“He Who Pays the Piper Calls the Tune”

    Drug companies have long kept secret payment details they make to medical professionals for promoting their drugs. This practice, though legal, raises many questions about potential conflicts, and whether the interests of patients may be compromised.

    Lee Spiller, Policy Director for the Texas branch of the Citizens Commission on Human Rights comments: “The practice puts patients and tax dollars at risk...It taints the whole process. I’d hate to think donations were shaping state mental health policy in particular.”

    The fact is they are!

    Extent of the Problem

    As the Texas Tribune reports:

    • “Between 2009 and early 2011, at least 25,000 Texas physicians and researchers received a combined $57 million, and probably far more, in cash payments, research money, free meals, travel and other perks.
    • Dozens of these medical professionals were paid more than $100,000 each during that period. 114 were professors, physicians, psychiatrists or researchers who were already paid a salary by the state, in some cases more than a half-million dollars a year.

    In the USA generally, the PLOS Medicine study shows how pharmaceutical companies spend more on marketing and promoting to doctors  than on research ($57.5 billion vs $31.5 billion respectively in 2008). This translates as “an astounding $61,000 in promotion per physician."

    The PLOS authors conclude: “There is something severely wrong with a system that emphasizes marketing over research. Profit is good, but profit at the expense of the public health is dangerous.”

    Similarly, data reported in JAMA (Journal of the American Medical Association) about a Duke University study shows the financial motives behind the increase in cardiac stress tests recommended by doctors over the last decade.

    The study found that doctors who bill for both the equipment and the interpretation of the tests were 50-100% more likely to order the testing than doctors who only interpreted the results.

    Duke cardiologist Dr. Bimal Shah who led the study said: "The way that financial reimbursement is structured for some of these tests may induce increased use, and in some cases, overuse."

    Time for a change?

    The good news is that this situation may slowly be changing.

    As customers and patients have become increasingly aware of and litigious about medical mistakes, and drug companies are pressured into making legal settlements with the federal government, drug companies have begun posting doctors’ payment information on their web sites.

    The nonprofit investigative news organization ProPublica  took these disclosures and assembled them into a single, comprehensive database that allows patients to search for their physician. The data is available “to news organizations, reporters, bloggers, policy wonks and anyone else who'd like it”.

    You can see a summary Here and search whether your US Health Professional has received drug company money.

    For the detailed data, you need to fill in their form.

    ProPublica now has payment reports from 12 drug companies comprising more than 40 % of U.S. drug sales. This shows “more than $760 million in payments from 12 pharmaceutical companies to physicians and other health-care providers for consulting, speaking, research and expenses.” Their investigation suggests that: “many doctors are being paid by the same drug companies whose medicines they prescribe.”

    In addition to this public information, a new health law The Physician Payments Sunshine Act dictates that all doctors must publically report any payments from pharmaceutical companies to the federal government.

    Already, these positive changes seem to have some tangible results. In Vermont for example, the Attorney General released data showing that total payments to physicians dropped 13% in fiscal 2009 to $2.6 million. The reporting requirement began in 2002.

    Objections to the New Health Law

    Of course, there have been objections to the Health Law and payment curbs. Some consumer groups   say that the new law is too narrow in its scope. While some doctors complain that it will unfairly stain legitimate work they do for industry. Dr. Thomas Stossel, a professor of medicine at Harvard believes concerns about relationships between companies and doctors have been overblown. "What's wrong with a company buying me lunch or giving me a tote bag?" he asks.

    Other physicians acknowledge that donations from industry – even small ones – can create conflicts of interest. "There is extensive literature suggesting that gifts can influence behavior," says Dr. Robert Steinbrook, adjunct professor of medicine at Dartmouth Medical School.

    Industry critics gripe that the federal law has too many loopholes. It only applies to physicians and teaching hospitals. Companies won't have to report payments they make to nurses, physician assistants, and other medical professionals who might influence which products are prescribed.

    "If any marketing avenue is not regulated, companies will find a way to exploit it," predicts Dr. Daniel Carlat, a psychiatrist and associate professor at Tufts Medical School. "I expect we’ll see a lot more nurse practitioners giving hired-gun talks."

    Lo and behold, in Vermont, corporate payouts to nurses totalled $288,000 in 2009—almost triple the amount they received the previous year!

    Oh dear!

    Ultimately “He who pays the piper calls the tune”.

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