Healthy Skepticism Library item: 20174

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: Magazine

Wiseman H
Riding a gift-horse: the risks
Australian Doctor 1996 Nov 1521

Abstract:

Macquarie Pathology recently offered a number of GPs computers and software for them to access test results from the company. The offer has been variously described as a promotional strategy, an unethical inducement and illegal. Heather Wiseman asks what doctors should do if they are offered anything resembling an inducement.

Full text:

Simply saying no is the most sensible response to being offered an inducement.

But sometimes the distinction between an inducement and a valid promotional strategy is unclear.
Commonsense dictates the pens and paperweights emblazoned with drug names are more of a bore than a bribe.

But where do you draw the line? How do you rate an exclusive evening meal, a bottle of port at Christmas, a free flight to a conference, or a free computer and software with no strings attached?

Receiving gifts from pathology or pharmaceutical companies raises ethical and legal issues for GPs.

The Royal Australasian College of Physicians takes a hard line on receiving gifts from pharmaceutical companies, saying doctors should “err on the side of rejection of gifts”, not accepting even drug samples.

Its guidelines say providing free drug samples is rarely an altruistic exercise by the pharmaceutical company.

“What may appear to be a service is in most circumstances a marketing exercise designed to accustom the physician to prescribing a certain product or to establish a cohort of patients on long-term treatment with a particular drug”, the guidelines say.

The AMA’s Handbook of Resolutions says doctors may accept free educational materials which are appropriate to their area of practice.

“Practising doctors should not accept, nor allow their prescribing habits to be influenced by, personal gifts from the pharmaceutical industry or similar bodies”, the handbook says.

But what if the gift would improve the quality of patient care?

The recent case of Macquarie Pathology offering GPs free computers highlights how blurred the distinction between a gift as an inducement or a valid marketing strategy can be.

Company spokesman Dr Ron Tomlins says the computers allowed GPs faster and more efficient access to their pathology results from Macquarie, giving the company a leading edge on its competitors.

GPs were using the computers only for gaining Macquarie test results, he says.

Because the computers did not encourage GPs to order more tests, Dr Tomlins says the computer were not an inducement.

The Macquarie Pathology offer triggered a HIC investigation, which is still under way.

A GP who breaches the Health Insurance Act by accepting a gift judged to be an inducement faces fines of up to $10,000, or jail for up to five years.

Ralph Watzlaff, general manager of the HIC’s professional review division, says GPs should not think they can receive goods or services from pathology companies on the condition that their test-ordering patterns will not alter.

“It doesn’t matter whether someone changes their behaviour”, he says. “The nature of the offence is acceptance of the benefit”.

He says when GPs are weighing up whether to accept a gift or free service, they should see themselves in a “quasi public official” position.

GPs are trustees of the medical system, just as judges are trustees of the legal system, he says.

Judges should never allow justice to be influenced (or be perceived to be influenced) by financial gain.

Similarly, outside financial influences should never interfere with GPs’ medical practice, he says.

Mr Watzlaff says GPs have no legal obligation to report suspected inducements to the HIC.
“But as a matter of prudence and commonsense they should raise the matter with us”, he says.

“I believe these practices will proliferate unless people are prepared to report them.”

Dr Sandra Hacker, who chairs the AMA ethics committee, says AMA members should contact their state branch for free legal advice if they fear a gift could be considered an inducement.

“I think it is clear that as the marketplace becomes more commercialised, such issues are more likely to arise”, she says.

The RACGP has no guideline or policy document specifically addressing inducements.

However, the college council has asked RACGP secretary-general Dr Michael Bollen to draft a paper on inducements for discussion at its December meeting.

Dr Bollen advises GPs against contacting the HIC if they are unsure whether a gift is a mere promotional strategy or an inducement.

“The HIC isn’t a custodian of ethics and morals”, he says.

“I don’t believe they have any special knowledge of these grey areas. It is up to the profession itself to determine whether it [the offer] may be in the best interest of patient care”.

He advises concerned GPs to discuss any offers with colleagues whose opinions they respect, as well as anyone in the college, from the president down.

GPs who contact the HIC to report suspected inducements may not find the process rewarding, according to the Australian Association of Pathology Practices (AAPP).

