Healthy Skepticism Library item: 8944

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: news

Alterio JM.
Prescription for conflict
The Journal News (White Plains, New York) 2007 Mar 17
http://www.thejournalnews.com/apps/pbcs.dll/article?AID=/20070317/BUSINESS01/703170330/1066

Full text:

When Gene Carbona sold drugs for Merck in the 1980s and ’90s, he spent a “couple hundred thousand” dollars a year on breakfasts, lunches, happy hours, dinners and perks like football tickets to make the doctors on his route happy.

All of it was to build “relationships” with the physicians so that when it was time to break out the prescribing pen, Carbona – and Merck drugs like the heartburn remedy Prilosec – would be remembered.

“In the pharmaceutical sales world, it is all about exposure, that face-to-face time with physicians. You’d have to ante up and give lunch to a staff of 50 or 100 and hope the doctor would take 20 minutes to have lunch and sit down next to you and say, ‘What’s up, Gene?’ “

Today, Carbona is the executive director of New Rochelle-based The Medical Letter, one of the most respected sources of drug information in the health industry. Its 250,000 subscribers are doctors who rely on its independent pharmaceutical reports.

He’s also one of the country’s leading voices in an emerging debate over the traditionally cozy relationship between doctors and drugmakers.

A small but vocal cadre of doctors – including those at top academic medical centers such as Stanford and Yale, as well as patient advocates such as the AARP and Consumers Union – say these ties hurt the health-care system because they expose patients to the newest, riskiest and costliest drugs.

“Pharmaceutical representatives push the high-cost drugs when we believe there are older name-brand drugs or generics that are just as effective,” said William Ferris, a lobbyist for the AARP in New York state.

The average price of a prescription rose 8.3 percent a year between 1994 and 2005 – from $28.67 in 1994 to $64.86 in 2005. That’s more than triple the 2.5 percent rate of inflation, according to the Kaiser Family Foundation.

Doctors are ordering more drugs, too. In 1994, doctors wrote 2.1 billion prescriptions. In 2005, they wrote 3.6 billion. That’s a 71 percent hike – during a time when the population rose 9 percent.

Carbona said the figures show that the 100,000 pharmaceutical representatives employed in the United States are doing their jobs well.

“Each one of those 100,000 reps usually calls on eight to 10 doctors a day. That’s 1 million discussions a day,” Carbona said.

Effect on patients

Although consumers may think they are more affected by ads for drugs like Viagra, Ambien and Nexium on TV and in magazines, the pharmaceutical industry actually spends 90 percent of its $21 billion marketing budget on doctors, according to the Journal of the American Medical Association, or JAMA.

Putting that sum in perspective, the U.S. Food and Drug Administration requested a budget of $2.1 billion for 2008.

“Patients don’t know, and they definitely should care,” Carbona said. “The physician has a fiduciary responsibility to the patient. If patients knew that their doctor put them on a very expensive arthritis medication that’s going to break the bank because they have a relationship with a drug representative that takes them to dinner or the theater – and there is another drug that costs $15 a month – I don’t think they’d still have that doctor as their provider.”

The JAMA article warned that trust between doctor and patient can be eroded by perceived conflicts of interest.

Putnam County resident Randy Mandel, 49, said she is constantly telling her doctors she doesn’t want more prescriptions. “I told one of my doctors that I was having trouble peeing and she starts writing a prescription out. I said I started menopause and she’s writing more. I said, ‘What’s all this about?’ “

During a visit to her internist recently, Mandel spotted an overflowing box of notepads with a sign that said, “Free.” When she asked about it, a nurse said they were leftover freebies from drug salespeople. “Why are these pharmaceutical companies so wasteful?” Mandel said.

“Because it works,” said New York City internist Bob Goodman, who started a nonprofit called No Free Lunch to get his peers to refuse free meals and gifts.

“Doctors who don’t think they are influenced are deluding themselves,” Goodman said.

Almost all doctors dispute the notion that food, notepads and pens have an influence on patient care.

“I’m going to pick the drug I believe is right,” said Dr. Catherine A. Mcgovern, a White Plains obstetrician and gynecologist.

Mcgovern said the meals are simply a convenient way to find time to talk. “The only way I’ll talk to a drug rep is if they come in and feed my whole office because I don’t have time in the day. I have to see patients every minute or I don’t make my overhead,” she said.

Dr. William H. Frishman, a professor at New York Medical College in Valhalla and director of medicine at Westchester Medical Center, put it this way: “It’s naive to think a doctor is going to be bribed by a pen or a pizza or a dinner.”

Ironically, it’s trivial gifts that are most effective because they seem so innocuous, said Dr. Jerome Kassirer, a Tufts University professor and author of the 2004 book “On the Take: How Medicine’s Complicity with Big Business can Endanger Your Health.”

“Doctors, like anyone else, are influenced by money,” he said. “They believe they can’t be influenced by gifts, but the evidence is overwhelming that they can.”

Calls for action

Kassirer would like more regulation by the American Medical Association.

