Reader feedback: Is limiting industry gifts a smart policy?

Dear Anne & Maureen
I wrote to you previously on this topic and I do not need to re-state my position. The UC Davis is not different. The only additional issue is the intolerance of the opposing point of views. It is well known fact that if you get a group of physicians in a room, you would not get an agreement on almost any issues. But when a physician enters a position of power, he or she thinks that he or she has such superior idea that he or she can push their personal point of view on everyone else. This applies to Dr Garen Wintemute. I respect his right to decide for himself on this matter, but when he wants to dictate his view point on the rest of UC Davis, instead of leading by examples, it gives an portrait of intolerance within the Physicians at UC Davis.
May be he should start with Do as I do, and not as I say and vote with his feet, rather than using his Position of Power to dictate his point of view.

I have just finished reading Paul Starr's 1982 book "The Social Transformation of American Medicine" where he describes how the medical profession got rid of marginally useful and harmful remedies back in the late 19th and early 20th centuries.

Doctors invented a concept "Ethical Medicines" defined to be preparations whose ingredients are disclosed, and which are marketed only to physicians. Yes, they did this to prevent the patient treating himself (thereby depriving the doctors of a fee), but they were also genuinely concerned about the safety and efficacy of the medicines, and rightly so.

Except for so-called "supplements" the disclosure part is now taken care of by the FDA. What's left is the question of the target market.

How `bout this: "If you want to market to our group at all, stop doing DTC marketing. Otherwise no thank you."?

Is it perfect? Heck no. But I think its better than what's going on now. If there are groups who want to adopt a Wal-Mart style strategy that limits the activities of the reps, more power to `em. But drug makers are the best source of information about their own medicines. Its foolish to cut them off entirely.

The sampling argument is unconvincing, especially with $4 generics and the possibility of an in-office dispensing program. If there are medicines having no good theraputic substitute and too expensive for patients, another solution should be found. I can imagine a credit-card looking thing the doc can give to an impoverished patient to take to the pharmacy for a starter supply, and at the same time apply to the pharma's assistance program. Having gobs of samples around will influence prescribing patterns. Which of course is why the reps leave them.

t

Maybe now the pharma companies will take the billions they are spending on "educational" programs, recruiting cheerleaders and other talking heads that sell their products and loiter in the halls ostensibly for a signature and put the money to better use. I can think of a few: Lower drug prices and more indidgent product for the needy.

I have seen the pharma reps first hand, when I worked in Oncology. I agree that there are some doctors who succomb to the "sleaze factor" - we are all human,yes? However, the vast majority I have observed are genuinely interested in what clinical trials have been held, how the efficacy of the new drug compares to the old one, etc. not what gifts they have to bring. As some of the others have pointed out, samples assist patients to try a new medicine for a few days to ensure that it works, prior to the insurance company purchasing a 30 day supply (or 90 day supply as more of us are "encouraged" to use the mail order companies). In addition, for those patients who make up the "underinsured" group, they make too much money to fall into the drug company "free" campaign, but not enough to pay without serious other consequences, the samples given to primay care physicians can be invaluable. JMHO

I find this comment very disturbing, "In the long run it will drive the expansion of CME type programs, sponsored by state health authorities/insurance companies that will provide balanced education on new therapies."

Why would anyone think that insurance companies would provide balanced education? The insurance companies are as much of a problem as the pharmaceutical companies. They are primarily concerned with turning a profit and often restrict access to medications even when the medication is better. The state health authorities are not much better. They are constantly pressured by Medacaid to reduce costs.

So there has to be a balance and the current balance of pharma fighting the insurance companies and government fighting both of them is as good as it is going to get.

Limiting Pharma gifts is an essential conflict-of-interest management rule. As a practicing healthcare architect, my professional organization strictly prohibits personal gifts from suppliers and product reps. That means no freebie furniture for my pad and no golf trips to St. Andrews under the guise of "product research" (checking out the Scottish woolen looms, you know...)

I still have tons of reps calling me all the time. I still get lots of luncheon and dinner invitations. I still get preferential (read dealer wholesale) pricing for stuff I might want for myself. And I still find out about all the new goodies that come on the market, as soon as (or even before) they hit the showrooms.
Yet I can stand up in front of my clients and say "I specified this product because it is the best choice for you," and be telling the honest truth, without any compromise in my professional judgement.

So just give up the freebies. They are only a destructive addiction.

I have been in the pharmaceutical industry for 12 years. I believe it was a UC Davis physician who stated that pens, notepads, and other such tokens had more influence on a doctor than educational grants,etc. Of course they would say that!!! These teaching institutions act like they are a notch above the rest ethically. Yet, they have no problem taking Fellowship scholarships, grant dollars, endowments to the university, etc from the pharma industry. And then have the audacity to say that these do not influence universities more than pens? If you really want to eliminate all means of influence, get rid of any help or subsidy from pharma or any medical company. My guess is that you will not. In the elimination process the only ones that get hurt are the patients(poor) or students that are not the beneficiaries of these "gifts". It seems that all legislators sat down and saw that money was being spent at the local level on golf outings, dinners, etc. How do you get those dollars to be spent at a higher level(lobbyist)? Congress and watchdog groups put in rules and legislature. Unfortunately, the pharma industry is no better. They remind me of the worlds' last 10 guys, who make a pact not to go out with Pamela Anderson, there will always be that substandard guy who says, "Now is my chance to make my move". American capitalism at its finest.

The first comment about the "highest bidder" gaining access to doctors through gifts is simply incorrect. In fact, I would challenge the opinion of those seeking to further restrict pharmaceutical sponsorship. I would also ask them to gain some education on the matter before pontificating on the evil of the pharmaceutical companies and physician bias. If we want to look at large companies who exploit patients to make money and do so by unethically influencing treatment decisions, we need look no further than insurance companies. We could make some real progress on this issue if we offered doctors some protection from insurance companies who seek to financially penalize them for recommending more expensive testing and drugs to their patients. We have made huge advances in medical science, yet insurance companies continue to restrict beneficial products and services based on cost. Worse yet, they don't even have doctors making those decisions to deny treatment.

Dear Anne,
I can still your initial article and my response to you stirred up quit a controversy. In reviewing the response since my first e-mail to you: there are the Interventionist, who feels that they have the moral superior blood to dictate their moral values on others, like Dr Swammi,
and there is the "Mine your own business" like me, who believe that every physician has their moral compass who cannot be bought. As to the latest survey, I think the wrong conclusion is drawn. My rule is unless there is sample, the drug does not get use. So, the percentage it goes to is pro-rata the payer-mix of my office. My rationale is that if there is a problem, then it occurred on freebies, and patient has no right to complaint. If there is no sample, the drug would not be used, unless it is the only one in the class.
SO if this means 82% goes to insured and 18% to the unsured, this means in MA, 18% of the practice is uninsured patient

Yours truly

Mike Wei, MD

It is truly unfortunate that the drug companies control so much of what gets on the agendas at our so called "scientific" conferences and in our journals. So many promising treatments that do not portend large profits for drug companies, such as naturals, hormonals, don't get the benefit of large scale testing because the drug companies so dominate the field.

And what with the drug companies obviously trying to "buy" the doctors' favor, the cost of medicines just goes up and up. I think that drug companies should not be allowed to market at all...let the science speak for itself...and keep costs down.It is truly not right that in our so-called highly developed country a large percentage of people can't afford their medications.

Why is the doctor/pharma relationship always the problem. Today, doctors are limited to prescribing based on the tier systems set by the reimbursement organizations. Why is there no investigation into how these tiers are set? I guess businessmen and poiticians are always ethical

The primary reason why medical centers don't want vendors: pharma, nursing homes, assisted living centers, dme, hospice,labs, small community hospitals' IRFs and LTCHs, home health, software & hardware companies calling upon the doctors is not to protect the doctors from learning and consulting about the solutions that the vendors offer, it is because the medical centers own their inhouse services with the exclusion of the being a drug manufacturer and they want the physicians to leave the discharge planning options to the control of the hospital not to the selection of the patient, family or the physician. Then there is the practice by the medical centers that the independent physicians will refer so many patients to the medical centers' services, if the physician wants privileges or referrals. And the contracted physicians know that they are monitored by the EMS systems of referring outside of the medical center. When will Medicare wake up to this abuse by the medical centers of the Starke law? The medical centers especially the not-for-profits and non-profits only turn to outside vendors/providers when the management of the patient is not profitable enough for them. Clearly, these bullish practices of not-for-profit and non-profit hospitals are not for the welfare of the patients and the community, but for the pockets of the CEOs and COOs and that their business methods break the federal racketeering laws. Soon the non and not for profit hospitals will be coming to the federal government for a bailout and they will cite the number of employees they have layoff or that vacancies are frozen.

Actually I am a physician and have always found time to read, despite long hours, young kids etc. There are monthly compendium newsletters free of drug company influence that help with this process. When there is a willthere is away.