Hostname: page-component-586b7cd67f-r5fsc Total loading time: 0 Render date: 2024-11-30T19:09:59.607Z Has data issue: false hasContentIssue false
  • English
  • Français

Trust and Transparency: Patient Perceptions of Physicians' Financial Relationships with Pharmaceutical Companies

Published online by Cambridge University Press:  01 January 2021

Joshua E. Perry ,
Dena Cox  and
Anthony D. Cox
Get access Rights & Permissions [Opens in a new window]

Extract

Financial relationships and business transactions between physicians and the health care industry are common. These relationships take a variety of forms, including payments to physicians in exchange for consulting services, reimbursement of physician travel expenses when attending medical device and pharmaceutical educational conferences, physician ownership in life science company stocks, and the provision of free drug samples. Such practices are not intrinsic to medical practice, but as the Institute of Medicine described in its 2009 report, these relationships have the potential to produce positive collaborations that improve patient care and public health, and most physicians view it as “ethically proper to accept items ranging from drug samples to a lucrative consultantship.”

However, financial relationships between physicians and pharmaceutical, medical device and biotechnology companies can also create negative influences on physician judgment that compromise patient care and jeopardize the public’s trust.

Type
Symposium
Information
Journal of Law, Medicine & Ethics , Volume 42 , Issue 4 , Winter 2014 , pp. 475 - 491
Copyright
Copyright © American Society of Law, Medicine and Ethics 2014

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Lo, B. Field, M. J., eds., Conflict of Interest in Medical Research, Education, and Practice (Washington, D.C.: The National Academies Press, 2009) (hereinafter COI);Campbell, E. G.et al, “A National Survey of Physician-Industry Relationships,” New England Journal of Medicine 356, no. 17(2007): 1742–1750, at 1746 (“Overall, 94% of respondents reported some kind of relationship with industry during the previous year.”).Google Scholar
Morgan, M. A.et al, “Interactions of Doctors with the Pharmaceutical Industry,” Journal of Medical Ethics 32, no. 10(2006): 559–563, at 559.CrossRefGoogle Scholar
See COI, supra note 1, at 166.Google Scholar
See Morgan, , supra note 2, at 561. However, while physicians are adamant in their denial that financial relationships inappropriately influence their personal medical decision making, studies consistently show that physicians believe these relationships may cause other physicians to be biased in their prescribing behaviors. Id., at 562.See Zipkin, D. A. Steinman, M. A., “Interactions between Pharmaceutical Representatives and Doctors in Training: A Thematic Review,” Journal General Internal Medicine 20, no. 8(2005): 777–786.Carthy, P.et al, “A Study of Factors Associated with Cost and Variation in Prescribing among GPs,” Family Practice 17, no. 1(2000): 36–41.McKinney, W. P., “Attitudes of Internal Medicine Faculty and Residents toward Professional Interaction with Pharmaceutical Sales Representatives,” JAMA 264, no. 3(1990): 1693–1697.Google Scholar
Id.Google Scholar
Patient Protection and Affordable Care Act, Pub. L. No. 111–148, § 6002, 124 Stat. 119 (codified as amended 42 U.S.C. § 1320a-7h) (2010).Google Scholar
Sclar, D. Keilty, G., “Sunshine and Strategy: Managing and Monitoring Compliance With PPACA's Sunshine Provisions – Evolving Legal Requirements and Operational Considerations,” The Health Lawyer 24, no. 5(2012): 14–24, at 15. Sclar and Keilty note that the PPSA had been previously introduced by Senators Charles Grassley (R-Iowa) and Herb Kohl (D-Wisc.) in the 110th and 11th Congresses. Id., at 16–17 (citing Physician Payments Sunshine Act of 2007 (S. 2029, 110th Cong.) and the Physician Payments Sunshine Act of 2009 (S. 301, 111th Cong.)).Google Scholar
