Whose Skin Is It Anyway? Big Pharma's Shell Game

Whose Skin Is It Anyway? Big Pharma's Shell Game

 You ever wonder about some things? I mean, really wonder. Like how a pharmaceutical company can push a drug, off-label, telling its sales reps to do something illegal, and then when it all blows up, the company pays a multi-billion dollar fine, and the folks who were really calling the shots just... walk away? Or move to another company, still pulling down the big bucks. It just doesn't sit right.

I was listening to Lisa Pratta the other day  ( https://www.youtube.com/watch?v=27qUyMuYZJw ), a pharmaceutical sales rep for 32 years, and she saw it all. Five-day snorkeling trips to Bimini for doctors. A $15,000 Birkin handbag. An Armani suit because a rep didn't like a doctor's old one. Concert box seats, Eagles games, Phillies games, even strip clubs and lap dances. You give a guy a Birkin bag, do you really think he's going to be objective about prescribing your medication? Common sense tells you no.

Then there's the Acthar story. FDA says one thing, five vials for 20 days. Company, Questcor, says "Nah, sell it as one vial for five days." Why? To get Medicare and Medicaid approval. And the poor patients? They don't get better. They get worse. Lisa saw a woman, Melanie, in her early 30s, already with a cane, asking for her opinion on the drug. And Lisa, knowing it was illegal to give medical advice, had to give the company line, then went to the bathroom and cried. She knew Melanie wasn't going to get better. She knew the company was selling snake oil, essentially, for a huge profit.

And the sales managers? They'd yell at reps for not pushing the illegal dosage. "You're going to do this! I don't care!" Veins bulging out of their necks. My goodness. If you yell at someone to break the law, and that law-breaking puts patients at risk, shouldn't your neck be on the line?

They'd even run these "studies" with doctors. Pay them $500 per patient for ten patients. Call it research. Lisa called it a "bogus study." It wasn't for science. It was to "subliminally condition" doctors to be "Acthar cheerleaders." To change their prescribing habits. Because the competitor, Solu-Medrol, wasn't "giving me any cash."

This is where you need a healthy dose of "skin in the game." It's not complicated, really. Nassim Taleb talks about it. It’s about symmetry. If you stand to gain from something, you should also stand to lose if it goes wrong. Right now, in big pharma, the upside is for the executives, and the downside is for the company (a fine, which is just a cost of doing business), and worst of all, for the patients.

So, how do you fix it? You put some real skin in the game.

First, law design. When a pharmaceutical company is hit with a multi-billion dollar fine for illegal practices – something like off-label promotion that puts patients at risk – that fine shouldn't just be absorbed by the shareholders or the company's balance sheet. A significant portion of it, say, 20% or 30%, should be personally recouped from the bonuses and stock options of the executives, board members, and sales leadership who were in charge during the period of the malpractice. And if they've moved on to other companies? Doesn't matter. Claw it back. Make it retroactive. Make it painful. That's real skin.

Second, company finance and bonuses. Stop tying executive bonuses solely to sales figures, especially when those sales figures might be inflated by illegal or unethical means. Tie them to patient outcomes. Tie them to FDA compliance rates. If your drug is found to be used off-label, or causing harm because of unapproved dosages, those bonuses should evaporate faster than a politician's promise. And hold those bonuses in escrow for five to ten years. If malpractice comes to light within that period, the money goes straight to victim compensation or public health funds, not into some CEO's offshore account.

Third, accountability for managers. If a sales manager is caught pressuring reps to break the law, they shouldn't just get a performance review. They should face personal legal consequences, including jail time if the actions led to patient harm. You put a manager in jail for encouraging illegal behavior, and suddenly, those bulging veins might calm down a bit.

We're not suckers. We're getting sick at the expense of someone laughing all the way to the bank. It infuriates me, and it should infuriate every American. Demand that the people who benefit from risk also bear the cost of failure. It's the only way to demand change.