By Peter Lurie, MD, MPH, Deputy Director, Public Citizen’s Health Research Group
Dr. Lurie is a contributor to Public Citizen’s drug newsletter, available at www.worstpills.org. He will present testimony on state doctor gift disclosure laws before the Senate Special Committee on Aging on Wednesday, June 27, 2007. This article originally appeared in the May 2007 issue of Public Citizen’s Health Letter.
The life of a doctor must be tough. To judge by most of their offices, doctors are unable to afford pens, mugs, refrigerator magnets, or pads of paper. Even lunch is beyond their reach, it seems. And dinner at a fancy downtown restaurant? Fuhgeddaboutit.
Fortunately, there’s a group willing to step into the breach and supply these missing morsels and amenities. You guessed it: the pharmaceutical industry.
Despite the growing prevalence of direct-to-consumer advertising on television ($4.2 billion in 2005), the pharmaceutical industry continues to lavish the lion’s share of its advertising budget on physicians ($7.2 billion, excluding the ubiquitous free samples). After all, it is the physician who wields the power of the prescription pen.
Somehow, doctors operate under the delusion that the pharmaceutical industry is misguided enough to squander close to $20 billion on promotion annually even though, according to many doctors’ reasoning, all this largesse has no influence upon their prescribing habits. Much research suggests otherwise. When doctors were sent on expensive junkets to exotic locales, purportedly to receive objective education on a drug or disease, researchers noticed that prescribing of the sponsoring drug companies’ products went up in those doctors’ hospitals upon their return. Doctors accepting gifts from drug companies are more likely to request that their hospital add drugs to the hospital’s formulary, its list of preferred drugs.
Some people have had enough. Recently, a number of prominent medical schools, including Stanford, Yale, and the University of Pennsylvania, have sharply limited interactions between their physicians and pharmaceutical representatives. And now states are getting in on the action.
In 1993, Minnesota passed a law that required drug companies to report to the state all gifts to doctors exceeding $100. Five other states followed suit between 2001 and 2005, and in 2006, 11 more states considered such bills.
In March, Public Citizen published the first evaluation of these programs in the Journal of the American Medical Association, focusing on the only two states that have so far made doctor gift data publicly available: Minnesota and Vermont. Actually, “publicly available” would be a bit of a stretch. In Minnesota, we had to literally go to the state agency housing the records, dust off boxes containing the companies’ paper reports, and arrange for copies to be made. In Vermont, the legislation permitted drug companies to decide for themselves if the reports were trade secrets – and then unilaterally withhold the information from the public (they still have to provide the data to the state). And withhold them they did; in dollar terms, two-thirds of the records reported to the state were kept from public scrutiny. Public Citizen’s Litigation Group then sued the state of Vermont and obtained additional records through a settlement agreement.
Still, the records told a compelling tale. In Minnesota, there were 6238 payments of $100 or more to physicians for a total of $22 million over three years. In Vermont, despite data withholding by the larger companies, 2416 payments of $100 or more to physicians were publicly disclosed, totaling $1 million over two years. The purposes of the gifts ran the gamut from speakers’ honoraria and research studies to detailing and marketing.
Taking a leaf from the book of courting couples, who know that the path to loves passes through the stomach, pharmaceutical companies seem to pay as much attention to the alimentary tract as they do to cranium, where most patients would hope prescribing decisions are being made. The voluntary guidelines of both the pharmaceutical industry and the American Medical Association suggest a $100 limit on gifts and require that gifts be educational in nature. (This is no coincidence as drug company executives sat on the AMA’s task force on gift-giving.) Yet, in Minnesota there were at least 164 payments of over $100 to physicians for food, totaling $25,685. In Vermont, nearly 68% of such payments were for food, for a total of $381,455. Until such time as someone can show us that the educational content of these meals approached their fat content, we’ll believe that many of these meals violated the guidelines.
Our study demonstrates that in these two states the efforts of legislators to make doctor-gift data available to the public have been thwarted by loopholes, industry non-compliance, lack of standardization in reporting, and lackluster enforcement. These are valuable lessons for states currently considering similar legislation.