an innocent?…

Posted on Friday 27 January 2012

Public Health Systems and Reimbursement doesn’t just roll off the tongue. I guess that’s why they said "P·H·S·and·R" instead. And when I was at the trial, I never quite connected that it was a Department at Janssen. So when Laurie Snyder was deposed and said she was a "Public Health Systems & Reimbursement manager," it didn’t even register on me that this was an actual Department. But I did understand this[4-102-1]:
    Did Janssen in any way support financially the Texas Medication Algorithm Project? "I can only go by what I know and what I did. So there were unrestricted educational grants given to support the Texas Medication Algorithm Project."
I’d never heard of an Unrestricted Educational Grant before the time when I was reading the communications between Dr. Nemeroff and the Administration at Emory [2006-2008-ish]. He was talking about his success in getting a lot of them as a positive, and Emory officials were slowly realizing that there is no free lunch. When I was at Emory through the mid-1980s, I never heard of such. So back to Janssen, Ms. Snyder worked in PHS&R and managed Unrestricted Educational Grants to Public Health Systems, among other things. In her deposition, we saw a document [exhibit 77] defining the departmental Mission[4-102-23]:
    Public Health Systems & Reimbursement Focused on Growing Risperdal Business by Focusing on Risperdal Payers.
    Mission Statement: Support CNS Sales by proactively working with Public Mental Health Systems to identify, maximize and protect Risperdal sales opportunities.
    Risperdal Total Sales = 85% Public Sector Payers!
    Atypicals are in the top 5 most expensive drugs in most state Medicaid programs.
As I said, there are no free lunches. According to an email [exhibit 81], PHS&R was good at the Mission[4-104-6]:
    The Janssen PHS&R department has led many medication algorithm initiatives for Risperdal, which have ensured open access within some payers and lead to favorable positioning for Risperdal in others. Janssen needs to remain the leader in this area in order to ensure access to Risperdal
In fact, in Ms. Snyder’s Performance Review [exhibit 82], she reported plenty of successes[4-105 thru 109]:
    Managed TMAP and PennMAP communications via phone conferences to ensure proper planning and execution
    Persuaded KOLs in Pennsylvania to adopt guidelines favorable to Risperdal
    Goal Statement: Educational Forums: Pennsylvania state OMH program to further establish atypicals as first-line with Risperdal as the standard of care.
    Influence KOLs to leverage PHS&R public sector program in order to meet long-term mutual goals – TMAP adoption.
    Successful TMAP meeting. Dialogue with key influencers around algorithms.
    Took advantage of Steve Shon’s schedule and influenced NJAHMA to support TMAP initiative
Or in her email [exhibit 98] after a successful Shon-lead CME presentation on the Schizophrenia Algorithm in Pennsylvania[4-108 & 109]:
    Wow!!! The Pennsylvania Public Sector Meeting was a success
    Over 95 attendees from all sectors of the state with key representation from inpatient [OMH] and outpatient [Medicaid] settings were present
    Every goal was focused on Integrating Best Practices for Schizophrenia patients via TMAP and measurement of outcomes based on TMAP implementation
    For the first time, the state is taking the initiative to ensure patients have a successful trial on atypicals. This can have a large impact on your business since there is still a large amount of conventional usage in the state system.
    Steve Shon, MD drove home the idea that algorithms make both clinical and administrative sense. He did a great job of explaining the basics of TMAP.
    Key influencers in the state are now seeking further information and many are trying to ‘own’ TMAP within their own system
    Overall, we have a major opportunity in Pennsylvania state hospitals and within Medicaid managed care. Both of those payers are looking to Janssen to assist them in creating algorithms
So the Lawyer asked[4-110-14]:
    Did you actually assist them in creating algorithms? Again, I only brought the people that knew about algorithms together. I was not the algorithm expert
    So are you saying you didn’t help them create them?  No. Just – just saying the assistance is really by bringing the people together, not creating them
    The "people" meaning like Dr. Shon – Correct, yes
    and the state representative? Right
And another one of Laurie’s emails [exhibit 101][4-111-8]:
    What a week?" "What a week! Last week we had well over 250+ key people attend the three Janssen sponsored TMAP programs in Pennsylvania [estimated total cost" of 5 to 6K]. "We had mostly staff psychiatrists from the state hospitals; medical directors, administrators, advocacy and others attended from not only the state hospital system, but also the community. More importantly, our competition has missed this moving train!"
    … they did not have a Public Health Systems & Reimbursement team and they’re – they really were not aware of Texas Medication Algorithm Project as much, or if they were, they weren’t doing anything about it.

