Drugs, Money, and Sunshine

On January 1st, 2013, my patients will be able access an internet site that will tell them exactly how much money I get from pharmaceutical and medical device companies.  The website (not yet created) will report data collected over the course of 2012 (the mandatory reporting period begins January 1, 2012) and will display a dollar figure for every physician in the United States who has received any payment or gift worth more than $10.

When I first heard about the "Sunshine Act," a provision of the new healthcare overhaul, my first reaction was "No big deal—it doesn't affect me.  If you look up my name you'll find a big fat zero."  I’ve now had a chance to look into the issue and have learned that it might have a bigger impact than I thought.

Here's a little background.  From the dawn of time purveyors of medical goods (drugs, stents, artificial hips, what have you) have tried to incentivize physicians to use their particular product. In the vast majority of situations the main impetus for a doctor to use a given medication was its effectiveness.  No one had to entice doctors to adopt the use of penicillin, for example, because the medical community was craving a truly effective remedy for common infections.  This remains the case today where most doctors prescribe a particular treatment simply because success of therapy is the driving incentive.

As the pharmaceutical business became more lucrative over the years, and as competing therapies sprang up, companies had to find ways to influence the prescribing habits of doctors to favor one particular product over another.  Such an approach is no different than seen in any other sector of our consumer world—it's one of the hallmarks of our capitalistic market.

At some point, however, the doctor-industry relationship became too cozy as companies went beyond simple advertising and started offering doctors lavish gifts, vacation trips, golf outings, and fancy dinners in an attempt to win over prescribing loyalties.  The heyday for such outlandish boondoggles ended after reports of these excesses began to raise public ire and companies voluntarily restricted their offerings.  As a medical resident in Salt Lake City in the 1990s, I enjoyed the tail end of this attentiveness in the form of visits to posh restaurants and an occasional day at the ski resort.  While I was never placed under any implicit obligation to prescribe a particular drug based on a day on the slopes, the activity nevertheless afforded the pharmaceutical representative several hours of uninterrupted time in which to elaborate on his product.  Furthermore, as extensive testing in the world of psychology attests, my acceptance of such largess imprinted onto my subconscious an indebtedness that was bound to be influential any time I had the opportunity to prescribe that company’s product.

My colleagues and I in the world of medical practice are small fries, however, in comparison to the academic experts who are responsible for writing standardized guidelines for large medical associations.  The American College of Cardiology (ACC), for example, produces reams of publications every year that outline standards of practice on nearly every subject in the realm of heart disease.  These ACC experts are the ones who tell us who should be on statin medications, who should get a defibrillator, and who might benefit from bypass surgery.  The trouble with this group of nationally recognized physicians is that they are often the recipients of considerable financial support from the pharmaceutical and device industry.  They receive research grants, consulting fees, and lecture honoraria, often in the tens of thousands of dollars or more.  How can these experts, critics ask, remain unbiased in their recommendations when they are beholden to the companies whose products they are reviewing?

In an attempt to address these potential conflicts of interest people have suggested a number of changes.  Regarding this example in particular, the ACC now has a policy stating that at least half of every expert panel be populated by doctors who receive no industry funds that might introduce bias.

The biggest and boldest plan by far is the Sunshine Act, the purpose of which, as I understand it, is to shame doctors into refusing any further remuneration from industry by publishing the dollar figure of their yearly compensation.  The name itself is meant to imply that the current relationship we have with our pharmaceutical associates is a shady, backroom affair onto which Congress will now shine the light of exposure and transparency.

Many doctors showing up on the internet list will have received relatively innocuous items of value, such as textbooks or a dinner served during an educational program.  Others will receive actual payments for services rendered: consulting fees, expert lectures, participation in research.  When asked about this, the public reacts unfavorably: according to a survey from the Pew Prescription Project, 86% of respondents feel that doctors should not be allowed to partake in dinners sponsored by industry reps, and that 68% believe all gifts and payments need to be openly disclosed.

On the surface such full disclosure seems like a good way to handle this—that is, until you consider other factors.  One potentially troublesome aspect of the Sunshine Act’s internet database is the confusion it may cause on the part of patients.  Let’s say, for example, you suffer from a rare disease and have the choice between two doctors of equal reputation.  You go to your computer to see how much money each as received and you find that Dr. X has $25,000 next to his name, while Dr. Y has received only $10.  Whom do you choose?  Your gut instinct might lead you Dr. Y on the assumption he is less “tainted” by the pharmaceutical industry.  What if you knew, however, that Dr. X received his payment as part of consulting and speaking fees received in conjunction with his nationally renowned expertise in your particular ailment?  Would you not do better to choose Dr. Y over Dr. X despite his ties to industry?

I can understand the sentiment that led to such a legislative effort.  If I, as your doctor, forego a generic and prescribe a more expensive non-generic medication, wouldn’t you want to know if I am doing this out of a legitimate belief in treatment superiority or if I’m simply trying to reward the drug rep who sported for last week’s lunch?  But will the Sunshine Act’s list help you figure this out?  Even if you knew the breakdown of expenses you’d have trouble sorting out those who have the ability to maintain their autonomy from those who’ve sold out.

As I said at the outset of this post, I’m not too worried about my own online listing since I don’t actively take money from pharmaceutical or device companies (full disclosure: I have previously been paid for expert lectures I’ve given and served as a paid consultant, but I haven’t done either in several years).  Still, anytime a drug rep brings lunch for the staff in my office there will be a dollar figure affixed to my name.  Also, if ever I attend in any educational conferences in which my participation is even partially sponsored by a medical company the value of that support will be reported.

So, my question for my patients is this: If you pull up my name on the database in 2013 and you see something other than a zero, will you go elsewhere for your cardiac care?  If you were to learn that I was paid $40,000 you might have reservations about me, but what about $40? What dollar figure should you pay attention to?

My personal opinion is that a professional relationship between doctors and the medical industry is a healthy way to promote research, disseminate information, and develop new treatments for patients.  Having said that I have to admit that I still cringe a bit as I scan the disclosure lists that the pharmaceutical companies already provide, even though I’m fully aware of both sides of the debate.

I’ve been in the business long enough to see a healthy transformation in the dealings doctors have with our industry colleagues.  From the days of ski trips and golf outings to the more professional partnership we see today, the relationship between the two groups has come a long way and will continue to improve—with or without a little sunshine from the government.