we tend to ignore them. In 2002, for example, one of the largest government-financed clinical trials ever found that generic pills for high blood pressure worked better than newer drugs that were up to 20 times as expensive. But most hypertension patients still use costlier drugs marketed by pharmaceutical companies.
Despite numerous studies showing that most ear infections aren’t helped by antibiotics, many parents still insist on prescriptions for their children. Last month, The Archives of Internal Medicine reported that 37 percent of doctors in one survey complained that patients routinely demanded unnecessary prescriptions. By some estimates, unnecessary antibiotic prescriptions add $2 billion a year to health care costs.
The list goes on. Whether it’s invasive back surgery, medical scans or expensive drugs, patients and doctors alike often refuse to believe that costly treatments aren’t worth it.
“Doctors believe the industry propaganda that new drugs are better than old ones, and that for every ailment there is a drug,” said Dr. Marcia Angell, a senior lecturer in social medicine at Harvard Medical School and the author of “The Truth About the Drug Companies: How They Deceive Us and What to Do About It” (Random House, 2004). “They learn to practice a drug-intensive style of medicine.”
In a 2004 study in The American Journal of Public Health, researchers found that technology played a surprisingly minor role in improving health. In analyzing mortality data from the 1990s, the researchers concluded that only about 1 in 16,000 Americans had their lives extended or saved as a result of recent improvements in health care technology. The real gains in health, experts say, have come from lifestyle changes like smoking cessation and seat-belt use or from public health improvements like vaccination, a cleaner water supply and increasing access to primary care.
“In American culture, prescriptions and procedures have become surrogates for real health care and real dialogue,” Dr. Newman said. “We need doctors and patients to conceive of medicine and health in a totally different way than they have been taught in the last 20 to 30 years.”