How much drug companies pay doctors for meals, giving talks, and serving on corporate boards was once as opaque as how these companies now price prescription drugs. That changed several years ago with the creation of the Open Payments program, which makes this information publicly available.
In an unsuspecting twist, this transparency program, which was meant to bolster trust, has actually decreased patients’ trust in their physicians, even those who have never taken a nickel from pharmaceutical companies.
My colleagues and I think this unintended consequence presents a marketing opportunity for astute physicians with no ties to drug and device companies.
A bit of background: Policymakers have long been concerned that the payments drug and device firms make to doctors can influence clinical decisions in ways that aren’t good for patients. The Physician Payments Sunshine Act (part of the Affordable Care Act passed in 2010) mandated public reporting of these industry payments through its Open Payments program so patients would be better informed about their physicians.
Today, anyone can go to the Open Payments website, type in a doctor’s name, and see if he or she has received payments from drug and medical device companies and what they were for. This program was a significant step toward transparency in the flow of dollars from such companies to doctors.
Although the Sunshine Act was designed to inform patients about industry money going to doctors, few patients use the site. A recent evaluation of the Open Payments program by our team showed that before Open Payments, about 3% of American adults reported knowing whether their doctor had received a payment from a drug company. Two years after the program’s launch, that number had barely budged.
Journalists, however, have made frequent use of Open Payments data. Their investigations have had a significant and measurable impact, at least on physicians. Reporters’ use of the database has focused on identifying and publicly scrutinizing physicians who received large amounts of money, mostly for consulting work, royalties, and investments. Journalists have also used the database to identify doctors in prominent positions who have been inconsistent in reporting their financial interests. Some, for example, reported zero financial conflicts of interest in their publications or while serving on scientific advisory committees even though large payments had been reported in the database. In many cases, these physicians were forced to resign after having been publicly profiled.
Much of this coverage — whether mainstream media, tabloid, or John Oliver — has tended to focus on extreme outliers and overall dollar amounts of industry money flowing to doctors, which may have led to patients painting all doctors with too broad a brush.
Small-scale studies in controlled settings have shown that patients report less trust in doctors who accept industry payments. In a nationwide study of nearly 1,400 U.S. adults that I and several colleagues recently published in JAMA Network Open, we found that this distrust extended to doctors who had not received any industry payments. Put differently, patients were reporting diminished trust in doctors who did not accept industry payments because they were aware that other doctors did.
In its current form, transparency of industry payments hasn’t helped patients distinguish between the true signal of their own doctors’ industry interactions — or lack of them — from the noise of all other doctors’ behaviors.
My colleagues and I believe there are several things that can be done to enhance the signal-to-noise ratio.
The Centers for Medicare and Medicaid Services, which administers Open Payments, could encourage individuals to use the database by better publicizing the website and linking to it on webpages that Medicare patients frequently use. Journalists could offer better context in their reporting by noting that the number of doctors receiving large payments is small and that the majority of doctors don’t receive any receive industry payments.
But the recommendation we most strongly endorse is that physicians, medical practices, and health systems take a more proactive role in supporting transparency and patient trust.
Physicians who do not receive industry payments, and who are tainted by physicians who do, should convey their payment-free status to current and prospective patients. Patients care about industry relationships and report greater trust in doctors who have none, so it is in the interest of these doctors to expend the small cost and effort to signal this status to their patients.
This status could be highlighted on a physician’s website with a statement that she or he doesn’t accept industry payments. Signs in the waiting room proclaiming that the doctor does not take industry payments could also advertise this status. Of course, nothing would prevent doctors who take money from drug or device companies from falsely stating they don’t, so a formal certification system that would verify and authenticate this status would likely be needed.
Why do we think this kind of signaling would help fix the informational and trust problems associated with Open Payments? An analogy from a different field might be helpful for starkly illustrating the role that signaling can play in improving trust and buttressing transparency programs.
Suppose there were only two airplane manufacturers in the world, A and B, and passengers couldn’t tell just by looking which planes were made by what company. Planes made by company B were prone to crashes, but without transparency no one knew that B planes were less safe than A planes. In this scenario, people trust B planes too much.
Now suppose the government introduces a transparency program that reports the safety record of each airplane model. But no one uses the list except journalists, who focus on B models with the worst safety records and report about all the B planes in the air.
Because passengers don’t use the list to examine the safety record of the planes they will be flying on, they become more fearful and skeptical of planes in general, even if they are flying on a safer A plane. In this post-transparency scenario, people trust A planes too little.
One solution is to make B planes safer (akin to all doctors cutting ties to industry). Another solution is for company A to signal to prospective passengers which planes are A planes (akin to physicians without industry ties signaling their status). With signaling, the level of trust is just right for both A and B planes.
