(Almost) Everybody Does It

A new study finds that the vast majority of doctors have some kind of financial relationship with the pharmaceutical industry.

Who's getting what? And what impact does it have on patient care?
Who hasn't been to a doctor's office and seen drug logos decorating pens, clocks, sticky notes? As one health-industry expert puts it, "It's the medical equivalent of NASCAR advertising. " Almost every doctor in the country has some type of relationship with pharmaceutical manufacturers, whose clear goal is to influence physicians to prescribe the company's newest, most expensive drugs. The companies offer physicians everything from scratch pads to trips worth thousands of dollars to attend medical conferences. But which doctors receive the biggest perks? A new study appearing this week in the New England Journal of Medicine reveals that it varies with the type of practice, the medical specialty, the patient mix and the doctor's professional activities. The study-the first of its kind-was led by Eric Campbell and David Blumenthal, both at the Institute for Health Policy at Massachusetts General Hospital. Anne Underwood spoke with Campbell.
Excerpts:

Underwood: How did you conduct the study?
Campbell: It's based on a survey of 1,662 practicing physicians in late 2003 and 2004. We focused on six specialties- family practice, internal medicine, pediatrics, cardiology, general surgery and anesthesiology. We also looked at whether these doctors worked in hospitals, universities, HMOs, group practice or solo or two-person practice. And we looked at gender.

Were you surprised at the findings?
I was surprised at the sheer percentage of physicians who have financial relationships with the drug industry. Ninety-four percent of all physicians have these relationships. Most commonly, it's things like receiving free samples of drugs or receiving food and beverages which may be consumed by their staffs. But a third of physicians are reimbursed for costs associated with professional meetings or CME [continuing medical education]. About a quarter are paid to serve on advisory boards, work as consultants or enroll patients in clinical trials. Those are the big-ticket items, versus getting free Chinese food for your staff on Wednesdays.

In recent years, the American Medical Association, the American College of Physicians, and the Pharmaceutical Research and Manufacturers of America (PhRMA) have all been promoting voluntary codes of conduct that set limits on these relationships. What effect have these had?
The most egregious examples have been reined in. PhRMA recommends that gifts not exceed $100 in value and be limited to items that are for the patient's benefit. There's really no benefit to the patient if the doctor receives free tickets to a Giants game, so you don't find much of that any more. Only 7 percent of doctors reported this type of payment. On the other hand, the drug companies now meet with physicians more frequently. In 2000, it was 4.4 meetings a month on average. Now family practitioners report an average of 16 meetings per month, followed by internists at 10 per month and cardiologists at 9 a month. All specialties except anesthesiology seem to be meeting more frequently with industry. What we don't know is how long these meetings last.
What fascinates me about this study is that I had assumed there were equal-opportunity handouts for all doctors. But you say that pharmaceutical manufacturers are actually fairly selective in who gets the best treatment. Drug samples and gifts of free food are widely given. But other types of relationships- serving as consultants, on boards, receiving speakers' fees-are concentrated among "thought leaders" in a specialty. Those are the doctors who develop guidelines for clinical practice, who publish the leading papers in big medical journals, who run large residency programs in major health centers. They have the potential to influence the prescribing practices of other physicians. The industry appears to form tighter relationships with these doctors.

And who is least likely to have these tight relationships?
Women physicians are significantly less likely to receive payments than their male counterparts. Also physicians with a high percent of patients who are uninsured or covered by Medicaid. There are a number of potential explanations, but our study did not address those.

In the second case, at least, it's pretty clear-those are not patients going out and buying a lot of expensive drugs. But you also say that doctors in group practices and private practices are more likely than doctors in hospitals to have these relationships.

Why is that?
Compared with those in hospitals, clinics and HMOs, physicians in solo, two-person and group practices were six times as likely to receive samples, three times as likely to receive gifts and nearly four times as likely to receive payments for professional services. We can only speculate why. It may reflect the fact that physicians in group practices have more freedom in their prescribing choices than physicians in hospitals, clinics and HMOs, whose formularies [lists of approved drugs] limit their ability to choose what drugs they prescribe. Hospitals and clinics may also be more likely to have policies limiting physician-industry relationships. Larger institutions are also more likely to provide medical information through educational programs, which may make physicians less dependent on industry. But more research is needed. And certain specialties are more likely to receive payments, especially cardiologists. Cardiologists were more than twice as likely as family practitioners to receive payments for professional services, such as serving on boards or as consultants. The prescribing patterns of cardiologists are thought to influence the prescribing patterns of non-specialists. Also, their patients take drugs for years, as opposed to a child who may take an antibiotic for a week. True. We didn't look at other specialties whose patients may also take drugs for a very long time, such as psychiatrists or endocrinologists [for diabetes].

What's the impact on patient care?
That's what we don't know, because there's no national data linking these relationships to patient outcomes. We know these relationships benefit companies, because they're selling drugs. They wouldn't do it if it didn't work. We know it benefits doctors because they get meals and CME. We don't know to what extent if benefits patients. If you look at the cost of all these things-billions of dollars per year-there's no doubt that it increases the prices people are paying for drugs. That price is not just reflected in what you shell out at the pharmacy, because you may only have a copay. It also drives up prices for Medicare and Medicaid, which we all pay for
through our taxes. And what if you're taking a medicine that's not covered by your insurance?
Does this lead to a situation where people are taking inappropriate drugs?
In some cases, older, tried-and-true drugs are actually better than the newer, fancier drugs that are still under patent protection. I'm not a physician. I can't speak to that. But even small gifts create a quid pro quo. The question becomes, is a gift really just a gift? If a man gives a woman a diamond ring, there's an expectation of a certain behavior there.

So expectations still exist, despite curtailing the most egregious forms of payment?
If a company hosts a continuing-medical- education seminar at a beautiful resort in Florida, and I get to go down there for a few days, listen to the leading people in the field and maybe whack a white ball around on the golf course, does that create the opportunity to influence my behavior? Or if a doctor receives $5,000-$10,000 for serving on a speakers' board, does that influence him? Some might say that's not much money, but it would pay for a normal vacation for a family of four.

So what differentiates this from old-fashioned payola?
It's not fair to compare it to payola. If you took the world's expert in schizophrenia and paid him for consulting with a drug company in order to help make better drugs, that's a good thing. It should happen. You want companies to have access to doctors' expertise. But you also have to say, what are the risks? To what extent are companies altering physician decisions in ways that are not consistent with evidence-based medicine? We don't know.

Should we be concerned?
It's clearly something the physician community is thinking about. They realize it's an area that requires attention. But I've also heard doctors say that they work hard, they studied a long time to acquire this expertise, and if someone wants to send them to a conference in Cancun along with their wives, then they deserve it. They claim it doesn't bias them in prescribing.
There's a new article in the online journal PLoS Medicine looking at the ways drug companies influence doctors and showing that doctors are not trained to recognize this subtle manipulation. This is not an issue that is going to disappear off the radar screen. The fact is, scrutiny will likely become more aggressive rather than less.
(Newsweek)