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