Healthy Skepticism Library item: 14678

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Publication type: news

Hall J.
Does drug consulting create conflict?
The Free-Lance Star 2008 Nov 23
http://fredericksburg.com/News/FLS/2008/112008/11232008/421630

Abstract:

The pharmacy director at Mary Washington Hospital also works for drug companies, a common arrangement in medicine

Full text:

Edgar Gonzalez is director of the pharmacy at Mary Washington Hospital and secretary of its drug-purchasing committee.

Yet, Gonzalez is also a spokesman for national drug companies, earning thousands of dollars a year to talk about new drugs.

Officials at the Fred-ericksburg hospital are aware of his apparent conflict of interests and have no problem with it. He’s not a drug salesman, they say, and patients benefit from his knowledge.

“We knew when we hired him that he was doing clinical research and professional speaking,” said Kathleen Allenbaugh, hospital spokeswoman. “We want him to continue with that.”

The Virginia Board of Pharmacy does not prohibit hospital pharmacists from also working for drug companies.

The American Society of Health-System Pharmacists, a trade group, recommends that its members disclose their relationships with drug companies but does not recommend against their moonlighting.

In short, it’s common for medical professionals to work for drug companies as consultants or paid presenters, or to take grant money and honoraria.

Supporters of the practice say it’s vital for the pharmaceutical industry to have access to experts such as Gonzalez and to use them to educate others.

“If companies are going to improve their drugs, they need the knowledge of these people,” said Dr. David Sarrett, associate vice president for health sciences at the VCU Health System in Richmond.

But critics say the practice translates into higher drug costs, damages the public’s trust, and can result in patients getting newer, more expensive drugs when older, cheaper ones would do just as well.

Doctors who serve on drug company speakers bureaus are little more than “paid marketers or spokespersons,” according to Dr. Troyen Brennan, the author of proposed guidelines for faculty members at the nation’s teaching hospitals.

And faculty members who have financial relationships with drug companies should not serve on drug-purchasing committees, Brennan said in his 2006 guidelines published in the Journal of the American Medical Association.

“Everybody is concerned about patients being given products that maybe aren’t the best thing for them, with decisions being influenced by some question of financial gain,” said Susan Chimonas, associate research scholar at the Center on Medicine as a Profession at Columbia University.

25 YEARS EXPERIENCE

Gonzalez began working at Mary Washington in 2007. He supervises the pharmacy staff and helps direct its drug budget.

Gonzalez also serves as secretary of the hospital’s P&T Committee, for pharmacy and therapeutics. This 25-person group consists of doctors, nurses, pharmacists, dietitians and therapists. Among its duties is to decide which drugs the hospital will buy for its “formulary,” or stock of medicines.

Gonzalez arrived at Mary Washington with more than 25 years of experience as a pharmacist, researcher and academic. He has worked in retail pharmacies, such as Rite Aid; helped found the University of Appalachia College of Pharmacy in Southwest Virginia; and has published dozens of research papers for medical journals.

He is a 51-year-old native of Puerto Rico who lives now in Mechanicsville, where he also owns a private consulting company called Capital Pharmacy Consultants.

Gonzalez declined to be interviewed for this story, though he did offer a statement through the hospital.

“I feel it is an important piece of my education and experience to participate in clinical research and educational discussion about effective new medicines,” the statement said. “It is industry standard that my time and expenses to present at educational forums are reimbursed.”

Gonzalez’s supporters at the hospital include Dr. Stephen Mandell, a Bowling Green internist and the longtime chairman of the P&T Committee.

“Edgar, without question, is the best pharmacy director we’ve ever had,” Mandell said recently. “Professionally, ethically and clinically, he is superb.”

DRUG COMPANY WORK

According to publicly available disclosure statements and documents obtained by The Free Lance-Star, Gonzalez works for several drug companies.

His work includes:

Regular talks by phone for Ortho-McNeil from the hospital pharmacy.

According to Ortho’s Web site, Gonzalez is a featured speaker for Doribax, a drug approved by the federal government last year to treat infections.

Gonzalez was scheduled to speak about Doribax on Sept. 23, Oct. 27, Nov. 3 and Nov. 18, according to the Web site. The site also says he will be the featured speaker Dec. 1 and Dec. 4.

Each presentation lasts about 45 minutes. Gonzalez’s contract with Ortho calls for him to receive $1,000 for any speaking engagement that occurs within 120 miles of his office.

