Life Science Compliance Update

March 22, 2016

ProPublica: Tying Open Payments Physician Data to Medicare Part D Data

ProPublica is once again trying to make a "correlation equals causation" argument between payments made to physicians and their prescribing patterns. ProPublica is arguing that an analysis they performed showed that "doctors who receive payments from the medical industry do indeed tend to prescribe drugs differently than their colleagues who don't."

They are arguing that doctors who received more than $5,000 from companies in 2014 had the highest brand-name prescribing percentages, giving an example that among internists who received no payments, the average brand-name prescribing rate was 20%, compared to about 30% for those who received more than $5,000.

What is interesting in the data is the absolutely high number ranging from 70-90% of generic medications both physicians who don't work with industry and those who do work with industry. In both groups a vast majority of their prescriptions were for generic medications which generally over 20+ years from initial development. A slight increase in the use of branded drugs should be considered a good thing for patients. As it is well known that it takes many years for physician adoption to newer therapies.

However, there is no proof that industry payments sway doctors to prescribe particular drugs, or even a particular company's drugs, just that payments are "associated with an approach to prescribing that, writ large, benefits drug companies' bottom line." There may be much more to the story if ProPublica found a link between payments made to physicians and the brand of drug they prescribed.

It is important to note, as laid out in more detail below, that physicians consider many factors when deciding which medications to prescribe. Some physicians treat patients for whom few, or no, generics are available; for example, doctors who treat patients with HIV/AIDS. Other physicians specialize in patients with complication conditions who have tried generic drugs with no success.

One physician that we discussed this with independently, thought it was appalling that there was no consideration of patient outcomes. If the physicians patients benefiting from the branded drugs then there should be credit given to those physicians working with industry.

According to Holly Campbell, spokeswoman for the Pharmaceutical Research and Manufacturers of America, "many factors" affect doctors' prescribing decisions and according to a 2011 survey of physicians, more than ninety percent of physicians felt that "a great deal of their prescribing was influenced by their clinical knowledge and experience."

Ms. Campbell believes that by working together, "biopharmaceutical companies and physicians can improve patient care, make better use of today's medicines, and foster the development of tomorrow's cures." Physicians provide insights and feedback to inform companies about their medicines to improve patient care and patient health.

By meeting with industry professionals, doctors get a chance to better understand the drugs that exist, the outcomes, and any side effects. Dr. Amer Syed of Jersey City, NJ, said that he does look at the quality of medication and the benefits patients get from taking the medicine before deciding what to prescribe, stating that his "whole vision of practice is to keep the patients out of the hospital."

Methodology

ProPublica examined Medicare Part D prescription data and pharmaceutical and medical device company payment data (found under Open Payments) to measure any relationship between industry payments and brand-name prescribing.

Interestingly, when ProPublica broke down the data by payment type, they found that physicians who received speaking payments had higher rates of brand-name prescribing than those who received other types of payments, and that physicians whose only payments were for meals had lower rates of brand prescribing than those who received other payments. This may speak to the idea that physicians who prescribe the same drug over and over again do so because they are comfortable with it, they know the results and the side effects, and since they know the drug so well, the company asks them to speak for them.

There is a huge "but" with the data cited to by ProPublica. The data does not consider whether branded drugs, for the indications prescribed, are superior to generic medications (or combinations of generic drugs), nor whether patient outcomes were different. Data that confirms safety and efficacy are much more likely to describe branded products than they are generics.

We are big proponents, however, of giving credit where credit is due. In this case, ProPublica did a nice job describing the circular relationship between companies and doctors. They published a quote by Dr. Kim Allan Williams, Sr., the president of the American College of Cardiology, who stated the more physicians learn and understand a new drug's "differentiating characteristics," the more likely they are to prescribe it, and the more they prescribe it, the more likely they are to be selected as speakers and consultants for the company. According to Dr. Williams, "that dovetails with improving your practice, and yes, you are getting paid to do it."

Dr. Williams also explained that new drugs are somewhat responsible for the significant decrease in cardiovascular mortality in the past three decades, and that the relationship between doctors and companies in cardiology may be driving that progress.

October 07, 2015

Study Looks At How Many Industry Boards of Directors Have Academic Affiliations

BoD

Conflict of interest rules for the medical community have been in the spotlight lately, though they typically center around rules that prohibit or restrict physicians from enjoying lunch on behalf of a pharmaceutical company or stocking their office with pens. A new study conducted by researchers from the University of Pittsburgh School of Medicine and published in the British Medical Journal recently decided to look at conflicts of interest from a different perspective: they looked at how many for-profit healthcare company positions were occupied by people with academic affiliations.

These researchers analyzed public disclosures of all publicly traded United States healthcare companies listed in the NASDAQ and NYSE in January 2014 that specialized in pharmaceuticals, biotechnology, medical equipment, and providing healthcare services. The researchers defined an academic medical or research affiliation as “a formal position at a US medical school, affiliated teaching hospital, or health system; overseeing research university; or medical research institute with a medical school partnership” and they further classified individuals with academic affiliations as either leaders, professors, or trustees, as each group holds a different set of responsibilities to their academic institutions that pose unique conflicts with their obligations as for profit company directors.

The study found that 41% of the companies surveyed had one or more academically affiliated board of directors members in 2013. Several of those board of directors members held positions on more than one company’s board of directors: the study found that 279 academically affiliated directors held a total of 309 healthcare directorships, which is less than 10 percent of all total healthcare directorships.

Over half of academically affiliated directorships were held by individuals with clinical training, predominately in internal medicine or related subspecialties, the most common of which were general internal medicine, cardiology, and oncology.

The compensation these academically affiliated board of directors members received for their board of director position varied widely, ranging from zero dollars to over one million dollars, with the median compensation being $193,000. In addition to their monetary compensation, many board of directors members received major stock in their company.

After looking at all of the data, study co-author Timothy Anderson, MD, does not believe that the existence of academically affiliated board of directors members is necessarily a problem in and of itself. Instead, he thinks that it simply poses legitimate questions for initiating a discussion about conflict of interest with academic institutions, healthcare companies, and their interrelationships.

When questioned about the link and possible problems, Dr. