Pharmaceutical Payments to Doctors Posted Online
How the online posting of all fees paid to physicians by industry — from payments for consulting work to the cost of dinner — may affect the medical field.
Regarding the pharmaceutical industry’s donations to his campaign, presidential candidate Rick Perry said, “If you are saying I can be bought for $5,000, I am offended.” We physicians may be soon hearing a similar question, such as “Dear doctor, how were those pharmaceutical dinners and does that have anything to do with the $800-a-month acne drug you just gave me?”
That question doesn’t arise frequently, but things may change, and coupons that decrease patients’ expenditures for expensive brand-name prescription drugs may not sate patients.
The healthcare reform law — passed in 2010 — contains provisions for posting pharmaceutical company compensation to doctors online. Fees could include those paid for participation on a speaker’s bureau, consulting, research and yes, even attending dinner. A backlash is already building toward doctors who are perceived as gluttonous and easily bought, and patients are venting their concerns online on forums like www.propublica.org and www.consumerreports.com.
The issue of how payments from pharmaceutical and medical device companies could influence physicians came to the forefront in a 2008 congressional hearing, held after a prominent Harvard psychiatrist was found to have received $1.6 million in fees in a 2-year period. He had not disclosed his relationship with the pharmaceutical company at the time. Medical device makers came under scrutiny after it was revealed that several prominent orthopedic surgeons received large fees (kickbacks?) for promoting implants that were later recalled or found to be defective in some cases.
The message of websites like www.propublica.org — a non-profit organization — seems to be that speaker programs lead to unnecessary prescribing of high-priced brand name drugs by the speaker and the audience, leading to the high cost of healthcare for us all. Side effects and less than stellar study results may be downplayed, whether the speaker is aware of it or not. Even the audience appears tainted to some because they believe doctors cannot separate the feeling of having to give something back for a nice dinner. Firms that track the data can tell manufacturers how often people who attended such talks then went on to write prescriptions for the drugs that were discussed. Propublica said they were rebuffed in their attempts to buy this same information.1
A Consumer Reports poll found that 74% of Americans disapprove of doctors taking payments from pharmaceutical companies in exchange for drug promotion.2 Most individuals think doctors should inform patients if they have received a fee from the manufacturer of the drug they are prescribing. Anywhere from 25% to 50% of respondents felt that doctors who take money from drug companies would be biased to prescribe that company’s drug. As more payment information becomes public, many predict physicians will back away from giving talks that are supported by pharmaceutical company funding. Companies are replacing some in-person speaker events with teleconferencing and webcasting.3
Is Industry Support a Bad Thing?
There are, of course, many reasons for an alliance between industry and doctors. Drug companies develop new and innovative medications from which we all share the benefits. Doctors are needed to run the clinical trials that determine safety and efficacy and, ultimately, FDA approval. Doctors help educate other doctors about how to utilize medication appropriately. Pharmaceutical companies cite industry regulations already in place.
Currently, eight major pharmaceutical companies that compose 40% of sales have posted their payments to doctors online. These companies include AstraZeneca, Cephalon, GlaxoSmithKline, Johnson & Johnson, Lilly, Merck and Pfizer. Payments listed may include a few dinners for $250 to as much as $200,000, which one dermatologist in Kentucky was listed as receiving for speaking, conducting research and consulting for GlaxoSmith Kline; this amount did not include his other affiliations. Some doctors are listed as having received more than $2,000 for dinners and no work; that is to say, no speaking, consultation or research. In addition, more than 70 companies have not yet disclosed physician payments.
By 2013, all pharmaceutical fees should be available online. Some major medical centers are restricting doctors from doing any speaking that is funded or supported by industry. In 2010, institutions like Harvard Medical School and Stanford University School of Medicine forbade all doctors from participating as paid consultants and speakers.4 Though pharmaceutical companies like to tout that they have the best doctors participating in speaking engagements, this new trend may lead to fewer prominent academic doctors in significant research roles.
Doctors often cite their desire to educate and inform other doctors. In rural areas, speakers may be one of the few forms of face-to-face education available. Traditionally, doctors liked to include their own anecdotes and slides to enhance the education value of the lecture. The situation is complicated, especially because of a rash of lawsuits regarding promotion of off-label uses. Due to settlements in the millions, if not billions, companies are instituting strict guidelines and dictating what slides can be used and even the order in which the slides can appear. We presume this is done to prevent further lawsuits and accusation of abuse. Many medical centers have countered by insisting that doctors must have final say over the educational content of a lecture. Some companies have agreed, while others will not negotiate.
Is it possible that websites and blogs that seem to bash doctors who participate on speakers’ bureaus are missing the big picture when it comes to the high cost of brand name drugs? Doctors have little to do with price setting, patent exclusivity and lawsuits blocking or discouraging generic manufacturers. In fact, doctors, unlike pharmaceutical companies, don’t even have access to their own prescribing data. Lastly, speakers’ fees are a tiny portion of the revenue for some companies. For instance, Pfizer, with sales of $26.2 billion, spent $34.4 million on speakers, for a grand total of 0.13% of revenue.5
Potential Pitfalls of Industry Influence
Nevertheless, pharmaceuticals are a capitalist enterprise whose business is making a profit. There have been cases of a doctor asking to become a speaker because of an interest in a particular disease or condition and being told he or she should write more prescriptions for the brand product if he or she wishes to be considered a speaker because the company can only justify expenditures for a speaker who highlights their product. In fact, this author gave what he thought was a balanced, educational lecture to a group of dermatology residents many years ago that was supported by industry. That was the last time that speaker was allowed to “educate” on behalf of the company.
If a speaker is still convinced that the pharmaceutical company is just helping to provide lectures for the educational component, he/she may take heed from the following anecdote from an article on www.propublica.org. Nurse practitioner Teri Warren in Oregon has been speaking on antivirals and genital herpes for many years. In 2008, she received over $100,000 in speaker fees.6 In 2009, when Valtrex (valacylovir) went off patent, she received only $300 in speaker fees. Did genital herpes go away? Did the need to educate doctors resolve itself? The only thing that changed is clearly the lack of incentive for pharmaceutical promotion.
A Middle Ground
While completely eliminating doctors from speaking is unlikely and possibly damaging to medical education, it will become increasingly unseemly to many. There are middle-of-the-road approaches. The Colorado University School of Medicine allows participation in speakers’ bureaus but industry representative are not allowed to select speakers or topics and cannot pre-approve the content.4 Clearly, new models are needed. Given the enormous income of pharmaceutical companies, they will surely find another way to get the message out. Dermatologists need to know that the public, the government and even insurers will be watching
Dr. Goldman is a clinical instructor of dermatology at Cornell Medical College and the Chief of Dermatology at New York Downtown Hospital.
Disclosure: Dr. Goldman has no conflict of interest to disclose regarding any content in this article.