Friday, August 27, 2010

Are doctors too cozy with drug companies?

The public thinks so, according to a new survey. The Consumers Report health blog writes that:

"More than two thirds, or 69 percent, of consumers surveyed said they think drugmakers have too much influence on doctors' decisions about which drug to prescribe. Half of those polled said they feel doctors are too eager to prescribe a drug rather than consider alternate methods of managing a condition. And 47 percent said they think gifts from pharma companies influence doctors to prescribe certain drugs, with 41 percent saying they think doctors tend to prescribe newer, more expensive drugs.”

The medical profession has taken steps to reduce financial practices that influence physicians' prescribing practices. A new voluntary code by the Council of Medical Specialty Societies (CMSS) has won praise in some circles including from the American College of Physicians.

Some purists would completely sever the link between physicians and pharmaceutical promotions, including banning any industry support for continuing medical education. I wonder, though, if an outright ban would have unintended adverse effects on patients. For instance, as this commentary points out, without pharmaceutical grant support, CME programs would likely have to charge higher registration fees to cover their costs, which likely could cause some physicians to forgo CME altogether, and reduced external funding could adversely affect the quality of CME.

Discussions of a ban on all drug company support for CME must address the competing public good of ensuring the availability of high quality and affordable CME and reducing undue industry influence over physicians. In my mind, the CMSS code strikes the right balance.

Today's questions: Do you think drug companies have too much influence over physician prescribing? Do current voluntary codes, like CMSS', go far enough?


Jay Larson MD said...

This may be a mute point in somewhat near future. Insurance companies are using prior authorization requests more often for brand name medications if a generic alternative is available. Those who practice medicine already know that this protocol will only cause more harm than benefit for patients who have been doing well on a stable medication regiment.

The path of least resistance will be to write a prescription for a generic rather than handing out a brand name sample then filling out a prior authorization request down the road when a prescription is needed for the brand name medication.

Before too long drug reps will be schmoozing insurance executives rather than physicians.

Oh gee, my nurse just laid down a prior auth request for a medication a patient has been on for years. Fortunately, as a general internist, I have so much free time to fill out forms to save the insurance company money. And they wonder why no one wants to do primary care.

ryanjo said...

"Half of those polled said they feel doctors are too eager to prescribe a drug rather than consider alternate methods of managing a condition." I know that half all too well. Yes, Mr. Smith, you WILL need to take a medication to control your skyrocketing blood pressure, your lethal level of LDL, and your HbA1c of 10.2. Oh, why do you need so many prescriptions, can't you use a diet and nutritional supplement? Isn't that what you said last year, when your BMI topped 35? But don't worry, after you talk to a few friends and scour the internet, you will be able to cite every one of those dreaded side effects that forbid you from taking those meds. See you at the ER!

Robert J. Sobel, M.D. said...

The interference with medical prescribing is indeed a problem and should have been a part of health reform. However, it takes many forms and comes from many different sides. Essentially, we have again misconstrued what healthy competition really would be in the health care environment. Both patients and physicians have an appropriate conservatism when it comes to new drugs. Nevertheless, there are times when the new option is promising and makes the most sense from a clinical point of view. If the physician and patient agreed on that decision, a healthy system would no longer create obstacles and red tape to redirect them. Our current one if far from it.

In actuality, I would argue there is reverse discrimination with prescribing new drugs. As Dr. Larson points out, we are now rewarded when prescribing generics (better grades with the insurance, better margin to the pharmacies, and, most importantly, less out of pocket to the patient.). If we prescribe the new, we are cost-ineffective, have to deal with prior authorization, get multiple types of feedback questioning our decision, and our patient is punished with a greater co-pay).

The ever-growing differential in the prices of the new and old is a direct result of the reforms of the Hatch-Waxman Act of 1984. It is from here that the Big Pharma apparatus has become so dependent on schmoozing physicians. Patients have every right to question how we come to make our decisions. What bothers me most is that the medical education process (from CME to journals to organized medicine to academic research) is so intertwined with the drug life cycle realities of our current environment. The desperation of proving value in the new during a time when the profits can still be obtained pushes the explicit and subtle manipulation that does interject itself into medical decisions. It is a markedly uneven playing field. It leaves little room for continuing the time-tested principles that have evolved in clinical medicine (prescribe agents you know, do not make multiple changes at once, actually have preferences among agents). Now, I am supposed to defer to the computer, the formulary, the warnings based on skimpy evidence (never use a tricyclic or muscle relaxant is someone > 65, reassess chronic therapy on any drugs that cost too much [couched as ?ing clinical validity of long-term SSRI or PPI therapy; legitimate questions but totally inappropriate to try to coerce patients and physicians as currently done]).

