W

e’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.

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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.

Providers who receive industry payments or meals prescribe more of the drugs being marketed. Hospitals can step in to change this dynamic.

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.

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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.

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  • A very narrow, biased article. It never occurred to the individuals who developed this “survey” that reps may have been introducing a NEW product, for which there was no generic?
    So, how would that product be on formulary??
    This should be obvious, but a product which physicians are unfamiliar with has ZERO demand! If they don’t know what it is, or what it can do for their patients, they will not ask to have it added to the formulary.
    After it is added to the formulary, it is appropriate that physicians are educated on its’ proper use and approved FDA indications. What about Resident physicians? Shouldn’t they have the opportunity, as part of their medical education, to question the companies that make these products in a direct way- a way that reading literature cannot provide?
    I can’t help but wonder what specific interests pharmacists have in this process? Are they competitors for the job of educating clinicians? Formulary control, vs the Physicians?
    Certainly there have been unscrupulous companies that have acted against the public welfare, in the past. But it is not “common.” It is, in fact, a crime. A Felony, in most cases. Of the thousands of Rx drugs that are available, the most significant example is from almost 2 decades ago?
    If the interest is in cutting costs, certainly pharmacists share some of that blame. A large part of that job is better addressed by automation, but lobbying groups representing Pharmacists and their schools have insisted on legislation that requires that filling med orders are supervised by pharmacists, when techs and machinery do at least as good a job. Let’s cut that bloat while we’re at it.
    “Pharmacy Benefit Managers” are also largely to blame for skyrocketing costs. Canada has Rx reps, but somehow their prices are lower? Do they have PBM’s? Do we need these middlemen?

  • There are a number of instances where hospitals and doctors have settled/lost lawsuits for a multitude of reasons (including negligence, greed, human error). This is in no way a reflection of the entire medical profession, hospitals or employees of offending institutions.
    Consider the airbag salesman. As technology evolves, the airbag salesman educates car companies on the benefits of the next generation airbags. Should the car companies stop sales people from coming because they are selling something?
    It’s disappointing to see sales equated to dishonesty. There is no shame in marketing a great product. Please remember that drugs like metformin, warfarin, and carvedilol were all heavily marketed products.
    The authors degrade an entire profession and industry, deeming them untouchable and suggesting they should be banned. They offer nothing but a paper showing interactions between industry and medical professionals increases prescriptions of branded products. They offer nothing suggesting that the outcomes for patients improve when industry education is removed.
    Sadly, keeping updated on clinical trials and practice guidelines isn’t within everyone’s bandwidth. Making a black and white policy doesn’t protect us from anything. It degrades our independent thinking and ability to assess the credibility of information we receive from any source.

  • The issue is far more complicated than presented in this article. Without an industry presence in the medical practice environment, there is an inherent selection bias.
    Providers will review what data they want to when they want to. Their knowledge of the data will not be challenged. Counter arguments challenging existing practices will not be made. To the providers not fully committed to hours of self study a month, isolation from advances in their field is common. The efforts to educate the provider community on the advancements in genomics and their impact on optimizing outcomes are challenging enough without roadblocks to access. Rather than over simplified “throw them all out“ approaches, we need responsible dialogue on processes to insure the integrity of the education process.

    • You do realize that the purpose of drug company reps talking to doctors is to sell them drugs? And that drug companies have almost ALL been sued for illegal marketing and hiding side effects in order to create blockbuster drugs? “Industry presence” can easily be accomplished by having monthly “grand rounds” where they can present their “data” and have it properly challenged by others who know the literature. Face-to-face meetings with doctors are absolutely not “educational” in nature. They are marketing, plain and simple, and they do not serve patients in any way except to obscure any attempt to objectively assess the truth.

  • Keeping avoiding to face the real problem.
    The single largest problem in healthcare are MDs. Both because of their ridiculously high salaries and because they are people with low morality and very easily corruptible

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