Public scrutiny of Big Pharma, doctor relationships
For decades pharmaceutical companies have been plying our doctors with all manner of perks and making generous payments to our specialists for speaking, consulting and advising. Defended as legitimate medical education, this promotion is decidedly unhealthy, evidence suggests, skewing prescriptions towards the latest and most expensive drugs even when older cheaper options are safer and more effective. And almost all of this has happened in secret with no public scrutiny. Until now.
Under reforms just announced by the Australian Competition and Consumer Commission, drug companies will have to start collating and then publishing many of their “transfers of value” to doctors – including payments for consultancies, speaking and sponsorship of accommodation and travel expenses.
Once the new transparency regime is up and running next year you’ll actually be able to check whether your doctor has been working for Big Pharma, and how much they’ve been paid, albeit with a threshold that will overlook some small yet still significant sums. It may be that you look at that psychiatrist differently next time he prescribes a powerful anti-psychotic for your child or elderly parent, when you know he’s been regularly earning $1000 a pop from the manufacturer for promotional presentations. To make it easy for you, the drug companies are being forced to ensure all names and fees are available on a central, searchable and accessible database.
“ACCC is requiring the regime to be strengthened to ensure that all relevant transfers of value are reported and that the data is accessible,” said ACCC commissioner Dr Jill Walker in a statement announcing the historic transparency reforms.
The aim is to reveal relationships that have powerful influences on how doctors prescribe drugs, ultimately enabling more informed decisions about where you seek your healthcare.
When 1000 Australians were surveyed a few years ago about drug company payments to doctors, nine out of 10 expressed concern. More than two-thirds worried payments might influence advice to patients, while more than half believed payments compromised doctors’ integrity and could even be considered a form of bribery.
The pharmaceutical industry hopes openness will make the payments more publicly acceptable: “Improved transparency shows the community the importance of the work our member companies does with healthcare professionals to improve patient health outcomes,” said Tim James, chief executive officer of the industry body Medicines Australia. Others believe the reforms will encourage patients to think more about the financial ties of their doctors, and encourage the medical profession to clean up its act.
“I always feel uncomfortable when I see drug company logos in doctors’ offices,” says Jon Jureidini, child psychiatrist at the Women’s and Children’s Hospital, and the University of Adelaide. “It always makes me wary. We should be severing almost all ties with pharmaceutical companies. Unless you’re a paid employee of a company with a contract, there’s no reason to be working with industry.”
The evidence that financial ties with drug companies can distort doctors’ decision-making is so overwhelming there are now official recommendations for much greater independence. In a landmark 2009 report, the prestigious Institute of Medicine in the United States found these ties can create “conflicts of interest” threatening the integrity of medical research, the objectivity of doctors’ education, the quality of patient care, and public trust in medicine.
The report called for an end to many of the financial relationships and a move away from drug companies sponsoring doctors’ education. It also recommended a radical new plan calling for all payments to be made public. In 2010 that’s exactly what the US congress did, introducing the Physician Payments Sunshine Act that launched the open payments scheme in 2013.
In the first five months of that scheme, more than four million individual industry payments to US health professionals were disclosed, totalling almost $US4 billion. Today, Americans can simply type in their doctor’s name and address and within moments find an up-to-date list of all the benefits their doctor receives from companies selling medicines and medical devices – even down to a $10 lunch.
Apart from breathing fresh air into the doctor–patient relationship, the new information also offers the chance for public scrutiny by researchers and media. Award-winning investigative journalists at the New York based ProPublica have used disclosures to produce a series of explosive stories, revealing that many doctors who’d been found to have acted inappropriately were still on the industry payroll as speakers or advisers. They’ve also named a high-profile heart specialist who received more than $US270,000 in one year for speaking and consulting for six companies, and a psychiatrist in Nashville, Tennessee, who made $US1 million from speaking and consulting in just four years.
Most doctors, of course, receive much smaller perks, and perhaps most importantly, a huge proportion of individual disclosures cover payments for meals – food, flattery and friendship being the foundation for the effective flow of influence.
By comparison with the US provisions, Australia’s incoming new rules are pusillanimous, with loopholes you could drive a road train through. All payments classified as “research and development” will be excluded, as will all meals under $120. That means your GP could be wined and dined every second week, hearing company-sanctioned spin on the latest drugs and the diseases that go with them, with direct impacts on your care, with no way of you knowing.
Wining and dining is not a thing of the past. In 2014 drug companies provided hospitality for doctors, nurses and pharmacists at more than 30,000 events in Australia: more than 100 events every weekday. While most events took place in hospitals, medical centres and universities, many still happen inside hotels, resorts and desirable restaurants.
Around this time last year, eight Melbourne GPs settled into a cosy educational session about the dangers of high cholesterol, funded by Pfizer, the manufacturer of one of the world’s most profitable cholesterol-lowering drugs. The classroom was the chic Enoteca restaurant in Church Street, Richmond, where diners can enjoy an entrée of rabbit loin with pancetta and parsnip for $25, and a main of Flinders Island lamb for $42.
Around the same time, Pfizer treated an even more fortunate group of 12 Sydney GPs to a similar “educational” event about cholesterol, this time at the Banjo Paterson restaurant, which boasts pressed quail and pistachio nut terrine, as well as Dom Perignon at just $270 a bottle. The bill for the night was $1732, or $144 per GP. The speaker was paid $2800 for two hours of content.
We know these events occurred because since 2007 drug companies have been forced by law to disclose them. What we don’t know are the names of the doctors attending. It’s long been anticipated that the new wave of disclosure reforms would force companies to name the doctors receiving free meals – as happens in the US – but following a relentless campaign by both industry and parts of the medical profession in Australia, the guest lists will remain secret. And as part of the recent horse-trading with the ACCC, the 2007 reforms have been dramatically watered down, so drug companies will now no longer even have to reveal the amount they spend on hospitality at these events.
“Not disclosing meals under $120-a-head is a step in the wrong direction,” says Jureidini. He points out that it’s often not the money that influences doctors’ decision-making about which pill to prescribe you, but the feeling of goodwill that creates the need to reciprocate. “Some of the most dangerous perks are labelled as the most innocuous,” he says.
Doctors who say they’re not influenced by gifts and payments are either disingenuous or negligently naive – pharmaceutical companies spend more than a billion dollars a year in Australia on marketing. The sales reps and sponsored education tend to push prescriptions towards the latest, most expensive and aggressively marketed drugs, and often exaggerate benefits and play down harms. Drug companies have paid out billions in fines in recent years, often due to dangerously misleading promotion. Major scandals have seen widely used new arthritis drugs cause heart attacks, dangerous diabetes drugs withdrawn after years on the market, and the uncovering of hidden data showing expensive flu drugs have marginal benefits.
That 2012 survey found two-thirds of us would view pharmaceutical companies more favourably if they were open about their relationships with doctors. The current reforms may well help consumers make more informed choices and policymakers track the flow of influence, but its shortcomings mean Australia is yet to reach the global transparency standard set by the US.
This article was first published in the print edition of The Saturday Paper on May 2, 2015 as "Pharma's market". Subscribe here.