Taking the knife to doctor-drug company relationships

With health care industry reaching unsustainable lows, media attention is on physician’s relationship with the  pharmaceutical industry. A Google search will give results that paints doctors as culprits, leading to a prejudiced opinion where doctors are thought of as co-conspirators with drug companies. This article teases this tainted relationship, from a typical doctor’s perspective.

Pharmaceutical companies have strategies not only to survive, but also to grow with general public investing in their stocks. They have stronger ties with hospitals, insurance companies and politics than they have with doctors. How little a practicing doctor has to do with the drug prices is exemplified here.

In hospitals, if Drug A is in the formulary, no matter how many free lunches come from drug B representatives, all prescriptions for drug B will be changed to drug A. Although doctors in a private setting may have more control on prescriptions, but all things being equal, a patient with current needs gains priority over a potential uninsured patient from the future. It is very perplexing how the price of a drug is calculated when it is first released, because some medications are prohibitively expensive that they are unaffordable despite insurance coverage. Who decides what medications are covered by what insurance companies? And what medications go on the formulary? It is a contractual business between non-physician entities. It is only inconceivable that doctors in clinical practice can have any significant impact on the initial pricing of a drug. If at all, by prescribing more, they probably will help bring the price down, by forcing large scale production.What goes unnoticed is that medications like warfarin, furosemide, sodium bicarbonate, hydrochlorothiazide, aspirin are some of the cheapest medications that have stood the test of time & are also doctors’ favorites.

Doctors are also frowned upon for eating at pharmaceutical dinners, blaming it for unaffordable costs. We probably are guilty of this. More so probably because it operates at a subconscious level and easy to believe there is no effect.  No matter how much we try to deny their effect, the studies have shown otherwise. In fact, these studies are originally published in the same renowned medical journals that also publish other industry sponsored research, before they get into magazines. Just an indication that  as a community, we do have introspection. The bigger bargains and deals that go on behind the curtains involving corporations, businessmen, government officials go uninvestigated if not unquestioned. Policy makers make it easy for companies to track prescribing patterns of physicians, dislike ban on gifts more than doctors, while condemning and restricting doctors for accepting them. However, doctors’ communities have been listening to these associations. It has resulted in changes to ease the knot and free the bias. But still there seems to be no difference in the last 10 years. In fact, the problem is only getting worse. Here is why.

Lunches are only one venue to be introduced to new medications. I am yet to find a medical journal without drug advertisements, a conference with no pharmaceutical banners. Severing the connections is not easy, because medications are an integral part of medicine. An essential part of the health care machinery, doctors are more like nuts and bolts and not the driver behind the wheel status they are given. The people who are behind the wheel are a handful, some of them are not even doctors. We are culprits to the extent that we let it tide by us, not because it benefits us, but more because it hardly affects us (unless we become patients) and there are always more immediately relevant patient concerns to worry about.

Hence, the check point would be probably more efficient if it is at the FDA instead of at the doctor’s office. What is the point of FDA approving a new alternative choice medication if a doctor cannot prescribe it due to its cost? A major fraction of high costs are by the sickest patients who are a small fraction. The major flow of money from drug companies is into a handful of people who for the most part have transparent relationships. I would not be using Xigris (drotrecogin alpha) on everyone everyday. But if no one ever used it, we would never learn anything more about it. Not all medications that enter market thrive. (a new drug is approved by FDA every month on average). They stay only if they work. Here is another important article.

If the gist of this is that doctors should avoid prescribing expensive medications over cheaper alternatives, what about the evidence showing superiority of expensive medication? And then another study follows showing how the new medication caused more harm while the lawyers wait anxiously. The vast community of doctors use the results, but only a handful produce them. How do we maintain quality and transparency in such research? If not published journals (inundated with drug company advertisements) what else do we rely our medical decisions on? It is necessary that drug companies, scientists, authors, and statisticians are transparent about their research.

It almost looks like a conspiracy against doctors where the professional and personal integrity are put to vigorous testing while the whole system is designed to fail you at every step.

There are currently 1.5 million doctors in US and as per the data available about money flow from doctors to drug companies, about 17,000 got paid. This would be about 1.1 %, distributing the amount among themselves with only about 300 or so distributing about half of it. Distributed into research, consultancies, and a minute fraction into meals. What is more important goes on before the FDA approval. I wonder if an engineer or an accountant working in a company making medical equipment or soft ware for electronic health records would be equally culpable for accepting & giving freebies in the form of gifts, travels, to market and sell their products. Because like everything else, the costs get transferred to the consumer, which in this case are hospitals and practices.

I will be the devil’s advocate for a moment and wonder, why hospitals and cannot get subsidized rates on land, their equipment, transportation and other resources they use. Why are not insurance companies held responsible for making huge profits without doing a penny’s worth of research. Would it be a bad idea to channel a percentage of their profits into medicare to help the sick, old and poor? Why is manufacturing PET scanners, dialysis machines, surgical equipment, performing special blood tests so expensive? Aren’t these companies as responsible (for public health) as pharmaceutical industries? Doctor-drug company relationships-do they deserve this incrimination? Ultimately, most industries connect to and impact health care costs, even if remotely and indirectly.

Greed and poor ethics exist in the field of medicine and like one rotten apple, stinks the whole basket. It would be a judgmental error to call all doctors unethical/immoral or greedy for  consuming meals offered by a drug company.

In conclusion, when it comes to relationship between doctors and pharmaceuticals, a system wide approach is necessary. A knife with a sharper and deeper cut is probably more effective than the superficial trimming gimmick at doctor’s offices.

Nagarathna Manjappa is a nephrologist who blogs at Kidneys, Inc

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