Federal Register 66 (February 8, 2013): 78,9457, 78,9477–78,9481: 42 CFR 402 (as specified by Pub. L. No. 111–148 § 6002, (2010) (codified at 42 U.S.C.A § 1128G(a)(1)(A)(vi) (West Supp. 2011)).Google Scholar
Federal Register 66 (February 8, 2013): 78,9457, 78,9458–78,9459 42: CFR 402 “Increased transparency regarding the extent and nature of relationships between physicians, teaching hospitals, and industry manufacturers will permit patients to make better informed decisions when choosing health care professionals and making treatment decisions, and deter inappropriate financial relationships which can sometimes lead to increased health care costs.”).Google Scholar
See COI, supra note 1, at 94.Google Scholar
Id.Google Scholar
Sismondo, S., “Key Opinion Leaders and the Corruption of Medical Knowledge: What the Sunshine Act Will and Won't Cast Light On,” Journal of Law, Medicine & Ethics 41, no. 3(2013): 635–643, at 635.CrossRefGoogle Scholar
Gorlach, I. Pham-Kanter, G., “Brightening Up: The Effect of the Physician Payment Sunshine Act on Existing Regulation of Pharmaceutical Marketing,” Journal of Law, Medicine & Ethics 41, no. 1(2013): 315–322, at 320.CrossRefGoogle Scholar
Loftus, P., “Doctors Face New Scrutiny over Gifts,” Wall Street Journal, August 23, 2013. In fact, the Open Payments scheme provides for physicians and teaching hospitals to register to access their data prior to public posting, initiate data disputes, and work with applicable manufacturers and group purchasing organizations to resolve any disputes. See <http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-Payment-Transparency-Program/How-OPEN-PAYMENTS-Works.html>(last visited November 5, 2014).(last+visited+November+5,+2014).>Google Scholar
See COI, supra note 1, at 46.Google Scholar
See Pellegrino, E. D. Relman, A. S., “Professional Medical Associations: Ethical and Practical Guidelines,” JAMA 282, no. 10(1999): 984–986, at 986 (“Temptations to use medical power for personal, commercial, or organizational advantage have always existed…Given the pervasive spread of commercialism throughout the health care system, the obligation to use medical power with ethical constraint is more urgent than ever.”).CrossRefGoogle Scholar
Kesselheim, A. S. Orentlicher, D., “Insights from a National Conference: ‘Conflicts of Interest in the Practice of Medicine,’” Journal of Law, Medicine & Ethics 40, no. 3(2012): 436–440, at 436.CrossRefGoogle Scholar
Rodwin, M. A., “Conflicts of Interest, Institutional Corruption, and Pharma: An Agenda for Reform,” Journal of Law, Medicine & Ethics 40, no. 3(2012): 511–522, at 511.CrossRefGoogle Scholar
Dana, J., “How Psychological Research Can Inform Policies for Dealing with Conflicts of Interest in Medicine,” in COI, supra note 1, at 358, 364. The credibility of physician denials that they are personally influenced, however, is compromised by those studies revealing that physicians do believe other physicians are susceptible to being influenced.See generally, Zipkin, Steinman, , supra note 4, at 781.Steinman, M. A. Shlipak, M. G. McPhee, S. J., “Of Principles and Pens: Attitudes and Practices of Medicine Housestaff toward Pharmaceutical Industry Promotions,” American Journal of Medicine 110, no. 7(2001): 551–557, at 554.CrossRefGoogle Scholar
Campbell, E. G., “Doctors and Drug Companies: Scrutinizing Influential Relationships,” New England Journal of Medicine 357, no. 18(2007): 1796–1797 (“Although most physicians deny that receiving free lunches, subsidized trips, or other gifts from pharmaceutical companies has any effect on their practices, research has shown that physician-industry relationships do influence prescribing behavior.”).See generally Brennan, T. A., “Health Industry Practices That Create Conflicts of Interest: A Policy Proposal for Academic Medical Centers,” JAMA 295, no. 4(2006): 429–433, at 431.Adair, R. Holmgren, L., “Do Drug Samples Influence Resident Prescribing Behavior? A Randomized Trial,” American Journal of Medicine 