AAPP chief executive officer David Kindon says HIC interviews and investigations would put a GP through a great deal of stress and trauma.

“People reporting the cases would have to be prepared to stand up in court and point the finger and a lot of people would think twice about putting themselves through the wringer”, Mr Kindon says.

He says GPs may not consider the effort worthwhile because few HIC investigations have resulted in pathology companies being found guilty.

Since 1992, the commission’s work has resulted in the Department of Public Prosecutions arriving at only two guilty verdicts.

Professor Alex Cohen, chairman of the college of physicians’ ethics committee, also advises doctors against turning to the HIC for help.

He says the possibility of retribution would make it “a risky business” for an individual to report a large pharmaceutical firm to the HIC.

Although the college has stringent and specific guidelines on the acceptance of gifts, the guidelines do not outline what action doctors should take if offered an inducement.

Professor Cohen says doctors should simply say no.

“A refusal on the part of every doctor to reject every inducement would solve the problem”, he says.

He says doctors should feel no moral responsibility to stamp out inducements by reporting suspected cases to the HIC.

“Doctors are increasingly being expected to act as watchdogs and policeman, which runs counter to their role”, he says.

“More and more we’re being sewn into a strait jacket of bureaucratic legislation from which we can’t escape. We’ve got enough problems of a heavy moral type.”

Test-ordering drops

The HIC’s work in targeting inducements has helped stem the growth of pathology ordering, according to Ralph Watzlaff, general manager of the commission’s professional review division.

Mr Watzlaff said pathology ordering was growing at a rate of 13% in April last year, compared with 4% in August this year.

“There has been a very substantial decline in the growth rate of pathology benefits”, he says. “I do believe our efforts have tended to pull that growth down.” He says of the 207 notices the HIC has issued to request evidence or documents from people, 188 have related to inducements.

“We have issued more notices in relation to pathology matters than the rest of Medicare combined (since mid-1994). The majority of the notices in pathology matters are related to inducement-type cases.”

Mr Watzlaff says the HIC is investigating 12 matters and the Director of Public Prosecutions considering another seven cases to determine whether charges should be laid.

Industry conduct code
The Australian Pharmaceutical Pharmaceutical Manufacturers Association’s code of conduct says brand-name reminders given to GPs should be only of token.

Any remuneration for services should be commensurate with the service provided.
In relation to health care professionals, the code says: “As responsible corporate citizens, members may choose to support, by financial or other means, professional activities. It is imperative that such support be able to successfully withstand public and professional scrutiny, and conform to professional standards of ethics and good taste. Entertainment or other hospitality offered to members of the health care professions should be appropriate and in proportion to the occasion; its costs should not exceed that level which the recipients might reasonably be expected to incur for themselves under similar circumstances.”

The guidelines of the Australian Association of Pathology Practices prohibit inappropriate financial payments to practitioners.

They also do not allow “the provision of stationery or computer software other than that solely concerned with the provision of pathology services” and the provision “of any materials other than those related exclusively to the collection of pathology specimens”.

The provision of “facilities for electronic data transmission (eg, computer terminals, printers, facsimile machines, etc)” is also prohibited.

Standard insights
The Royal Australasian College of Physicians’ booklet Ethical Guidelines in the Relationship Between Physicians and the Pharmaceutical Industry was not designed for GPs.

However, it offers interesting insights into the standards of other areas of the profession.

The booklet defines gifts in two ways: as discrete items and payment for dinners or other living expenses.

“Physicians must judge for themselves what is and is not acceptable, but should err on the side of rejection of gifts”, the guidelines says.

“Service-oriented items may on occasion be acceptable, eg, patient counselling or teaching aids, or monograms for surface-area calculations. Non-service-orientated items should in general not be accepted”.

It says there is an “obvious gradient of acceptability” which deems items of trivial value to be acceptable and more substantial items unacceptable.

“Particular care should be taken in the light of a trend to provision of lavish dinners, disproportionate to the content of the accompanying scientific presentation.”

Doctor’s choice of drug treatment should not be influenced by the presence of a sample.

“On the rare occasions that there is good reason for accepting a sample, only sufficient sample should be accepted to enable the particular problem at hand to be resolved.”