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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  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    The backroom deals between high level executives and politicians have a much higher impact than any mild MD/drug company relationship. I recieve next to nothing from big pharma aside from a once a week lunch and crates of overpriced almost useless drugs(tekturna/azor anyone?) We are villified for lunch, i mean seriously….the jerks who got rid of generic colchicine and generic albuterol, who are they? how did they do this?? no one ever talks about that….it’s not the low hanging fruit,

    • http://glomerulus.wordpress.com/ Ratna

      yes, agree with you. I think part of it is to just please the public and show that they are addressing the issue right at its core, which is not true. Not enough doctors speak up against it, and hence co-conspiracy is inferred. Doctors need to speak more openly about such issues and make people aware of the complexities of the matter 

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem


      What Vikas Desai said.

      What this means is the drug companies will stop handing out useful sticky pads and pens to doctors who work for a living, and give real-live bribes to hospital administrators.

      What Desai said goes double for the colchicine, what URL did with that drug……..aided and abetted by GOVERNMENT policy……..is absolutely reprehensible. Now seniors can pay five bucks for a pill that used to cost ten cents, for a drug that would have been familiar to Hippocrates himself.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    For years now community physicians have been the whipping boys of regulators, media and patient groups for accepting a sandwich, cup of coffee or black and white cookie during a short meal break while listening to a pharmaceutical rep discuss their new product. We are expected to accept the fact that less expensive generic products produced in non inspected overseas production plants and not formally tested by the FDA are safe and as effective as brand name products ( produced in plants that are inspected far less frequently than most of us are comfortable with) because the generic company ( often a subsidiary of the patent holding major pharmaceutical producing company) submits data from an outside reference lab to the FDA that the product is as effective. As physicians we are criticized for accepting pens and paper from the same academic communities that accept six and seven figure compensation for evaluating new medications and speaking about their research, while these same people sit on the editorial boards of peer reviewed supposedly non biased journals which exist solely because of the pharmaceutical advertising of these same large companies.
    The truth is that every professional and business person is confronted on a daily basis with ethical issues including conflict of interest scenarios. The practice of medicine is one of the few areas where the law, regulations and general opinion of its academic world treat all physicians as guilty and unethical in their behavior rather than weeding out those who break the rules of the profession and the society.

    • http://glomerulus.wordpress.com/ Ratna

      nice comment Steven! 

    • http://twitter.com/Wisdom_2 Better_Fly

      Who does the weeding out?  Good Doctors know their peers are practicing bad medicine and do not turn them in.  Not all Doctors are unethical, but for every unethical Doctor, there is an ethical Doctor that knows them and has knowledge of things that are not right. At the end of the day the patient is the one that suffers and pays.  Some patients pay in money and some patients pay with their life.

  • Anonymous

    What doctors just don’t seem to understand is that prescribing expensive medicines, when a suitable generic is available, is forcing insurers to raise premiums on their subscribers. If premiums go up, more and more consumers are forced to opt out and join the growing number of uninsured. A number that has already exceeded 50 million. The more consumers that opt out means less patients in the risk pool and less patients coming in to see a doctor. For a lousy free lunch or for a token pen and pencil gift set, doctors are cutting their own throats. Very short sighted! I am currently on an extremely expensive diabetes oral medicine. It’s a brand named drug for which a suitable generic is available. My doctor refuses to make the switch. I have asked him repeatedly and have shown him letters from my insurance company urging me to ask him to switch me to the less expensive generic. He continues to refuse. At some point, my insurer will stop urging me to switch to the generic and simply raise my premium to help cover their costs. Then, if the premium for me goes too high, I must decide if I should continue to pay that premium or opt out and take my chances of being uninsured. Millions of Americans face this situation today. Why? So a doctor can have a free lunch? So a doctor can continue to get free trinkets or tickets to a football game? How short-sighted is that? Doctors may be riding the gravy train today, but the game must come to an end. Consumers can not sustain such abuse just to satisfy their short-sighted mentality. Soon, like so many others who are going broke with these abuses, I may simply get my care at a clinic that accepts Medicaid or, if necessary, just visit the hospital emergency room when  my symptoms become bad enough.

    • http://glomerulus.wordpress.com/ Ratna

      “prescribing expensive medicines, when a suitable generic is available, is forcing insurers to raise premiums on their subscribers.”
      we need to take a step back and think about it. why is the medicine expensive when it is first introduced? why doesn’t FDA regulate the pricing of a drug when it is released? why is it only concerned with ‘effectiveness of the medication for a given condition’ ? regardless of whether a physician gets paid by a certain pharmaceutical company, they will continue to prescribe them, as long as studies/research proves them to be effective or more effective than an older treatment option. My question is- instead of accusing doctors as lacking integrity shouldn’t we all try to sees little farther and dig a little deeper? It is a good thing all these regulations are in place. If the accusation that doctors are responsible to raise the costs of medicines and health care is indeed true, it should soon be evident with a positive change in the healthcare industry, now that the doctors are out of the equation with all the regulations.