118, no. 8(2005): 881–884, at 883.Mizik, N. Jacobson, R., “Are Physicians ‘Easy Marks’? Quantifying the Effects of Detailing and Sampling on New Prescriptions,” Management Science 50, no. 12(2004): 1704–1715.Keim, S. M. Mays, M. Z. Grant, D., “Interactions between Emergency Medicine Programs and the Pharmaceutical Industry,” Academic Emergency Medicine 11, no. 1(2004): 19–26, at 23.Finucane, T. E. Boult, C. E., “Association of Funding and Findings of Pharmaceutical Research at a Meeting of a Medical Professional Society,” American Journal of Medicine 117, no. 11(2004): 842–845, at 843.Blumenthal, D., “Doctors and Drug Companies,” New England Journal of Medicine 351, no. 18(2004): 1885–1890.Brett, A. S. Burr, W. Moloo, J., “Are Gifts From Pharmaceutical Companies Ethically Problematic? A Survey of Physicians,” Archives of Internal Medicine 163, no. 18(2003): 2213–2218, at 2217.Wazana, A., “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?” JAMA 283, no. 3(2000): 373–380, at 378.Caudill, T. S., “Physicians, Pharmaceutical Sales Representatives, and the Cost of Prescribing,” Archives of Family Medicine 5, no. 4(1996): 201–206, at 205.Chren, M. M. Landefeld, C. S., “Physicians' Behavior and Their Interactions with Drug Companies: A Controlled Study of Physicians Who Requested Additions to a Hospital Drug Formulary,” JAMA 271, no. 9(1994): 684–689.Orlowski, J. P. Wateska, L., “The Effects of Pharmaceutical Firm Enticements on Physician Prescribing Patterns: There's No Such Thing as a Free Lunch,” Chest 102, no. 1(1992): 270–273, at 273.Lurie, N., “Pharmaceutical Representatives in Academic Medical Centers: Interaction with Faculty and Housestaff,” Journal of General Internal Medicine 5, no. 3(1990): 240–243, at 242.Avorn, J. Chen, M. Hartley, R., “Scientific Versus Commercial Sources of Influence on the Prescribing Behavior of Physicians,” American Journal of Medicine 73, no. 1(1982): 4–8, at 7.CrossRefGoogle Scholar
See COI, supra note 1, at 167.Google Scholar
Id., at 169 (“Physicians' ownership interests in facilities to which they refer patients constitute a conflict of interest. Their secondary interest (i.e., increased income from increased services) has the potential to bias physicians' primary interest in their patients' welfare.”).See also Perry, J. E., “Physician-Owned Specialty Hospitals and the Patient Protection and Affordable Care Act: Health Care Reform at the Intersection of Law and Ethics,” American Business Law Journal 49, no. 2(2012): 369–417.CrossRefGoogle Scholar
Medicare Payment Advisory Commission, Report to Congress: Medicare Payment Policy 21 (March 17, 2009) “The Commission recommends that the Congress require manufacturers to report their financial relationships with physicians and other health care entities and that the Secretary post this information on a public, searchable website.”).Google Scholar
See generally supra note 1 and Alpert, J. S., “Doctors and the Drug Industry: How Can We Handle Potential Conflicts of Interest?” American Journal of Medicine 118, no. 2(2005): 99–100, at 99 (“Thus, I would propose a national Internet-based registry of transactions between doctors and pharmaceutical companies with the market values of these transactions…. The public registry would allow everyone to evaluate the level of financial gain and potential conflict of interest that a particular doctor, partner, or medical lecturer has with respect to a specific product or company.”).CrossRefGoogle Scholar
See 153 Cong. Rec. 11,217–18 (2007) (Senator Grassley speaking on the Senate floor describing the need for greater transparency regarding industry payments and the importance of this issue for all Americans who take prescription drugs or use medical devices); 154 Cong. Rec. 2,320 (2008) (Senator Grassley discussing the influence of industry payments over physician decision making); 155 Cong. Rec. 787–88 (2009) (Senators Grassley and Kohl discussing their hope that the Sunshine Act serve as a catalyst for patients to discuss with their physician any concerns about improper financial relationships and noting their attempt to balance “legitimate” industry payments to physicians for research, as well as industry's right to spend an unlimited amount of money on marketing their products).Google Scholar