No. I’m not going to go through the entire list of the 26 witnesses that testified before they pulled the plug on the trial and settled it [well, maybe a couple more?]. But I remembered Laurie specifically. Her video-taped testimony came right after Allen Jones’ live testimony, but that’s not why I remembered her. It was that she struck me as something of a true innocent – a young woman about the age of my own daughters who had a good job and who wanted to do it well. I expect that she didn’t see P·H·S·and·R as a very bizarre department tasked in part with making sure that Janssen’s Unrestricted Educational Grants were anything but "unrestricted." I’ll bet she has a Facebook page with lots of Friends and a long list of Likes, maybe she watches Downton Abbey religiously eating Kashi® Bars. I couldn’t see any sign that she knew that she’d been a small cog in a big machine that pulled off a heist that put the Brink’s Robbery to shame, edging halfway to Bernie Madoff’s Ponzi scheme.

I doubt that it ever occurred to her that the TMAP Algorithm she was helping Dr. Steven Shon sell to Pennsylvania, New Jersey, and others had been brought into being by her own company, first in the form of the TriUniversity Guidelines – or that another part of her company was working overtime to keep the downside of Risperdal out of the public eye. Likewise, I expect that it hasn’t dawned on her yet that the selling points that Risperdal was more efficacious and safer that the alternatives, and that by spending more than forty times as much for it the State would save money, were completely indefensible fabrications – obvious even before they were definitively refuted by the large clinical trials that came later. Her  job was to "to identify, maximize and protect Risperdal sales opportunities." The Texas Medical Algorithm Project and the Director of the Texas Department of Mental Health and Mental Retardation, Steven Shon, were key pieces, maybe the key pieces, on the road to success.

Even though I know otherwise, sitting here in my cabin writing about the machinations the drug companies went through to pull off their immensely profitable over-medication of America abetted by the Laurie Snyders and my colleagues in psychiatry, I see Demons, Monsters, Sociopaths – people who knew exactly what they were doing and didn’t care about the consequences. And then I watch a Laurie Snyder and see someone you might see wearing a pink tee-shirt at a fun-run for Breast Cancer Awareness Week. I don’t think it ever occurred to her what she was a part of. I wonder if she knows even now?

There is an inertia to the internal morality and ethics of human cultural systems that never ceases to confound us after the fact. It has the strength of Super-Glue. Allen Jones returned to the Office of the Inspector General after a decade of construction work in rural Pennsylvania – way outside the world he found himself looking into. On his very first case, he almost immediately saw what people in multiple systems [including his own office, an oversight agency] either ignored, hadn’t seen, or refused to see [even when shown]. Once he saw it, Allen Jones’ internal morality and ethic carried the day to his great credit. And sitting in that courtroom, one could only be awed that this scam went on as long as it did – as clear as it is now. But we’re looking from outside those systems, and we’re being educated by people who’ve spent years working on making it crystal clear [and they did].

Note: [4-110-7] keys to volume 4, page 110, line 7 in the transcripts…
    January 27, 2012 | 5:41 PM

    My husband and I were dismayed when his daughter took a job at Janssen several years ago, with her freshly minted MBA and relatively poor science education. About the time I was doing nothing but watching TV, taking laxatives and gaining weight on Risperdal, she was pitching other medications. She actually believed all the stuff that she was taught in her training, and thought she understood it, when she had no science or medical background whatsoever. She didn’t know enough science to know that she had no idea what she was talking about.

    She is the biggest sweetheart and does run for breast cancer. I am so glad she left that job after a relatively short period of time. My husband and I are very grateful that the medications she repped (hmm, is that the word?) were not too controversial. I think there are a lot of naive sweethearts pitching these antipsychotics. I hope no dirt comes out about the drugs that she pitched, because it would devastate her.

    January 27, 2012 | 10:17 PM

    I keep a folder on the desktop – essentially a text file containing quotes. I added this just now: “There is an inertia to the internal morality and ethics of human cultural systems that never ceases to confound us after the fact. It has the strength of Super-Glue.” Fits well with having just finished “Unbroken” by Lauren Hillenbrand. As always, thank you for being a thinking person. _fcm

    January 28, 2012 | 8:50 AM

    I agree with Carl that there are parallels between all this and “Unbroken” (what a book!). I would also mention the famous B&W movie Judgement at Nuremberg. The judges followed the law of the land; it’s just that the law was wrong, terribly wrong.

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