Healthy Skepticism Library item: 19731

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Publication type: news

Uken C
Payment debate: Health care workers defend their payments from drug companies
Billings Gazette 2011 Nov 20
http://m.billingsgazette.com/mobile/article_63c91049-2b73-5a5b-b6dc-69adf1c6f768.html

Full text:

Doctors, pharmacists and other health care professionals in Montana received $692,983 in payments and perks from drug companies between 2009 and early 2011, according to a database that includes disclosure information from a dozen pharmaceutical firms.
Nearly 200 of the doctors and health care professionals who received payments in Montana are from Billings, and some received upwards of $60,000, a Billings Gazette analysis shows.
The payments were for travel, meals, research, consulting and speaking engagements, the data show. Nationally, the 12 drug companies disclosed $761.3 million in payments to promotional speakers, researchers and consultants for their products. The most popular speakers included doctors who specialize in cancer treatment or diabetes.
In Wyoming, the 12 drug companies doled out $319,996 to doctors and other health care professionals during the same period.
The database of drug company disclosures was compiled by ProPublica, a national investigative news organization, and allows the public to search for individual physicians.
Critics say financial relationships between doctors and drug companies can threaten patient care by influencing physicians to prescribe certain medications whether or not they are the best choice. The most controversial payments involve consulting arrangements and promotional speeches.
Drug company officials argue they are paying for talks that provide much-needed medical education, led by physicians who are experts in their fields.
The 12 companies now disclosing payments are doing so either voluntarily or because they have been forced to by whistle-blower lawsuits. Eleven of the 12 companies paid hundreds of millions of dollars in the last several years to settle lawsuits, resolve allegations or reconcile government investigations.
This snapshot of drug company payments is a precursor to what the public can expect in 2013. That is when the Affordable Health Care Act will require all drug and medical-device companies to disclose such payments to the federal government for posting on a government website.
This concern is nothing new. Several studies have indicated that when doctors receive even small gifts from a pharmaceutical company or medical device manufacturer, it increases the likelihood that the doctor will prescribe the company’s products. With speaking fees, there are thousands of dollars involved, and many experts call it “payola” while others call it a “bribe.”
Those receiving the payments tend to call it “honoraria.”
Leaders at St. Vincent Healthcare said they have strict, formal policies in place to minimize possible conflicts of interest. Billings Clinic has a Code of Business Conduct, which leaders say is an organizational policy that provides guidance to ensure work is done in an “ethical and legal manner.”
Kristianne Wilson, executive director of health policy at Billings Clinic, said nothing on the list “alarmed” her, because she knows the people identified on the list, their niches of expertise and the vast rural region they cover. Many travel or speak on their own time and some of those payments are made directly to the hospital, not the individual.
“I don’t think it’s any big investigation,” Wilson said. “I think the public pretty much knows that pharmaceutical companies have a huge influence in where dollars are spent this in country.”
Of the 15 highest-paid individuals or organizations on the Billings list, eight work at Billings Clinic. Wilson said that’s because it’s the biggest hospital in the state, is a teaching hospital and historically has more specialists on staff than its competitors.
Still, in reviewing the list, Wilson said that in working with the hospital’s 240 physicians on its conflict of interest disclosure statements, there is work to be done.
“We probably need to be more descriptive about the kinds of things people might perceive could be a conflict of interest,” Wilson said. “It’s better to be over-disclosing.”
Only one of the top 15 on the list from Billings is employed at St. Vincent. That is no accident, said John Kinna, executive director of the St. Vincent Physician Network. St. Vincent has a “robust, very clear and definitive” policy.
“We have a lot of checks and balances with this whole issue,” Kinna said. “We make it really difficult for our people to engage in this type of behavior. It is a no-tolerance policy. We have it. We live by it. It keeps us on the right side of the tracks.”
Kinna embraces both the current and upcoming disclosures of pharmaceutical companies. “There has unfortunately been some misdeeds by others that have made this a minefield.”
One of their employees, Jane Meszaros, a certified diabetes nurse educator, received direct payments totaling about $3,000 from Merck for speaking in 2009-2010. She signed the hospital’s “Potential Conflict of Interest” form and took time off for the educational speaking engagements. She followed policies and procedures and received the go-ahead from her employer.
Drug company executives, doctors and other health care workers argue that the purpose of the speaking and consulting engagements is to educate others in the more rural areas of Montana where there are sometimes no physicians let alone specialists and ultimately improve patient care. If they don’t do it, no one will.
A pediatrician from Billings Clinic, who specializes in pediatric diabetes, for example, has been known to draw as many as 70 health care providers to his lectures to tap his expertise on the issue. They are promoted as “educational” talks followed by a question-and-answer period where attendees can ask questions about specific drugs and benefits.
Critics quickly point out that many of the drug companies control the message in such presentations. They require the physicians to use slides developed by the company to have a pitch-perfect sales message. Critics also maintain that any health care worker who speaks on behalf of a drug company, essentially becomes an employee and advocate for the company stripping away their objectivity. The U.S. Food and Drug Administration must approve all material used in the presentations because the talks are deemed advertising.
Dr. Carl Elliott is a professor in the Center for Bioethics and the departments of pediatrics and philosophy at the University of Minnesota Medical School. He has studied the intersection of medicine and the market. Payments to any health care professional from drug companies biases their clinical judgment, he said.
“Patients should care because their own treatment could be compromised,” Elliott said. “The payments bias clinical judgments, even if doctors themselves don’t realize it. There is a clear, unambiguous body of evidence showing this. And nobody wants their own treatment determined by whichever company happens to be paying their doctor.”
Drug companies are shrewd, sophisticated and savvy enough to know it’s big money, critics say. If paying physicians didn’t play a critical role or didn’t matter, they wouldn’t do it.
The Pharmaceutical Research and Manufacturers of America (PhRMA) vigorously defends drugmakers’ interactions with physicians and other health care practitioners, saying such relationships are an important element of patient care.
“In order for doctors to make informed treatment decisions, they need to be aware of emerging information about medicines, such as … safety issues,” Karl Uhlendorf, vice president of communications and public affairs for PhRMA, said. “Companies are committed to ensuring that these relationships are educational, professional and ethical, as reflected in the PhRMA ‘Code on Interactions with Healthcare Professionals.’ “
Physicians consider many factors when making prescribing decisions — and research has shown that they find the information provided by companies as one valuable resource, Uhlendorf said.
PhRMA cites a recent survey of 508 physicians in which nine out of 10 attendees of pharma-sponsored physician speeches said they found information they received to be useful. More than half of attendees said they often gain knowledge or skills helpful to their practice.
In a separate survey conducted by Consumer Reports last year, more than three-fourths of 1,250 adults said they would be “very” or “somewhat” concerned about getting the best treatment or advice if their doctor was accepting drug-company money. And 70 percent said doctors should tell their patients about such payments if they are going to prescribe drugs from one of those companies.
While some relationships are bona fide, often it’s a “sham,” said Dr. Adriane Fugh-Berman, a licensed general physician who teaches at Georgetown University. Drug companies select doctors who support their marketing goals, Fugh-Berman said. They will fly these doctors around to medical meetings, write their articles for them and make sure their voices drown out the voices of researchers who are saying things inconsistent with their marketing goals.
Pharmaceutical companies lure physicians into their promotional talks and speeches by preying on the egos of physicians, telling them that they are “so great, so fabulous and an opinion leader,” Fugh-Berman said.
“It’s hard for people to believe doctors are that naive but believe me, they are that naive.”
Rest assured, she said, anyone with a message that runs counter to a drug company’s marketing goals will pay their own way, not be asked to speak and certainly not be tapped as a consultant.
Dr. Charles Rosen, president of the Association for Medical Ethics, said if doctors are accepting money for services from drug companies, patients should be informed of this in their physician’s office, Rosen said.
A recent PEW research study showed that about 60 percent of patients want to know if their doctor is paid by any companies, particularly if he or she is about to write a prescription for a drug that company makes.
Dr. Christopher Sorli, chair of the department of endocrinology, diabetes and metabolism at Billings Clinic, received nearly $9,000 from Eli Lilly for speaking in 2009-2010. His payments reportedly went directly to Billings Clinic, not him. He said he has probably worked with other companies not yet disclosing their payments just as much and makes no apologies. He welcomes the public scrutiny of the database.
“I’m actually totally for this because if you go back 10-15 years, you can blame both pharmaceutical companies and physicians for this,” Sorli said. “Things tend to settle to the lowest common denominator and things got out of hand.”
Sorli is tapped repeatedly to speak and is considered a national leader in his field. He gives lunchtime and evening programs, educating others both in and out of state.
“(Even) if I did personally profit from this, I would still do it,” Sorli said. “These are very valuable programs for education. And, I can without a shadow of personal doubt say I have never written a prescription for a patient without thinking it is the best drug for them.”
Dr. Larry Severa, a family medicine physician and interim medical director of research at Billings Clinic, is identified by Eli Lilly as receiving a $7,531 payment. It reportedly went to Billings Clinic, not him.
Drs. Sorli and Severa both have defined roles in research that require their income be given to Billings Clinic. Dr. Fred Gunville, a pediatrician specializing in pediatric diabetes, is on the top 15 list. He, unlike Sorli and Severa, was personally paid. The educational speaking and teaching Gunville does is not a defined part of his job but Billings Clinic encourages and supports physicians in doing education outreach.
Severa, like Sorli, said when all companies begin disclosing their payments his name will appear multiple times. He and Sorli are constantly tapped for their expertise because Billings Clinic has “such a high quality team,” Severa said.
“We do exciting, exciting work for people,” he said. “This is what brings new innovations of health, new medicines, new possibilities, and new healing. Our job is to advance medicine, support our community and support research.”
He welcomes the disclosure laws and says it will not alter his approach to future research opportunities that come his way.
“We need to hold people accountable,” Severa said. “We need to know where people’s allegiances lie. We need to know why they do what they do. There are too many people … that get into medicine for money and do things for money and that’s the exact opposite of why we’re here.”
Gunville personally accepted more than $15,000 from Eli Lilly for speaking between 2009-2011. He used time off to travel and speak to health care professionals in Bozeman, Helena, Butte and Miles City.
The pharmaceutical companies tap him because they want experienced providers in a specific area of expertise and have used their particular products, he said. Gunville said he has come to the attention of the corporations through pharmaceutical representatives.
Still, Gunville said he feels no obligation to push their products. There are times, he said, he couldn’t even if he wanted to.
“Insurance companies dictate which pharmaceutical (drugs) we use,” Gunville said. “If I see a new patient with diabetes, their insurance company tells me which (drugs) I can use. In a lot of ways it’s quite sad because sometimes I can’t use the (drugs) that I want to and may have to use something that is secondary.”
Gunville said he puts in exhausting days traveling the state, often starting his days before dawn and not winding down until 11 p.m., to educate others in pediatric diabetes. He said he would not do it if he weren’t paid.
“I feel good about what I do because all of what I do is to educate,” Gunville said. “These people a lot of times are not going to be educated in their community unless someone goes in and provides that education.”