Stamatoglou, A., “The Physician Payment Sunshine Act: An Important First Step in Mitigating Financial Conflicts of Interest in Medical and Clinical Practice,” John Marshall Law Review 45, no. 3(2012): 963–1008, at 977.Google Scholar
Green, M. J.et al, “Do Gifts from the Pharmaceutical Industry Affect Trust in Physicians?” Family Medicine 44, no. 5(2012): 325–31, at 325.Google Scholar
Id., at 326. We do have the benefit of a few previously published findings. For example, most patients interviewed in a cancer-research trial neither worried about nor seemed to care greatly about financial ties between researchers or institutions and life science companies.Hampson, L. A.et al, “Patients' Views on Financial Conflicts of Interest in Cancer Research Trials,” New England Journal of Medicine 355, no. 22(2006): 2330–2337, at 2335.See generally Pearson, S. D., “A Trial of Disclosing Physicians' Financial Incentives to Patients,” Archives of Internal Medicine 166, no. 6(2006): 623–680 (“Patients who received a disclosure felt more competent to judge the impact of their physician's compensation on their health care, and…. patients who remembered receiving a disclosure reported that it had increased their trust in their primary care physician”).Gibbons, R. V. et al., “A Comparison of Physicians' and Patients' Attitudes toward Pharmaceutical Industry Gifts,” Journal of General Internal Medicine 13, no. 3(1998): 151–154 (finding that patients generally consider pharmaceutical gifts more influential and less appropriate than do their physicians).Mainous, A. G. Hueston, W. J. Rich, E. C., “Patient Perceptions of Physician Acceptance of Gifts from the Pharmaceutical Industry,” Archives of Family Medicine 4, no. 4(1995): 335–339 (finding that patients are more likely to see personal gifts to physicians as having negative effects on both the cost and quality of health care than gifts – such as drug samples – that might have patient benefit).Google Scholar
Hall, M. A. Schneider, C. E., “Patients as Consumers: Courts, Contracts, and the New Medical Marketplace,” Michigan Law Review 106, no. 4(2008): 643.Hall, M. A., “Trust in Physicians and Medical Institutions: What Is It, Can It Be Measured, and Does It Matter?” Millbank Quarterly 79, no. 4(2001): 613–639.Pearson, S. D. Raeke, L. H., “Patients' Trust in Physicians: Many Theories, Few Measures, and Little Data,” Journal of General Internal Medicine 15, no. 7(2000): 509–513.Mechanic, D., “The Functions and Limitations of Trust in the Provision of Medical Care,” Journal of Health Politics, Policy, and Law 23, no. 4(1998): 661–687.Google Scholar
Grande, D. Shea, J. A. Armstrong, K., “Pharmaceutical Industry Gifts to Physicians: Patient Beliefs and Trust in Physicians and the Health Care System,” Journal of General Internal Medicine 27, no. 3(2011): 274–279, at 274.CrossRefGoogle Scholar
Centers for Medicare and Medicaid Services, “Open Payments User Guide for Industry” (July 2013), at 1.1b.Google Scholar
But see Loewenstein, G. Sah, S. Cain, D. M., “The Unintended Consequences of Conflict of Interest Disclosure,” Journal of the American Medical Association 307, no. 7(2012): 669–670 (“[D]isclosure can have adverse effects, exacerbating bias and hurting those it is ostensibly intended to help.”).Pearson, S. D.et al, “A Trial of Disclosing Physicians' Financial Incentives to Patients Archives of Internal Medicine 166, no.6 (2006):623–628 (“Disclosure's limitations must be acknowledged: It will most likely always be imperfect and inadequate to endow all patients with an understanding of compensation and the risks for conflict of interest.”).CrossRefGoogle Scholar