  • http://twitter.com/ddwebster Dana Webster

    It saddens me that there is so much bia aagainst the pharmaceutical industry in general.

    Having worked in the industry most of my career, I am tained in my own opinion.  However, my eyes have been opened to some of the less-than-savory things unscrupulous people have done over the years as far as sales and marketing.

    I’m also a recent cancer survivor……for the second time.  While I was in the hospital undergoing a lethal concoction of chemo and a stem cell transplant, the FDA was approving the first new treatment for my disease, Hodgkins lymphoma, in 33 years.  Unfortunately, while Hodgkins is well known, there aren’t a lot of us that end-up being diagnosed with it compared to other cancers.  So, why study a disease affecting less than 10,000 patients in the US each year?  Because we need to have a fair chance to fight and survive.  Hence, the high price of Adcetris from Seattle Genetics.  Other than being able to get on the FDA fast track for approval, they had to do the same trials and complete the same FDA scrutiny as a large pharmaceutical company releasing a new hypertensive medication.  There are just fewer of us to recoup the costs and only two currently approved indications.

    It’s time for pharma to stand up, admit to the wrong doings of the past and set the record straight.  Why don’t people admonish the wholesalers, distributors, pharmacies, insurance companies who all make money on the drugs and help push the costs up as well?

    My final statement:  brand doesn’t equal generic.  It’s the same with any formula for any consumer product. While active ingredients may be the same, there are different inactive ingredients, different forms (pill, capsule, etc) and different manufacturers.  I think one of the travesties of medicine is that, when a generic fails, we skip the brand and call the product ineffective.  I’m taking a medication for nausea, post transplant, that I’ve had both in brand and generic.  The generic is far from as effective as the brand.  So, I choose to pay the higher copay each month.

    Healthcare professionals can be just as much to blame as the industry at the end of the day.  The model is broken at all levels, but to assign blame in general isn’t fair.  We should be working together to fix the problem, not just sitting around the table pointing fingers.

  • Preston Gorman

    Would it be a bad idea to channel a percentage of their profits into medicare to help the sick, old and poor? ”
    Like through taxes? I think that already happens…

  • Anonymous

    If intellectuals in the health care and PhRMA industry are so smart, why aren’t they coming up with ways to include “everyone” in the system and do all they can to make consumers happy? Today, we have over 50 million Americans that simply have given up and don’t even try to participate in our costly health care system. We also have an estimated 25 million more Americans who don’t know what they have until they try to use it and find out that they are underinsured and aren’t covered for certain things. Is that how we measure success? Is that how doctors and hospitals and insurers and drug companies determine that America has the best health care in the world? With 1/4th of our population either uninsured or underinsured, how does that make our health care system the best? Huh? Doctors and PhDs, the people with the so-called brains, and all they think about are quarterly profits? NEWS FLASH:  The system is broken! Maybe beyond recovery! So where are the smart people, huh? 

  • Anonymous

    As a 30 year veteran of the pharma industry, I wouldn’t argue with many of the valid comments here from all perspectives. The bone I want to pick with Dr. Manjappa in this article (and in reality I know he agrees with this if being honest) is the role of the physician in preventive medicine. Most of the prescription drug use in this country could be eliminated if physicians continued to educate themselves after med school on non-traditional medicine like the evolving science of diet (f.ex., Americans are dying of carbohydrate “poisoning”), nutriceuticals (why isn’t everyone on a pure form of fish oil, CoQ10, etc.?), environmental toxins (heavy metals in fish, bpa in all canned goods, additives in skin/hair products, etc.) and exercise (cardio is WRONG, high intensity exercise 3X week for 20 minutes is a much easier way to go, which almost everyone can do).
    I can hear the push back now…”but we only get paid for specific medical interventions”…”we have to see 20, 30, 40 patients a day to break even”…”Medicare (or an uninsured) doesn’t pay enough so I can’t treat the weakest, most vulnerable patients out there”…
    What happened to the Hippocratic Oath of do no harm? Let’s take statin drugs for example. There is a growing body of evidence that only 25% of the patients taking a statin should be on them. The whole concept of cholesterol, LDL, HDL is much more complicated than the way the vast majority of physicians currently treat a cholesterol number and involves f.ex. fractionating the lipid panels, looking at the breakdown of the sub-units and using less toxic, less expensive supplements to attack the problem than the statins. So why don’t physicians try this approach? The lab work is expensive and usually not covered, there is a risk of malpractice…if statins are considered a standard of care by a payor and something goes wrong they could be liable. Statins drugs have horrible side effect profiles which are vastly under reported and many enlightened Cardiologists know they should be reserved for a very narrow patient profile.
    So if I know this as a non-physician (and as I said – most MDs know this also), why aren’t physicians rightiously indignant with their bretheran, standing up to be heard within their respective associations, lobbying against harmful treatment paradigms trust upon them by payors with economic incentives to “construct” standards of care that could be harmful to patients? Sadly, it’s “don’t rock the boat”, “I’ve got huge loans to pay off”, “I need to be a part of these payor networks to get enough patients to make a living”. Physicians still make very good livings in the US and not biting the hand that feeds them is more important than good preventative medicine and patient well-being.

    • http://glomerulus.wordpress.com/ Ratna

      “not biting the hand that feeds them is more important than good preventative medicine and patient well-being”- why would there be screening tests like fecal occult blood tests, mammograms, pap smears. they are also preventative medicine probably second tier. I get your point about dietetics, neutriciticals etc. But whoa, is this yet another thing we will be blamed for? Why oh why we do not go after why these toxic substances (carbs, bias etc) have found a comfortable place in the shelves of our supermarkets & restaurants? I spend a significant part of my time counseling my patients about salt intake, exercise, weight loss, healthy diet- with very very minimal impact. why is this culture of ‘taking responsibility’ instead of blaming doctors for everything that goes wrong with one’s health & the health care industry so popular? - btw I am a woman 

      Nagarathna Manjappa

      • Anonymous

        This isn’t an argument about patient behavior. This is an argument about greed. This is an argument about payola. This is an argument about honor and integrity. This is an argument about principles and morals. Stop trying to change the argument. Stop trying to divert the focus away from the stinking rotten behavior that goes on in private between doctors and drug company reps. Doctors have taken an oath to put their patient’s wellness ahead of all other considerations. At least that’s the tripe we are told to believe. We keep hearing that nothing should come between a doctor and his/her patient. I say, if the doctor is taking payola from a drug rep to influence his decision about prescribing certain medicines, that’s a violation of the doctor/patient relationship. Once he/she takes the bribe, he/she has become prejudiced. Once the doctor takes the bribe, however large or small, his/her opinion is no longer unbiased, independent and autonomous. If you don’t see that, your are in compete denial. 

  • susan popp

    Big Pharma and $$$ for doctors. What about the under the table fees doctors are paid? Drug reps and FAB. Shame on all of you. 

  • Anonymous

    This post seems to be sidestepping the point – a few points, in fact.  Physicians don’t have to be on the company payroll to be influencing what’s now known as “marketing-based medicine”.  Consider these numbers, for example:

    - What drug companies spend annually on full page ads in medical journals: $500 million
    - Amount drug industry spent on marketing directly to doctors last year: $7 billion
    - Amount drug industry spent on Direct To Consumer “Ask Your Doctor” ads: $5 billion
    - Drug industry’s research and development budget compared with marketing budget: 1 to 2
    - Favourable change in a doctor’s prescribing habits after less than 1 minute with a drug rep:  16% increase
    - Prescribing change seen after 3 minutes with a sales rep:  52% increase
    - Number of presentations last year where North American doctors paid by drug companies pitched that company’s drug to peers:  237,000

    Although almost every doctor will deny that he/she is even remotely influenced by their friendly neighbourhood drug reps, studies continue to confirm that there is a very good reason Big Pharma invests heavily in convincing docs to get onside to help promote specific (brand name) drugs: it works!

    More on this at Drug Marketing By The Numbers at:  http://ethicalnag.org/2009/10/24/drug-marketing-by-the-numbers/ 

  • Anonymous

    The entire system is broken. Why? The fee-for-service model rewards the wrong things! Pharma’s outrageous corruption will begin to end when small one-doc and tw-doc practices dry up and blow away in the near future. The Accountable Care Organization (ACO) model, a model that rewards wellness and good outcomes and does not reward keeping patients sick, will become the new way for consumers to access health care. More and more one-doc and two-doc practices will need to make a decision. They will need to join the ACO movement or they will simply be forced out of business. They will not be able to compete with an ACO. Simple as that! Will ACOs happen overnight? No! It will take a few years to see them proliferate. In my area, every hospital group is in the process of implementing an ACO. Small one and two doc practices are being offered buyouts. My PCP has already signed an agreement of intention to join a nearby Hospital ACO at some point in the future. FACT IS, consumers can’t afford you any longer! You have milked the cow dry! You have killed the goose that lays the golden eggs! You have created a health care system where over 50 million Americans are uninsured and another 25 million are underinsured. Are you happy with what you and your industry did? Are you happy with an industry that has been on a suicide mission for the last few decades. You did it to yourselves! It’s you own fault! Consumers didn’t create the broken health care system we have today, YOU DID!

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