I am more than prepared to go "No Free Lunch." I find it frustrating, bad for my health, and of marginal value. I can't deny the role of samples however, especially in a rigid, insurance dominated, system where patients are given little flexibility to deal with inevitable availability issues (bureaucratic delays; irrational quantity limits; clinical instability). The lunch problem I will solve; the freedom to care for patients without coercion is more intractable.

What Washington and organized medicine should have helped us with is the failure to control pharmaceutical pricing. It's direct costs and the administrative hassles it engenders have grown to 30% of Medicare expenditures (see recent NEJM), while the Doctor Fix remains elusive and the Medicare bureaucracy is slowly crumbling through undue complexity. We are paying a price for perpetually undervaluing clinical care while over-valuing the new players (from drugs to scans to procedures). Innovation will not be furthered by a bankrupted system. Quality will not be improved by bureaucracy. Quantity would take care of itself if growth centers were not so overtly rewarded over the tried and true. It is a real shame.

Steve Lucas said...

In discussing this issue I first try to remember that there is a lead/lag in action and perception. Changes in the doctor’s office will take time to be perceived by the patient.

Another major issue is the doctors this would most impact do not blog. My experience is that those doctors with the most questionable business practices do not take the time to blog, since they could be making money, and they do not want to be confronted or defend their business model.

KevinMd recently hosted a post by Charles Bankhead regarding drug company interaction and a survey of 590 doctors produced the following results:

Among the overall survey findings:
* 58.2% of respondents believe drug samples improve patient care.
* 65.6% said company materials are useful for learning about new drugs.
* 78.5% said such materials are useful for learning about new devices.
* Most felt sponsored grand rounds are instructive (80.5%) but biased in favor of the sponsor’s product (68%).
* 69.5% said accepting lunches or gifts is okay (69.5%).
* 35.6% said accepting lunches or gifts influences their own prescribing.
* 52.2% said doing so influences colleagues’ prescribing.
* About three-quarters believe company marketing does not influence their own prescribing (72.7%) or use of devices (74.4%).

In another KevinMd post we find an excerpt from Daniel J Carlat’s new book Unhinged. Here he highlights the “off-label” prescribing of Neuontin and the access given to drug reps of exam rooms and patient files for a fee.

In thinking about this issue over the weekend I found myself returning to this statement: In the last 20 years I have not seen a front line doctor where medicating me was not their top priority. On more than one occasion this has lead to confrontations between myself, doctors, and nurses with the final outcome always ending with a statement that with my insurance I have an obligation to be medicated to support the practice.

One doctor went so far as to tell me I was taking food from his children’s table.

While I sympathies with the business issues now facing doctors, I also find myself concerned about the influence of drug reps and pharma in general. The point was made to me decades ago by the sales manager of a drug wholesaler, drug reps sell.

Pharma’s message is: Drugs are good. Why are you not taking a drug?

Some where in this the message has become muddled to become: Drugs can help your business model through gifts, fees, and cutting down on patient interaction.

The comments made so far are fair:

Not all new drugs are bad.

Patented medicine may be the right choice for some patients.

Doctors are not compensated for time spent with patients explaining why they need a medication.

Doctors need to remember:

Reciting verbatim DTC ads to patients does not justify a medication.

Having patients wait while the drug rep serves lunch does not help a professional image.

There is no justification for medicating a patient for financial gain, or to meet a vague standard set by a drug company.

Steve Lucas

Jay Larson MD said...

The young physician starts life with twenty drugs for each disease, and the old physician ends life with one drug for twenty diseases.
Sir William Osler

Steve Lucas said...


Good one.

This does bring up the concept, touched on by ryanjo, of personal responsibility.

My wife and I are considering not renewing our tickets to a summer concert series in an upscale venue. The reason is the decline in the quality of people attending. This sounds very pompous, but having an overweight guy in a tank top block you view does not add to the evening. You don’t want to know what we pay for those tickets.

People just believe they can live whatever type of life they want and there is a pill for that.

Steve Lucas