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.

廠業築舍之由：論「成本內蘊」之世

廠業築舍之由：論「成本內蘊」之世

夫寰宇大戰未啟，約自十九稘末葉至二十稘四十載間，工廠建鎮造舍之舉，多為業主所視，乃 內蘊之本，雖巨然實務所必需者也。 其因，恆繫於時世之財計與勞動景況：

其一，開荒設廠之必需也。

蓋多數原材之業（如礦、織、鋼、木），皆繫於特定之地利。斯地多僻遠，基建與居所闕如。故築室修路，設水電，非擇也，乃 興業安工之巨資所必投者也。 無此，則廠莫能立。

其二，固傭穩力之計也。

夫廠業迅張之世，勞力者，要而易動之資也。

• 徵召之誘： 供舍，乃強誘也，尤於求職安之遷徙者（內外皆然）。此紓工者於薪俸之外，最切之需也。
• 汰換之減： 傭工汰換頻仍，募訓之費耗甚。居所既穩，則工者忠誠益固，去意自減，實 降久遠募工之費，以保嫻熟之工不絕也。
• 控馭與訓導（主恩）： 舍雖似惠，亦為社會與道德控馭之具也。廠主經管工者之居處、購物（賴廠肆）、交遊諸事，則可施其影響，抑止結社，以保「訓導有紀」之工隊，此乃 增產降亂之由也。 蓋將工者之平生，盡納於廠業之垂直統合之中。

其三，公私基建之闕也。

地方官府，或乏財力，或缺意願，難於新興廠埠供廣大之居所及市鎮服務。當時私宅市廛，或不敷，或未立，此空缺則廠必填之。

昔者業主之觀，此非徒「佳設」也，實為 戰略之必需，以保勞力之穩供易馭，尤於公建未普、勞工未善流動之世。其耗費，乃生產總成本中之必含者也。

廠業供舍之廢：戰後財計之慎與股東價值之重

夫寰宇大戰既終，尤自二十世紀五十載以降，廠業謀略根本丕變，其驅動者，乃 財計之學日進與管治之業益專，而商學院之影響，其重也深矣：

其一，股東價值極大化之興也。

• 商學碩士之倡： 戰後商學盛，尤以工商管理碩士之科為甚。此等學科，重於 財計、會計與量化分析。其核心教義，乃股東價值之極大化——為投資者創至高之報酬也。
• 資金運用回報之重： 習此業者，漸以 資金運用回報率 或類同之利潤指標，審察諸般資產與作為。蓋居舍乃巨資所投，其直接財報，常遠遜於投諸新器械、研發或營銷之利也。
• 棄非核心資產： 純以財計觀之，持管居舍乃 偏離製造本務之舉。 其耗鉅資於非核心之產，此資本若投於改進產線，或能獲更高之報。故習商者，持財計模型與成本效益分析，力倡售棄此非核心之資。
• 側重精簡運營： 倡「精實」運營與高效之風，則將非生產本務之物盡棄之。居舍，若外市或公部門可供，則顯然可棄也。
• 父權式管理減，專業管理興： 昔者父權式業主，或視傭工福祉為己責或道德義，漸為「專業」管事者所替。此新輩管事，多習財計，視傭工為生產要素與人力資源，而非廠邑之居民。其注重乃議薪與福利，非經管整社也。

其二，成本日增與管理益繁也。

• 維護之累： 居舍既舊，維護之費遂劇增。廠賈則如房東，應對修繕、租客紛爭，與日趨繁雜之法規（如屋宇規、環保規），此皆非其本業。
• 勞資關係之困： 居舍初為控馭之具，然戰後益成 勞資摩擦之源。 傭工因工會強盛，自主意識漸起，怨廠主之恩惠與私生活之控。居舍問題，屢入集體談判之議，增營運之繁，潛在罷工之險。廠方始悟，掌居舍反可 激化 勞工之困。
• 不定與風險： 財計衰退，或技術革新，足使廠鎮速廢，遺廠方龐大之折舊、難售資產。擱淺資產之險，益成財政之憂。

其三，外市與基建之漸熟也。

• 公共基建之進： 戰後政府，重投公屋、交通（高速道）與市鎮服務。工者得居於獨立之社，通勤赴廠，減廠方之累。
• 住宅市廛之發： 私宅市廛既熟，供多樣之居所。廠方無須為房東，工者可自覓其所。
• 傭工流動之增： 汽車普及與公眾交通便利，工者不復拘於廠門。可遠途通勤，亦可輕易轉業，損及廠舍「穩工」之利。

總而言之，廠方供舍之廢，乃歷史之複雜結果也。戰後社會與政治之變，固使廠鎮於工者而言，失其 必需 與 意欲，然其 主因，乃根植於財計之實用主義。 夫管治之學日興，重效率、報酬率及股東價值，此乃商學所力倡者也，驅使廠賈捨棄非核心、需巨資、且管理繁冗之資產，如職工居舍是也。此乃於新財計局勢下，優化資本配置，專注製造本務之戰略決策也。