- Associated Press - Sunday, May 29, 2016

BOISE, Idaho (AP) - Robert Wechsler calls himself “the Rain Man of epilepsy for Idaho.” A neurologist who specializes in seizure disorders, Wechlser also says that because of his work with the pharmaceutical industry, he is something of a “hired gun … who comes in and talks about a drug.”

And he’s proud of it.

Wechsler was among the top five doctors in Idaho receiving payments from pharmaceutical and medical device companies in 2014, the most recent year for which records are available through the federal Open Payments system.

Drug companies funded Wechsler’s trips in 2014 to 40 cities, where he talked to other physicians about certain medications. To compensate him for those engagements, the companies paid Wechsler more than $147,000 in honoraria, speaking and consulting fees.

He also received about $25,000 for clinical trials and studies of seizure drugs.

The pay is compensation for his time and expertise, he said, and also helps subsidize his care of uninsured or underinsured patients.

“There’s been so much concern about these perceived conflicts of interest that some of these (academic medical centers) are no longer allowing their physicians to interact with industry on the promotional side,” he said. “It’s created a unique business opportunity for me.”

Treasure Valley physicians and hospitals received $3.8 million in payments from medical device and pharmaceutical companies, and $2.8 million for clinical research funded by those companies, in 2014.

Several local doctors received more than $100,000 in benefits - cash, in-kind payment or other compensation - during the year.

Twenty-four Treasure Valley doctors received more than 100 paid meals or drinks in the year. Dozens averaged more than a meal or drink per week.

Drug companies reported providing meals or drinks to Stephen Spencer, an internal medicine physician at Selah Medical Center in Boise, on 206 days in 2014.

Spencer did not return calls from the Statesman.

Those payments must now be disclosed under the Sunshine Act portion of the Affordable Care Act.

The investigative journalism nonprofit ProPublica found in March that, based on data analysis, doctors who received money from drug companies were “two to three times as likely to prescribe brand-name drugs at exceptionally higher rates as others in their specialty.”

The analysis, ProPublica noted, did not prove the money caused doctors to prefer brand-name drugs. But it proved there is a relationship between industry spending and prescribing behaviors that are a boon to the pharmaceutical industry.

The industry has made subtle changes in response to scrutiny, investigations and lawsuits, and as reforms such as the Sunshine Act pull back the curtain on the development and marketing of devices and drugs.

The drug company GlaxoSmithKline in 2013 announced it would stop paying doctors to talk about its products by 2016. In 2014, the company spent $28,000 on speaking fees and $17,000 on food, drinks, consulting fees, travel and lodging for Idaho doctors.

PAID EXPERT

Wechsler says his decisions are not influenced by his speaking gigs. If anything, he said, he works with so many pharmaceutical companies that he’s become familiar with more epilepsy drugs than peers who aren’t allowed to interact with the industry.

“I would say, honestly, I’ve done some work - either advisory work or consulting work or speaking - for pretty much every company that has any kind of product related to epilepsy,” he said.

He relates a story from one of his drug consulting jobs, during which he was talking with a “big cheese” epileptologist at one of the major academic centers in the country.

“I said to him, ‘You know what really kills me is we have 24 drugs to choose from, (and) four out of those 24 drugs make up about two-thirds of the prescriptions in the U.S.,’ ” he said.

Three of those drugs came out before 1980, and while “most of the drugs that came out since then are available as generics,” they aren’t as widely used, he told the other doctor.

“He looked at me and said, ‘There are not 24 drugs for epilepsy.’ And he’s a big academic professor guy, right? And I’m a little guy from Boise, Idaho,” Wechsler said. “I write out the drug names for him, and I hand it to him, and he looks at it and goes, ‘Huh, there are.’ “

CONFLICT OF INTEREST

Other Idaho doctors who received hundreds of thousands of dollars from the industry say they have put a buffer between themselves and those financial interests.

The top-paid doctor in the Treasure Valley - and in all of Idaho - in 2014 was Michael Coughlin, an orthopedic surgeon who focuses on feet and ankles.

$467,754 Payments from drug and device makers to Saint Alphonsus Regional Medical Center in 2014

$205,094 Payments to St. Luke’s Regional Medical Center

$36,191 Payments to West Valley Medical Center

Coughlin isn’t a stranger to local pay rankings. He is among the highest-paid physicians at Saint Alphonsus Regional Medical Center, making more than $961,000 from the hospital in the 2014 fiscal year.

He also received about $448,000 from medical device companies in 2014. The majority of that pay was from royalties or licenses, as well as consulting fees.

The doctor ranking No. 2 in pay that year was Michael Tullis, a vein care and vascular surgery specialist at St. Luke’s Health System.

Outside payments to Tullis in 2014 of $267,066 were almost entirely from the sale of a medical device startup in which he invested about five years ago. The company, Sapheon, was sold to Covidien, then sold again to MedTronic, said St. Luke’s spokeswoman Beth Toal.

“The company has done well and the original investors in Sapheon are receiving payments in three installments,” Toal said. “It’s important to note that Dr. Tullis no longer has any ownership interest in any of the companies. He also has never used the technology that was developed by the startup that received his original investment.”

Coughlin’s office directed a Statesman reporter’s calls to Joshua Schlaich, a spokesman for Saint Alphonsus Health System. Through the spokesman, Coughlin said he could not do a telephone interview because he was busy with surgery.

Instead, Coughlin provided a written statement to Schlaich.

“You can tell the reporter that I have been practicing locally for many decades, and I have been fortunate enough to be a part of innovating foot and ankle treatments with prominent surgeons at (University of California San Francisco) and other highly regarded institutions,” Coughlin wrote.