A 2007 article in a supplement to the Journal of Managed Care Pharmacy.

According to the article’s disclosure statement, Gonzalez received an honorarium from Forest Pharmaceuticals for participating in the supplement.

Gonzalez also has financial relationships with Amgen and King Pharmaceuticals, according to the disclosure.

Speaker’s training for Lilly.

In September, Gonzalez accepted an invitation from Lilly to go to San Francisco to learn to give presentations about the company’s new anti-platelet agent for heart patients. Lilly offered $1,200 to attend the Saturday session.

Marketing presentations for Wyeth.

In recent months, Gonzalez has given talks about Wyeth drugs at restaurants such as Bookbinder’s in Richmond and Claiborne’s in Fredericksburg. He has also visited Culpeper Regional Hospital and Columbus Regional Hospital in North Carolina for Wyeth.

Presentations before a government committee.

Gonzalez has traveled to Charleston, W.Va., to speak at public meetings of a committee of the West Virginia Department of Health and Human Resources.

He recommended that Altace, a blood-pressure medicine, be added to the state formulary.

Two years ago, according to the minutes of the meeting, Gonzalez represented King Pharmaceuticals, the manufacturer of Altace.

Last year, he was identified in the meeting minutes as representing MediCorp Health System, the parent company of Mary Washington Hospital.

ON THE P&T COMMITTEE

At meetings of Mary Washington’s P&T Committee, Gonzalez has spoken about and voted to purchase drugs made by companies that employ him.

The hospital’s conflict-of-interests policy requires employees to disclose their potential conflicts. If a conflict exists, employees are told to refrain from voting on the matter or participating in discussions.

Mandell, the chairman of the P&T Committee, said the committee knows of Gonzalez’s involvement with drug companies and does not require him to disclose it each time he speaks.

The committee also does not require him to recuse himself from voting when the committee is deciding whether to purchase a drug made by a company he represents.

Mandell said that the committee includes leaders from throughout the hospital, and that its membership serves as a check on members.

“It wouldn’t be like his one vote would make a difference,” Mandell said. “His expertise supports our decision-making.”

OTHER CONFLICTS POLICIES

Mary Washington’s “disclose and review” approach to conflict of interests is common among hospitals in Virginia but not universal.

The University of Virginia Health System in Charlottesville has a similar policy, as does Inova Health System in Northern Virginia and VCU Health System in Richmond.

However, the HCA hospital chain prohibits managers from doing work that could be perceived as a conflict of interests. The policy applies to its senior executives, including department directors, the type of position that Gonzalez holds at Mary Washington.

HCA defines a conflict as a “circumstance where an employee’s judgment could be affected because he or she has a personal interest in the outcome of a decision.”

“It’s a comprehensive policy that applies to anybody in middle-management leadership and above,” said Mark Foust, HCA spokesman.

HCA operates 12 hospitals in Virginia. It is building the 126-bed Spotsylvania Regional Medical Center near Massaponax.

RELATIONSHIPS COMMON

It is hard to say how many doctors or pharmacists receive drug-company money, but payments are common.

Drug companies spend $21 billion a year on marketing, about 90 percent of which goes to doctors, according to the Journal of the American Medical Association.

This money is spent on gifts, grants, honoraria, speaking fees, consulting fees and travel.

Companies spend this money to influence purchasing and prescribing. But patients pay the tab through higher co-pays and deductibles.

Sen. Chuck Grassley, an Iowa Republican, has introduced federal legislation that would require drug companies to disclose their payments to doctors and pharmacists.

The Physician Payments Sunshine Act of 2008 would require publication of payments greater than $500 per year. The bill is now before a subcommittee.

Four states and the District of Columbia already require these disclosures.

And some hospitals are changing how they deal with drug companies. As of Oct. 1, the University of Virginia Medical Center and the University of Virginia School of Medicine banned all gifts, meals and promotional items from vendors and contractors, including drug companies.

“We felt it was important to take a strong position to ensure our physicians, nurses, students and staff are free from any potential conflicts of interest,” Dr. Steven DeKosky, vice president and dean of the School of Medicine, said in a statement.

The Pharmaceutical Research and Manufacturers of America, the trade group that represents drug companies, adopted a similar ban that takes effect Jan. 1.

It recommends that its members not give doctors small gifts, such as pens or coffee mugs.

However, the ban does not apply to speaker fees, consulting fees or free office meals.