While this film seemed to get more hype for revealing innuendo between Hollywood eye-candies Jake Gyllenhall and Anne Hathaway (not sure if the Global Globe acting nominations were deserved), “Love & Other Drugs” was meant to satirize the seemingly cozy relationship between big pharma drug reps and doctors (based on the book “Hard Sell: The Evolution of a Viagra Salesman” by Jamie Reidy). The hilarious Hank Azaria plays Dr. Stan Knight who courts drug reps for generous kickbacks and is not shy about having a drink at the bar with them. Aside from accepting lavish conference trips, free samples (of Viagra!) and various trinkets, Dr. Knight allowed a drug rep to shadow him as an intern and watch him evaluate patients and prescribed drugs in a “preceptorship” deal.
The curious relationship between big pharma and the medical profession has always been scrutinized by former insiders, consumer safety advocates, politicians, patients, insurers, etc. Back in 2007, Dr. Daniel Carlat wrote a piece in the NY Times Magazine entitled “Dr. Drug Rep” in which he reflects on his experience as a physician receiving “speaking fees” from Wyeth to convince other doctors to use its antidepressant drug Effexor – a practice also known as “academic detailing”. In 2005, former editor at the New England Journal of Medicine, Marcia Angell, published her book “The Truth about the Drug Companies” in which she chides big pharma for even going so far as to exploit med school settings and continuing medical education programs in order to further promote educate on their drugs.
Things have changed since the portrayal in “Love & Other Drugs” which was set against the backdrop of Pfizer’s 1998 launch of Viagra. In 2009, the PhRMA (industry trade group) implemented a voluntary “Code on Interactions with Healthcare Professionals” which banned certain handouts like pens, concert tickets and travel costs to conferences. This was meant to be a proactive statement by the industry against undue influence, but many critics pointed out that several things remained on the table, including CME funding, lunch presentations with “expert speakers” and free samples. And it is still clear that drugmakers are paying doctors millions of dollars even to this day. (This article suggests as high as $7 billion in payments to doctors in 2005 but the source is not clear.)
Additionally, the current health reform legislation included the Physician Payment Sunshine Act which requires companies to disclose payments to doctors in excess of $10 starting in 2012. In advance of the law taking effect, several companies have already volunteered data on physician payments in a preemptive show of transparency. In a Mar 2010 NY Times article, Pfizer reportedly paid out $20 million to doctors and medical professionals in the first half of 2009 (excluding clinical trials), a seemingly low number according to industry critics as the amount was not independently audited. Pfizer joined Eli Lilly, Merck and GlaxoSmithKline in volunteering this data to the public, but these databases have not been user-friendly and currently do not conform to the reporting requirements in the Sunshine Act. The public interest group ProPublica has resorted to manually piecing together these databases and has reported $320 million in doctor payments over 2 years (2009-2010) across 8 companies representing 1/3 of total US drug sales. But it is not clear until the “Sunshine” database takes effect whether these numbers really add up.
Some states (Minnesota, Vermont and Massachusetts) had already been requiring physician payments to be reported in a public database. Minnesota was the first state to have this requirement, and a 2007 NY Times analysis showed that drugmaker payments to Minnesota psychiatrists increased 6-fold to $1.6 million from 2000 to 2005, and that those who received payments totaling more than $5,000 from atypical antipsychotic drugmakers were three times as likely to prescribe atypicals in children compared to psychs who received less during that time span. So the data does contribute to the view that physician payments can influence physician prescribing behavior.
Another key development in changing the rules of the game has been the recent bans by state legislatures in Vermont and Maine in selling physician prescribing data to drug companies. Drug companies rely on this data to track the prescribing behaviors of physicians and focus their resources on the most frequently prescribing doctors. This knowledge enables the pharma industry to court these doctors and target them for speaker programs and consulting engagements. Prescriber data provider IMS and the PhRMA sued Vermont Attorney General William Sorrell (IMS v. Sorrell) over the law’s enforcement, claiming that prescribing data represents “commercial speech” and could not be restricted. While the proposed ban remains entangled in a legal appeals process, the Supreme Court is scheduled to hear the case this year.
So there has been motion towards greater transparency between drug companies and doctors and one of the hidden avenues of influence that is starting to draw attention is industry sponsorship of continuing medical education programs, a drug marketing tactic that Dr. Daniel Carlat has passionately criticized. This purported marketing vehicle allows the drug industry’s marketing message to masquerade as medical education, as doctors rely on this education to make their decisions about how to practice medicine. Drugmakers can do this by directly creating content and presentations for the CME courses, or by indirectly funneling their dollars based on whether the content is favorable to their marketing objectives or not. Marcia Angell articulates it clearly in her book:
We need to end the fiction that big pharma provides medical education. Drug companies are in business to sell drugs. Period. They are exactly the wrong people to evaluate the products they sell. [...] Good education about prescription drugs, like all education, needs to be as objective and critical as possible.
As reported by Dr. Carlat in KevinMD, several large academic centers and teaching hospitals have already renounced industry dollars in their CME programs. The University of Michigan most recently announced that they would end all industry support of CME effective at the start of this year, following the ranks of Sloan Kettering Memorial Cancer Center, East Carolina University’s Brody School of Medicine and Kaiser Permanente’s mid-Atlantic region. Stanford almost followed suit except that they accepted a $3 million block grant from Pfizer to fund CME initiatives, although not for any specific course. Some institutions try to rationalize that they can take the money without letting pharma have a say. But if the CME courses somehow do not favor the drug company sponsoring the program, you can pretty much guess whether or not those dollars will be there the next time around.
What is absolutely tragic about the spotlight on the relationship between drugmakers and doctors is that many doctors adhere to a higher standard and do not accept money from industry and have closed their doors to drug reps at large. There are always those bad apples that always seem to taint the whole batch. And yet I feel that with cultural references as in “Love & Other Drugs” and the media attention that hone in on greedy doctors who make millions in the service of the drug industry, there is an ostensible skepticism on the part of patients around whether their doctors are controlled by industry strings or whether they are making medical decisions in their best interest. This is why I feel that it is crucial for the medical profession to take a definitive stand in defining the terms and code of conduct by which doctors engage with the drug industry instead of letting the drug industry and politicians define those terms for them. Dr. Brian Vartebedian at 33 charts blog shares some ideas on how this dynamic may evolve:
Going forward I suspect that our future encounters with industry will be more permission-based and contextual. Pharma and medical device manufacturers will evolve to embrace a more open, social business design that cultivates a supportive rather than sales relationship with physicians. [...] Responsible doctors and industry professionals should open their dialog so that the social public can see that the conversations are properly centered on the patients.
And yet some of the resistance on the part of some doctors and groups to become more transparent is disconcerting. Some doctors say that legislative efforts to restrict the relationship between industry and doctors will impede innovation, particularly in medical devices where doctors have a more active role in working with companies to optimally design products. In these cases, we wouldn’t argue that this is an important partnership role, but the financial ties need to be completely transparent in developing and marketing the product. The American Heart Association and National Institutes of Health say that limiting industry funding of CME will “unfairly cut physicians off from scientific knowledge.” This is mainly because without industry funding, medical associations and doctors will need to find other sources of funding for their own CME programs. However, it is the responsibility for these associations to seek out funds free from any conflict of interest even if it means raising membership dues. If doctors are responsible for funding their way through med school, why does that automatically mean that they shouldn’t have to pay a cent afterwards? There has to be a better way than to sell out.
The pharma industry continues to go through a crisis of credibility because of questionable practices and tactics to enhance their bottom line. Yes, they make tons of money and people continue to use drugs because they have to. However, the medical profession absolutely cannot squanders the trust they have from patients who look to them to make the most informed and objective decisions about their health and livelihood.
Filed under: Drug Companies, Drug Marketing, Healthcare Regulation, Medical Profession Tagged: academic detailing, continuing medical education, physician detailing, physician payments