Herzlinger, R. E., Market-Driven Health Care (Reading, MA: Perseus Books, 1997): At 290–291.Porter, M. E. Teisberg, E. O., Redefining Health Care (Boston: Harvard Business School Press, 2006): At 83–84.Google Scholar
Cutrona, S. L.et al, “Characteristics of Recipients of Free Prescription Drug Samples: A Nationally Representative Analysis,” American Journal of Public Health 98, no. 2(2008): 284–289.CrossRefGoogle Scholar
These payment amounts were selected after review of the payments voluntarily disclosed by Pfizer on their website. See <http://www.pfizer.com/responsibility/working_with_hcp/payments_report>(last visited November 5, 2014).(last+visited+November+5,+2014).>Google Scholar
Ritchie, J. Spencer, L., “Qualitative Data Analysis for Applied Policy Research,” in Bryman, A. Burgess, R., eds., Analysing Qualitative Data (London: Routledge, 1994): At 172–194.Leydon, G.et al, “Cancer Patients' Information Needs and Information Seeking Behavior: In Depth Interview Study,” British Medical Journal, 320, no. 7239 (2000): 909–924.The use of open-ended questions to interpret experimental findings dates back at least to Merton and Kendall's classic article on the “focused interview.” Merton, R. K. Kendall, P., “The Focused Interview,” American Journal of Sociology, 51, no. 6 (1946): 541–557 (“The primary purpose of the focused interview was to provide some basis for interpreting statistically significant effects of mass communication [in experimental studies].”).Google Scholar
Keppel, G. Wickens, T. D., Design and Analysis: A Researcher's Handbook (Upper Saddle, NJ: Pearson, 2004).Google Scholar
Cohen, J., Statistical Power Analysis in the Behavioral Sciences (Hillsdale, NJ: Erlbaum, 1988).Google Scholar
See Ritchie, Spencer, , supra note 36Leydon, et al, supra note 36.Google Scholar
A cautionary tale in this regard: The 2013 problem-plagued launch of the Healthcare.gov website. Stolbert, S. G. Shear, M. D., “Inside the Race to Rescue a Health Care Site, and Obama,” New York Times, November 30, 2013.Google Scholar
Donohue, J. M.et al, “A Decade of Direct-to-Consumer Advertising of Prescription Drugs,” New England Journal of Medicine 357, no. 7(2007): 673–681, at 675.CrossRefGoogle Scholar
Pinckney, R. G.et al, “The Effect of Medication Samples on Self-Reported Prescribing Practices: A Statewide, Cross-Sectional Survey,” Journal of General Internal Medicine 26, no. 1(2010): 40–44 (“Research suggests that samples result in increased prescribing of brand name medications when more evidence-based, less costly generic or over-the-counter alternative exist.”);Cutrona et al., supra note 34, at 284:“Studies [of free samples] have described potential safety problems, health professionals who divert samples for self-administration or resale, the influence of pharmaceutical representatives who distribute samples, and the contribution of samples to rising drug and health insurance costs.”CrossRefGoogle Scholar
See Cutrona, et al, supra note 34, at 287.Google Scholar
Centers for Medicare and Medicaid Services, “Open Payments User Guide for Industry” (July 2013), at 1.1b.Google Scholar
See text accompanying note 8.Google Scholar
See generally Lamkin, M. Elliott, C., “Curing the Disobedient Patient: Medication Adherence Programs as Pharmaceutical Marketing Tools,” Journal of Law, Medicine & Ethics 42, no. 4(2014): 492–500 (“Medical professionals have built a vast reservoir of public trust by acting as fiduciaries with duties to protect patient health. Building that kind of trust is a long and arduous process. Squandering it is quick and easy.”).CrossRefGoogle Scholar
See supra note 32;Loewenstein, G. Cain, D. M. Sah, S., “The Limits of Transparency: Pitfalls and Potential of Disclosing Conflicts of Interest,” American Economic Review: Papers and Proceedings 101, no. 3(2011): 423–428, at 427 (“Care must be taken, however, to ensure that disclosure does not replace more effective measures, such as working harder to eliminate conflicts of interest in the first place.”).Google Scholar