What a Tangled Web We Weave - Among Risk Management Education, a Pharmaceutical Manufacturer, a MECC, and an Insurance Program Manager

We have often blogged about the tangled web of conflicts of interest that now spans health care. Here is a story about just how tangled that web may be.

Most of the strands were unearthed by Dr Daniel Carlat on the Carlat Psychiatry Blog. Dr Carlat published a series of posts about how Eli Lilly and Company funded a continuing medical education (CME) program which first seems to have been produced by a medical education and communication company (MECC), PV Updates. The purpose of the program was ostensibly to educate physicians about risk management. But Carlat thought that the idea was to make learners more comfortable about prescribing risky medications.

Perusal of the online slide show to which Carlat referred immediately suggests how knotty this web may be. The program has a copyright notice from "PV Update Publishing," but a Google search revealed no listing for this company, and the URL http://www.pvupdate.com/ yields an error message, albeit with the PVUpdates logo. But the slide show was also noted to be "developed by PRMS, Inc., and under the sponsorship of Eli Lilly and Company." Stay tuned for a moment...

Meanwhile, amazingly, a Lilly spokeswoman answered Carlat almost immediately, arguing he had misunderstood the intent to "to provide helpful, independent, non-product-specific information to psychiatrists to keep the risk of litigation in perspective and to understand what they can appropriately do to reduce that risk." The response begged the question of why Lilly would choose to spend its money on such an educational program, and who actually produced the program.

But here it gets more tangled. An article in the Indianapolis Star noted that Lilly "hired a medical education company, Professional Risk Management Services [PRMS]of Virginia, to help spread the message that psychiatrists can manage risk. The company recently mailed a 14-page brochure to psychiatrists across the U.S. with the message that the best way to avoid malpractice claims is to provide good care and document it carefully." Note that PRMS was listed as the "developer" of the slide show.

But the Indianapolis Star article did not clarify what PRMS does. PRMS is not a MECC. It is an "insurance program manager" which handles "underwriting, claims, and risk management," although in connection with its insurance business, it also provides CME. Thus, a psychiatrist protested to Carlat,

I am outraged that PRMS has accepted money from Lilly and has chosen to offer its authority and reputation toward this Lilly effort. PRMS is the American Psychiatric Association-endorsed entity which directs APA members to a selected malpractice insurance agency. PRMS is thus the agency many or most of us psychiatrists turn to for guidance and direction as to liability exposure and malpractice coverage. For PRMS to work for Eli Lilly is a glaring conflict of interest between their psychiatrist clients and a pharmaceutical corporation whose interests do not necessarily coincide with those of the psychiatrists with whom they have a professional relationship. This is analogous to the same law firm representing two individuals opposing one another in a law suit; in that situation we assume that there cannot be fair representation of either client, and we may imagine that the client with an attorney who has more clout in the law firm may well prevail in the action. How can we trust PRMS, or the APA for that matter, to provide us with the best liability support?

The threads among a pharmaceutical company, apparently a MECC, and an insurance program manager are certainly is hard to follow. So Carlat concluded,

Look, I get as annoyed by conspiracy theorists as the next guy. But the web of money and influence here is so murky and repugnant that it leaves me wondering what's going on.

Sometimes you are paranoid, and sometimes they are really out to get you.

It seems that many trusted medical or health care institutions are now connected to some favored health care corporation(s), and many physicians, academicians, and academic, government, and not-for-profit health care leaders have part time gigs for such companies. The complexity of such relationships sometimes defies understanding. Who can you trust? Who really is for patient care, education, or science?

We may have to expose every such tawdry conflict of interest before we can answer these questions. "Sunlight is the best disinfectant."