“The AMA guidelines are insufficient. They allow doctors to take small gifts worth less than $100. They allow doctors to have meals as long as they aren’t extravagant. But drug companies violate that all the time,” he said.

On the industry side, the Pharmaceutical Research and Manufacturers of America adopted a new code in 2002 that stipulates meals are to be “modest as judged by local standards” and gifts should be related to patient care or education. In other words, an anatomical model of the brain with a drug logo is OK, a golf bag, not.

In the absence of more stringent self-policing by the medical profession, activists are calling for legislation.

Last year, the New York Assembly passed a bill that would require any company selling drugs in the state to report gifts over $75 to the Department of Health. It died in the state Senate.

In an AARP survey, more than 85 percent of New York members said that they would support a law requiring drugmakers to reveal marketing expenses.

Four other states – Vermont, West Virginia, Maine and Michigan – have passed gift disclosure laws, according to Yonkers-based Consumer Reports.

Other activists, including the National Physicians Alliance, want to hit drug salespeople where it would really hurt: By barring the commercial sale of prescribing data. New Hampshire has already passed such a law.

It’s common practice today for pharmacies, such as CVS, Rite Aid and others, to sell the prescription records of individual doctors to database companies such as IMS Health.

These companies merge the prescription data with details about doctors, which is sold by the AMA. The combined data is sold to drug companies.

The Medical Letter’s Carbona said he knew from week to week exactly which drugs his doctors prescribed. “That physician level prescribing data was the best tool to gauge my efforts, to target my efforts and to see what my competition was doing,” he said.

The next generation

The American Medical Student Association, with 68,000 members, has started a “Pharm Free” campaign to persuade young doctors to avoid ties with drugmakers.

Earlier this month, the association released a scorecard grading 159 medical schools on their drug company policies. Schools such as Yale University and the University of Michigan received A’s for having a comprehensive policy that restricts access while many others garnered lower grades or F’s for failing to even discuss the topic.

“We are using the scorecard as leverage to get schools to adopt policies. We want these policies to be a new metric to take into consideration when choosing medical schools,” said Justin Sanders, a fourth-year med student at the University of Vermont College of Medicine. “We’re trying to light a fire, basically. Medical schools, like medical students, aren’t using to failing.”

New York Medical College wasn’t graded because it didn’t respond to a questionnaire, but would likely receive an “F” based on the fact that it encourages interaction with medical salespeople.

Frishman said he believes that it is important for students to get exposure under the guidance of experienced doctors who can set boundaries.

“When they go into practice, they are going to be bombarded. They have to be aware this is a practice that goes on,” Frishman said. “This is the way of the world, and the students and residents have to see this is going on. Then once they are in practice, they will be able to make their own judgments.”

Farid Razavi, a second-year medical student at the Valhalla college, said he likes the idea of enacting a policy at his school. “If the onus falls on the individual physicians, it’s easy to get swept up in the advertising and gifts,” he said. “We’re all overworked. Who’s going to turn down a free lunch?”

Razavi, who is 26, said he believes that younger doctors will be less willing to accept the status quo. “I am, like many in my generation, more skeptical. We’re coming into a time when medicine is going through a lot of changes. It’s natural for us to question things. We have 46 million people who are uninsured. There’s something wrong with the system,” he said.

Defending drugmakers

It pains veteran doctors like Frishman to hear talk that tars pharmaceutical companies, particularly the phrase “Big Pharma,” which brings to mind “Big Tobacco.”

“They’re not tobacco companies. They are doing good things on balance in the whole scheme of things,” Frishman said.

People are vilifying an industry that has saved his patients’ lives, Frishman said, noting that as a cardiologist, he’s seen a explosion in care options over his career.

“We had nothing for cholesterol. We had primitive drugs for high blood pressure. We had no clot-busting drugs. There was a revolution in cardiology over the past 35 years. That would never have happened without industry input,” Frishman said.

Frishman and other doctors also say that salespeople provide valuable information about new drugs.

Dr. Michael Giannone, a podiatrist in Mount Kisco, said he learned about a drug called Metanx six months ago from a salesperson. A medical vitamin, Metanx eases the numbness and tingles of neuropathy.

“I must have 30 to 40 patients on it, and 75 percent have noticed an improvement. Patients who have been on it for two to three months want another prescription,” he said.

He started taking it himself for pins and needles in his right hand because he has a compression of his cervical spine.

But Carbona questions whether he taught doctors anything of value during his time as a salesman.

“I liked to think I was providing good information, but I was regurgitating what I was told to provide,” Carbona said. “In retrospect, here is a guy with a business degree entering into clinical discussions with a top cardiologist about how pressure in the renal tubules is affecting cardiac load. It is amazing to me that I had these discussions, and I have no medical background whatsoever. I was able to change their prescribing habits.”

Giannone said you can’t blame the salespeople: “The onus is not on the drug rep. He’s a salesman. It’s on the doctor. He’d better read the package himself. He has to read the literature himself.”

Reach Julie Moran Alterio at jalterio@lohud.com or 914-694-5228.