Those pushing to ban all physician-industry interactions certainly won’t be satisfied with the signaling solution. Such a ban, however, is likely to be in the far-off future, if it ever happens at all. A policy like that would require extended discussion and deliberation because not all physician-industry relationships are equally problematic and because there would be significant consequences for research and clinical care given the entrenched “soft-money” funding model of medical research conducted at universities.
In the meantime, signaling about industry payments is a practical, low-cost way to improve information going to patients. It could also push the system in the direction of fewer physician-industry relationships, as patients differentiate between physicians who do not accept money from drug or device companies and those who do, and as physicians themselves become more cognizant of the industry interactions of their peers.
Open Payments has illuminated the previously opaque financial relationships between drug and device companies and physicians. Effective transparency, however, requires more than a public data dump. Health care providers, journalists, researchers, and other stakeholders play important roles in, and can make thoughtful contributions toward, helping the public separate important informational signals from unhelpful noise.
Genevieve P. Kanter, Ph.D., is an assistant professor in the Department of Medical Ethics and Health Policy and the Division of General Internal Medicine at the University of Pennsylvania’s Perelman School of Medicine.
Of course, a data “DUMP” can b construed as INFORMATION which, out of Prof Kanter’s department of ETHICS, cud b translated into informed decisions, reducing the Med Biz & Ca industry profits.
And while on the subject, just from where do the good doctor’s “research” grants arise?
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Mr. Eckardt (below) raises very good points, and I certainly didn’t mean to imply that physicians with no interactions with industry are fundamentally better doctors than those who do not. I do think, however–as do physicians and other academics who have studied this issue–that some industry interactions may lead some physicians, unwittingly or not, to not always act in the interest of their patients. It is these specific set of interactions that are of greatest concern.
In response to the points you raised:
On point #1, you asked for an example of a study that shows that patient outcomes are worse because of industry interactions. Perhaps the starkest example of this are the studies that draw associations between opioid marketing and opioid-related overdoses and mortality. We now know that opioid sales reps encouraged frequent and high-dose prescribing, motivated by the profits accruing to their firms and their own commissions.
Although this is an extreme example, it is not a stretch to note that, given the structure of sales incentives, even well-intentioned sales reps would have good reason to encourage the prescribing of their products.
It can be hard to detect inappropriate prescribing (primarily because of the difficulty in linking EHR data with marketing data) but some studies show, consistent with theory, over-prescribing associated with marketing. While over-prescribing doesn’t necessarily kill patients, it certainly imposes a burden on them and diminishes their quality of life.
On point #2, I agree that it is important to draw a distinction between research payments and other types of payments. Perhaps the certification program that we proposed can distinguish between the different types of industry interactions.
Regarding point #3, you mention that “making conclusions that all payments are bad is irresponsible.” I agree. In fact, transparency is a policy that is put in place in exactly the circumstances where an activity is not unambiguously bad. If it were, banning it would be a no-brainer. Given that an activity isn’t obviously bad in all circumstances, a politically easy decision is simply to make the information available, driven by the notion that consumers (in this case, patients) can decide for themselves how bad they think different activities are. The problem is that the information provided is in a form that is difficult for patients to understand and process, and they must therefore rely on informed intermediaries. It is for this reason that, for transparency to be effective, intermediaries like physicians, journalists, insurers, and the government become engaged more deliberatively in disseminating information.
There are many problems with the reporting of payments to physician, however, making the assumptions that physicians that do not have ties to the pharmaceutical industry provide better care or make better decisions for patients does not have any backing in reality. Just a few points:
1) It is true that interactions with pharmaceutical representative can influence behavior. However, the question is that behavior positive of negative for the patient. This can depend on the context of the interaction, if a physician learns about a better therapy that improves outcome for a patient that he/she did not already know this could be very positive. Many of the newer treatment can have unique deliveries and toxicities, without education from the manufacturer the physician may not deliver the treatment appropriately. This education is not coming from the government, from the hospitals, or from the insurance companies. So even though you believe it is a negative influence, show a study that demonstrates patient outcome is worse.
2) Since a high percentage of new therapeutics came from private industry, the true experts in the field and researches have to have interactions with industry. If you look at all the top clinical cancer specialist in the US they do research in their field of expertise often with pharmaceutical support. This is captured in the database. Would you recommend a community physician who does not do any clinical research over a academic expert with multiple cutting edge clinical trials with relations to pharma companies?
3) If the research physicians have the most experience with a drug in a clinical setting isn’t that the right person to teach others how to use the therapy. Shouldn’t you pay that physician for his time and effort? Who should pay him?
The concerns that pharma influences physician came from a politician who wanted a campaign issue to get votes. Without any study on what is appropriate or inappropriate interactions with pharma. Making conclusions that all payments are bad is irresponsible. The amount of money given to a physician is inappropriate if that money is given to have the physician inappropriately use a treatment.
We need to be much more clear and accurate in the positives and negative of physicians interactions with pharmaceutical companies
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