Nestled in the emerging Affordable Care Act is a groundbreaking provision that will require pharmaceutical companies and other medical industries to report all direct payments or gifts over $10 that are made to physicians. It’s called the Sunshine Provision, and will take effect in January of 2012.
Physicians have always had a complex relationship with the health care industries. The medical advances these companies provide are critical to what we do, and we need to stay informed of what’s happening, but as with any business, communication and marketing are just different hues of the same color scheme. Physicians as a group have been a little slow to admit that we are as susceptible to corporate marketing as everyone else on this planet. Our overarching obligation is to our patients, and when our encounters with manufacturers of pharmaceuticals and medical devices involve receiving gifts, even small ones, communication turns into marketing turns into… conflict of interest.
Pediatricians generally spend more energy keeping their patients off medicines than they do prescribing, and as a result we are probably the most industry-ignored specialty. This explains why the big perk at a national pediatric conference a few years back was getting your picture taken with the Berenstein Bears out in the exhibit hall. Yes, the moral high ground is just a hop, skip and a jump for us. Contrast that to the previous week, when my husband Randy attended a national neurology conference. Neurologists need to routinely prescribe a wide variety of expensive medications for chronic conditions such as seizures, migraines, and multiple sclerosis. Randy still recalls with a dreamy smile on his face how during session breaks, beautiful women in alluring evening gowns shucked oysters for the attendees in front of an open bar, compliments of a big-name drug manufacturer. One night they all received free tickets to the Boston symphony from another industry sponsor. No bear costumes.
Physicians have historically been adamant, sincere, and wrong in their assertion that such perks do not influence their decisions. Both Randy and I would have sworn on our Labrador retriever’s grave that our clinical decisions were not affected by such marketing strategies. An oyster’s just an oyster, right? If the industry wanted to waste their money on such independent thinkers, then that was their problem. So what’s the harm?
Plenty, it turns out. As study after study has born out, being the recipient of a gift - even a small one – confers a sense of obligation. Businesspeople know this. Over the past decade, significant data has accumulated to show that gifts subtly shape the prescribing practices and clinical decisions of conscientious physicians in ways that they are completely unaware of. Even gifts as trivial as a pen with a logo or a bag of sandwiches for the medical staff were shown to alter prescribing behaviors.
And what about those free samples? Well, it will come as no surprise to anyone that there are no free samples of generic meds in the doctor’s office cabinet. Those shelves are filled with the latest and priciest versions of available drugs. The doctor may be well-intentioned in passing them out, but they often cost the patient much more in the long run when the actual prescription is filled. And the fact that in the short term they were “free” may not necessarily mean they were even the best choice of medication in that instance; they may have simply been the most convenient to reach for. In pediatrics, the mere presence of formula samples in the office storeroom diminishes the success rate of breastfeeding for our patients. The undeniable fact is that free samples are a very effective marketing tool. It is as true for drugs as it is for chicken salad on rye – there’s no such thing as a free lunch. And who pays for all these perks in the long run? The consumer of course – the patient. Conflict of interest with a side of unfairness.
One of the thorniest issues around physician gifts is the use of industry grants to fund medical conferences. Doctors want to, and in most states are required to, participate in many hours of expensive continuing education. Industry grants help defray that cost. The industry has voluntarily taken measures to remove overt marketing influences from these settings, but more nuanced strategies remain. For instance, speakers at sponsored conferences (or “thought-shapers” as they are known in the industry) may offer presentations that, while factually accurate, weigh much more heavily towards treatment than diagnosis and prevention. To justify industry intrusion into the medical education process because it will ultimately benefit the patient, is like allowing soft-drink vendors into schools because it will help fund after-school sports. The means shouldn’t run counter to the ends.
Over the past decade many of our professional organizations have been working hard to raise physician awareness on these matters. Doctors are becoming more aware, active, and vocal in the way they manage these relationships. Growing numbers of private practices limit access to sales representatives, and refuse any gifts or samples from them. Many teaching hospitals no longer allow their faculty to have financial relationships with industry. Ethical discussions on these issues are prevalent in our professional journals.
The Sunshine Provision, by allowing more transparency in the ways corporate gifts are used to influence medical practice, is only offering a reporting system. It does not, in itself, change the way we do business. But, it is one more indication that both doctors and patients are coming to terms with the complex role that the health care industry plays in shaping medical practice. Understanding that is an important step towards meaningful reform that will hopefully someday include availability of an excellent formulary of generic drugs to all patients, and medical education that is not so expensive that it in itself drives health costs. Let the sun shine!