Doctors and Payors
by James Cavuoto, editor
One of the most hotly discussed topics at the recent meeting of the North American Neuromodulation Society was how to respond to recent negative reports about neuromodulation, and in particular, two recent studies published in the Journal of the American Medical Association and JAMA Neurology [NBR Dec 22 p1].
During the opening plenary session at the conference, Anuj Bhatia from Toronto Western Hospital presented a detailed rebuttal to a Norwegian study of SCS published in JAMA last fall. Noting the high-impact nature of the journal, he expressed concern that the article could have a negative impact on pain doctors and their patients. He expressed frustration that the article’s authors did not adequately respond to his inquiries after the piece was published. Among the concerns he raised was that this was a single-site study and the complication rate suggested that the implanters might not have all been at the top of their game. There were also serious issues in the trial design, including the introduction of bias in what was billed as a double-blind trial.
Several presenters in other sessions took aim at the more recent piece in JAMA Neurology, which was co-authored by several insurance-industry collaborators. Corey Hunter from the Ainsworth Institute of Pain Management and NANS President-Elect has authored a formal rebuttal to that piece that is scheduled to be published later this year.
One of the points noted by several speakers at the conference was the alarming trend of insurance companies buying medical practices. Many observers see this as a potential conflict of interest, particularly when clinicians working directly for insurers are involved in studies where the parent company has a decided financial interest.
Much support for this point of view was published in a recent issue of none other than the Journal of the American Medical Association. In a viewpoint piece entitled “Salve Lucrum: The Existential Threat of Greed in U.S. Healthcare,” Donald Berwick from the Institute for Healthcare Improvement sounds the alarm about a number of distressing trends, including monopoly ownership of medications by pharma companies, flaws in U.S. patent laws, and the failure of meaningful drug price regulation.
“Particularly costly has been profiteering among insurance companies participating in the Medicare Advantage program,” Berwick wrote. “By gaming Medicare risk codes and the ways in which comparative “benchmarks” are set for expected costs, MA plans have become by far the most profitable branches of large insurance companies.” As an example, he cited the firm Oak Street Health, a primary care company that plays heavily in Medicare Advantage. Three of the 10 highest paid corporate executives in the U.S. work for that firm, he noted, and their recent IPO fetched $15 billion.
Of course, insurance firms are not the only entities capable of gouging the public. Even nonprofit hospitals have pursued policies that punish low-income patients unnecessarily, Berwick contends. And surely, the medical device industry is not without its bad apples who have placed profit far ahead of patients’ needs.
But in the end, journals, regulators, and payers must be on the alert for conflicts of interest in studies that stand to have a profound effect on a particular field of medicine. Otherwise, we risk becoming a society where science research is controlled by those with the deepest pockets.