We’re in an era of increasing scrutiny toward the cost of medications. Health care providers, patient groups, and even our president have criticized the disproportionately high prices that patients in the U.S. pay for drugs compared to other countries.
Much of the responsibility, of course, falls to the chain of businesses that develop, manufacture, distribute, and sell medications — and those in between — all of which determine how much it costs to fill a prescription.
But the medical-industrial complex and the many roles within it also contribute to the problem. In our work practicing and studying pharmacy, we’ve become particularly interested in the relationship between hospital-based health care providers and pharmaceutical sales representatives — individuals who sell a company’s drug and also educate doctors about its use.
What we’ve found is that in spite of evidence that sales reps skew prescribing habits, relatively few hospitals have taken the step of barring them. We believe this is a disservice to these hospitals’ patients and a missed opportunity for hospitals to help address the problem of high drug prices.
A recent study focused on 19 academic medical centers in which administrators changed hospital policy to either limit visits by pharmaceutical sales reps, limited the gifts their staff members could accept from these individuals, or set penalties for clinicians or sales reps who broke the rules. In the years after enacting such a policy, overall prescribing of marketed drugs fell while prescribing of non-marketed drugs — mostly generics — rose.
Still, such policies haven’t fully caught on among hospitals. According to a survey conducted by research firm SK&A, just 36 percent of hospitals in the U.S. denied access to pharmaceutical sales reps in 2016, up from 22 percent in 2010.
To gather more data on the current landscape of drug marketing within hospitals, we conducted our own survey. We contacted members of a national hospital electronic mailing list, asking them to share their hospitals’ policies about allowing drug company sales reps to visit doctors in the hospital. To those who expressed interest, we sent a more detailed list of questions. Pharmacists representing 15 hospitals responded. Ninety-three percent of these hospitals allowed visits by sales representatives. Most of them — 73 percent — had a formal registration and credentialing process. That seems to say to us, “We’ll let you in, just check in first.”
A majority of the hospitals (53 percent) allowed sales reps to provide meals, which has been shown to influence prescribing. And 60 percent of the hospitals that allowed sales reps to visit said the reps were allowed to discuss drugs not on the hospital’s formulary, its list of approved treatments. That seems to say, “We want our formulary to guide cost-effective treatment, but it’s not like we’re in love with it.”
Why don’t more medical institutions ban sales reps, or at least limit their interactions? Surely physicians can manage without the free meals. Many of the doctors that we speak with in the hospitals we serve point to something else entirely: They say that the medical education that sales representatives provide is invaluable. Doctors say that other resources — such as seminars provided by the institution or online compendia — are limited to mainstream questions and are unable to cover emerging literature or complicated questions, so there’s really nowhere else to go.
But the fact is, if hospitals allow salespeople to educate their doctors, they aren’t prioritizing patients’ health. The case of the painkiller Vioxx is an example of what can go wrong in such a system. The Food and Drug Administration approved Vioxx in May 1999. Just one year later, the VIGOR study revealed a fivefold increase in heart attacks and strokes among individuals taking the drug. Despite these data, Merck’s salespeople were instructed to keep selling the drug and deflect questions about adverse events. The company doubled down on marketing, spending more to advertise Vioxx than Pepsi, Nike, and Budweiser spent on their products combined. By the time Vioxx was withdrawn from the market in 2004, 100 million prescriptions had been filled for it, representing $1.5 billion in sales and an estimated 88,000 to 139,000 heart attacks associated with its use.
The Vioxx example is not uncommon. Medical reversal is defined as a medical practice that did not work all along, either failing to achieve its intended goal or carrying harms that outweighed the benefits. And though it should be rare, it’s considered ubiquitous by leading experts. Part of the reason is that conflicts of interest obscure such failings.
To avoid these kinds of conflicts of interest, we should turn to data. Data should inform doctors about their patients, direct their interactions, and guide their treatment decisions. And instead of coming from sales reps, that data should come from unbiased sources free of conflicts of interest.
It’s the responsibility of hospitals to make that happen, for the health of their patients.
Ashish Advani is a clinical associate professor and director of the Drug Information Service at Mercer University College of Pharmacy in Atlanta and founder of InpharmDTM, a virtual network of academic Drug Information Centers that facilitates evidence-based practices. Ashley Dolphus is a third-year pharmacy/MBA student at Mercer.