He developed a device called the Scandinavian Total Ankle Replacement - or STAR - system, which payment records show provided him at least $40,000 in consulting fees in 2014.

Coughlin also has written “the most widely used textbook in foot and ankle surgery today,” he said.

“A good majority of the education and innovation I provide to the nationwide practice of foot and ankle surgery is actually unpaid, and I assume many of those costs personally,” he said.

I fully disclose my relationship with device manufacturers and research organizations with my patients, and they are often proud that their surgeon is part of providing cutting-edge technology to the nation’s surgeons. Michael Coughlin, orthopedic surgeon, Saint Alphonsus Regional Medical Center

Coughlin said he does not receive any royalties on his own inventions for any surgery done in the Treasure Valley or at Saint Alphonsus.

Another top-paid orthopedic surgeon at Saint Alphonsus, Richard Moore, was unavailable for an interview because he was out of the country, Schlaich said. Moore also does not receive royalties from medical device companies when his inventions are implanted or used in this region, Schlaich said.

“In the end, I want what any passionate surgeon wants - better patient care,” Coughlin wrote. “I feel that through the education and innovation I have provided to the field, I have helped do just that.”

‘SOMEONE HAS TO TEACH DOCTORS’

When a Statesman reporter contacted Wechsler about his payments, he said, “I’ve been looking forward to having a phone call like this.”

Wechsler started a practice in Downtown Boise after moving here in 2005. He and a physician assistant see 40 to 50 patients a week. Wechsler also goes out to the Southwest Idaho Treatment Center in Canyon County to care for about 30 patients there.

Within three years of starting that practice, Wechsler was actively involved in clinical research for epilepsy. Then he started talking about the drugs he was helping to test.

Wechsler considers himself a paid teacher to other neurologists. He thinks it’s worthwhile for other doctors - especially those who don’t specialize in epilepsy - to hear from him.

5 Treasure Valley physicians who traveled to Switzerland for a weekend conference on hip, spine and knee products

$34,230 Total Medacta spent on the trip

“Over the last seven or eight years, we’ve become one of the busiest epilepsy centers in the country,” helping to test multiple drugs, he said. “Once the product becomes available, someone has to teach doctors about it - how to use it appropriately, what the concerns are that they need to be made aware of.”

And if he’s taking time away from his medical practice and his family to do those speaking engagements, he’s not willing to lose money on it. He needs to be paid at least as much as he makes at home, he said.

The trips are not vacations, he said. Because of “sheer paranoia” in the new, transparent world, the drug companies put strict limits on travel expenses. Wechsler takes economy-class flights, picks up a basic rental car and typically stays in a Hilton Garden Inn or similar hotel, he said.

He rarely goes to Las Vegas because of the concern drug companies have about sending doctors there or hosting conferences in the indulgence capital of America, he said.

“But you know what? People in Las Vegas have epilepsy,” he said. “I absolutely agree that one needs to be very, very careful in this day and age with regard to conflict of interest and perceived conflict of interest, but I think the pendulum has gone almost a little bit too far.”

At the same time, Wechsler said he steers clear of companies whose drug representatives come into his office and break the law by pushing a drug for an unapproved use.

His role allows him to play the companies against each other to improve medical care in general, he said, by getting one company to agree to let him show videos about different types of seizures or include a primer about sudden death from epilepsy. “All you need is one,” and the others follow suit, he said.

When it comes to being a doctor, he prescribes the best treatment is for his patient, he said. He denied that his close involvement in the development and marketing of a drug sways his treatment decisions.

The drug companies want to sell you drugs. The device companies want to sell you devices. And the surgical centers want to sell you surgeries. My job is to protect you from all of them. Robert Wechsler, Boise epileptologist and pharmaceutical speaker

Wechsler said that although many of his friends have looked up their records on the Open Payments system, he has not.

The Statesman read aloud his tallies - the companies that paid him, the dollar amounts and the nature of those payments.

Wechsler’s reaction? The speaking money seemed a little low.

He recalled doing work for Belgian pharmaceutical company UCB Pharma, on Vimpat, a drug that is FDA-approved to treat certain types of seizures. The company wasn’t listed in his general speaking-fee records. But Wechsler was one of the lead investigators on a study that found it works as a standalone drug, so he did “quite a bit” of speaking in 2014 for the company that created it, he said.

Sure enough, the company’s payments to Wechsler for his work on Vimpat appeared in a separate database - payments for research - that also is now public.

Medicare prescription records assembled by ProPublica show that in 2013, Wechsler was among the top 10 prescribers of Vimpat in the country, with 56 of his Medicare Part D patients getting 621 Vimpat prescriptions filled or refilled. It was the most common drug he prescribed to patients that year.

“Most of the folks I see in my subspecialty clinic have already been tried on a lot of other things by other docs, so I will always turn up as a high utilizer of newer agents,” Wechsler said.

Why not allow physicians to learn organically, instead of while eating a meal bought by a drug company or listening to a doctor paid by a drug company, with the conversation revolving around what often is a high-priced brand-name drug?

Wechsler’s arguments echo those of other Idaho physicians, who have told the Statesman over the years that their speaking stints are a necessary part of the process. Doctors are too busy to read journal articles about every new drug - much less decide which studies have the most merit or the least amount of conflict of interest, they say. Drug companies host conversations about their products that, now, are strictly regulated and monitored by lawyers, they say.

The Boise epilepsy specialist last weekend gave one of those talks. A drug for a previously hard-to-treat condition is rolling out in Japan, so Wechsler flew to Japan for the first time, talking to doctors about a pharmaceutical company’s latest invention.

Flying into Tokyo early to acclimate to the time zone, he said: “I’m taking a personal day that I’m paying for myself.”

___

Information from: Idaho Statesman, https://www.idahostatesman.com


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