Nestled in the emerging Affordable Care Act is a groundbreaking provision that will require pharmaceutical companies and other medical industries to report all direct payments or gifts over $10 that are made to physicians. It's called the Sunshine Provision, and will take effect in January of 2012.
Physicians have always had a complex relationship with the health care industries. It requires careful collaboration and communication to bring the latest innovations to our patients. And who doesn't enjoy a free steak dinner in the process? But in business, collaboration often involves payment, and communication is marketing. Physicians as a group have been a slow to acknowledge that we are as susceptible to corporate marketing as everyone else on this planet, and this hubris/naïveté has allowed us to be manipulated in ways that can influence our clinical decisions.
As doctors are learning, being the recipient of a gift -- even one as seemingly benign as doughnuts for the office staff -- can confer a sense of obligation on the recipient. Over the past decade, significant data has accumulated to show that all manners of gifts shape the prescribing practices and clinical decisions of conscientious physicians in ways they may be completely unaware of. Doctors who receive gifts tend to choose the marketed product more frequently and rapidly, and acquire them for the hospital formularies at a greater rate, while their prescribing of generic drugs declines.
Free drug samples are probably the most widespread form of "gifts" to doctors. Those over-packaged samples sitting in a doctor's cabinet represent the latest and priciest versions of pharmaceutical products. The doctor may be well intentioned in passing them out -- the patient may not have insurance, or the pharmacy may be closed -- but they often cost the patient much more in the long run when the actual prescription is filled. And the fact that in the short term they were free does not mean they were the best choice of medication in that instance; they may have simply been the most convenient to reach for, or the first to come to mind thanks to that five minute chat with the very likeable drug rep earlier that day over a free bagel and cup of coffee.
Non-medically-related gifts to physicians -- tickets to an NFL game for example -- have largely become a thing of the past, as pharmaceutical companies have taken voluntary steps to restrict such overt attempts to gain favor. On the other hand, medical device industries are still famous for wining and dining specialists in exotic locations. There's nothing like an all expenses-paid vacation to a five-star resort to make an artificial hip look interesting -- especially when you are honestly convinced that palm trees and Mojitas would never cloud your objectivity about hip replacements. Clinical influence aside, there is no such thing as a free lunch. Consumers, aka patients, ultimately pick up the tab.
One of the thorniest issues around physician gifts concerns medical conferences. Doctors want to, and in most states are required to, participate in many hours of expensive continuing education. Grants from the health care industry help defray that cost. The industry has voluntarily taken measures to remove overt marketing influences from these settings, but more nuanced strategy remains. For instance, speakers (or "thought-leaders" as they are known in the industry) may offer presentations that, while factually accurate and useful, weigh much more heavily towards treatment than diagnosis and prevention. To justify industry insertion into the medical education process because educating doctors ultimately benefits the patient is like allowing soft drink vendors into schools because that will help fund after-school sports. The means shouldn't run counter to the end.
Over the past decade many of our professional organizations, like the American Academy of Pediatrics, have been working hard at raising physician awareness on these matters and providing explicit guidelines.Ethical discussions on these issues are prevalent in our professional journals. The Institute of Medicine has published recommendations on limiting the role of industry in medical education. The AMA has had a shakier role here, enraging doctors a few years ago by selling physician databases to pharmaceutical manufacturers for the express purpose of providing them marketing tools. On the other hand, landmark articles have appeared in JAMA, the AMA's journal, urging stringent restrictions on physician/industry relationships.
Meanwhile, individual doctors and practices are becoming more aware, active and vocal in the way they manage these encounters. Growing numbers of private practices limit access to sales representatives, and refuse gifts or samples from them. Some teaching hospitals now restrict the financial relationships their faculty can have with industry. The Sunshine Provision only provides a reporting system. It does not, in itself, change the way we do business in health care. But it is one more indication that doctors and society at large are coming to terms with the complex role that the health care industry plays in shaping medical practice. We will never achieve meaningful, cost-effective health care reform that puts the patient's interests first until we understand just what it is that needs reforming. For that we need transparency, and this provision of the Affordable Care Act appears to be a step in the right direction.
Follow Maggie Kozel, M.D. on Twitter: www.twitter.com/barkingmd