| Ilena Rose 2005-07-30, 11:52 am |
| EXCERPT: The pharmaceutical industry estimates that it spends about
$5.7 billion a year on marketing directly to physicians, which works
out to about $6,000 to $7,000 per doctor.
These Gifts Are Bad for Our Health
By Stephen Cha
Post
Sunday, July 24, 2005; B02
NEW HAVEN, Conn.
When it comes to accepting gifts from the marketing reps of
pharmaceutical firms, the American college of Physicians-American
Society of Internal Medicine suggests that its members apply a simple
litmus test: "What would the public or [our] patients think of this
arrangement?"
Most patients never find out. If they did, they'd probably go into
shock over the goodies doctors accept, like meals, travel, gift
certificates or parties. The pharmaceutical industry estimates that it
spends about $5.7 billion a year on marketing directly to physicians,
which works out to about $6,000 to $7,000 per doctor.
Three years ago, Vermont enacted a groundbreaking law intended to
remedy the situation by requiring the drug companies to publicly
report promotional gifts and payments to physicians. As in many areas
of government and business, the law was tailored with the idea that
sunshine is the best cure for the ethically questionable practices
that thrive in secret. If shame alone fails to curtail excesses, then
at least information about gifts and contributions can empower voters,
investors or consumers to make more educated choices, aware of
potential conflicts of interest.
Yet in the world of medicine, this is a new concept and, judging from
Vermont's experience, legislation about it may require further
surgery. Not only have pharmaceutical companies and doctors
circumvented the disclosure rules, but it's virtually impossible for
patients to find the information.
"It's not surprising that this extraordinarily well-financed industry
circumvented the law," says Peter Shumlin, the former Vermont
legislator who sponsored the bill. "The surprise is that we consumers
still take it."
The scope of the problem in medicine is well known -- at least among
doctors.
As a medical student, a colleague of mine once walked into the offices
of a practice where she was working and unexpectedly found herself at
a party. Food, trinkets, pens and coffee mugs were being handed out to
the whole office staff, about 20 people including med students and
doctors -- all courtesy of Merck & Co. And to the physician who was
the number one prescriber of Vioxx in the entire region that year, a
marketing rep of the company awarded a pair of Philadelphia Eagles
season tickets.
That was almost five years ago, and the party for Vioxx has ended --
the painkiller got yanked from the market because it could cause heart
problems. Recent congressional investigations revealed that Merck
marketers had misled physicians, wrongly suggesting that Vioxx was
better for the heart than other pain relievers, even after research
suggested possible dangers.
Did Merck's perks encourage that doctor to prescribe a drug that he
might otherwise have avoided? It's difficult to judge. Like political
contributions, these gifts are not necessarily improper, and some
industry-physician collaborations can lead to important advances. But
research shows that such largess affects physicians' prescribing
practices and may compromise their objectivity.
Certainly if I knew that my doctor was getting $5,000 to $20,000 a
year from the maker of Vioxx, I would wonder why the doctor was
prescribing it.
"I think the public would be outraged if it knew the extent of the
industry's influence in prescribing decisions," says Shumlin. "We
hoped to force industry to show the extent of these practices, and
hoped to embarrass doctors into changing their own practices." Hoping
that these changes in practice would help stem the rising costs of
prescription drugs, 23 states have since considered, and a handful
have adopted, similar legislation.
So far, however, industry has exploited loopholes in the Vermont
legislation to avoid full public disclosure. For instance, the law
says that gifts under $25 or grants for "research" need not be
reported. And even when those gifts are reported to the government,
the disclosure can be withheld from the public if the industry
designates its own reports as "trade secrets." And the reports of
gifts are made to the state attorney general's office, which doesn't
keep a public database with real-life physicians' names and gift
descriptions.
Instead, the attorney general issues annual overviews. In the May 2005
report, the most recent, the industry reported about $3.11 million in
gifts in Vermont. None of the state's 2,200 doctors are named.
Nancy Chard, a Vermont state senator on the conference committee that
forged the legislation, says, "Doctors' names should be out there. But
the bill got toned down to a point where it's just a happy memory. I'm
proud of having done it, but it's not a viable piece of legislation.
There are so damn many bad guys in this thing."
Worried that Congress might spoil the party, some organizations have
begun self-regulation. The American Medical Association and the
pharmaceutical industry issued a set of voluntary guidelines on gifts.
For instance, gifts should be under $100 in value unless they are
payments as part of a formal consulting relationship. This gesture,
and $91 million in campaign contributions the two industries made
during the 2004 election cycle, have been enough to keep Congress out
of this dogfight.
Given the amount spent on marketing per physician, it's clear that
many gifts are not within the AMA guidelines. In Vermont, many
reported payments to individual physicians ran into the thousands of
dollars. "I'll tell you one thing," says Chard. "There are still
plenty of [pharmaceutical] dinners going on at the local fancy
restaurants."
"It's unconscionable that they're spending $3 million on trinkets here
in Vermont when my patients can't afford to pay for the medications to
treat their high blood pressure," says Benjamin Littenberg, director
of general internal medicine at the university of Vermont. Littenberg
accepts no gifts, no drug detailers and no materials from drug
companies or their sales reps. (He's also never written a single
prescription for Vioxx.)
Legislators in Vermont started with the simple idea that the billions
of dollars industry hands to physicians should be public knowledge.
And there are some simple ways to fix the rules the law established.
· Remove trade secret exemptions that subvert the entire point of the
law. Allowing a drug company to decide what is a trade secret is like
permitting John McEnroe to make his own line calls.
· Require disclosure of the identities of gift recipients. Imagine if
all political contributions had to be disclosed, but the public never
learned who received them.
· Improve data quality. More than half of the "name-identified data"
in Vermont contained only a last name and amount of gift.
"Do-not-call" lists that are made public could provide broad
recognition and encouragement for physicians who rebuff drug reps. No
Free Lunch, an organization that advocates a complete ban on
promotional gifts, also collects commitments to spurn industry gifts.
Already, more than 250 physicians have taken the pledge.
Littenberg says, "Taking anything from drug companies violates a
trust. They shouldn't be allowed to offer [gifts], and we shouldn't be
allowed to accept them, and it's appalling it's even an issue. It
would be like Consumer Reports taking money from the washing machine
manufacturers."
While people have criticized the pharmaceutical industry for promoting
less-than-desirable drugs, the fact is that for every dangerous or
inappropriate drug prescribed, there is a prescribing physician -- one
who may have been unduly or unconsciously influenced by these quiet
billions in gifts. Physicians should serve as patients' trusted
intermediaries, but that trust must be built on openness; the public
has a right to know about potential biases. Public disclosure may not
stop the distorting influence of money in medicine, but it should be
the first step.
Author's e-mail:stephen.cha@yale.edu
Stephen Cha is an internist and a Robert Wood Johnson clinical scholar
at Yale university School of Medicine.
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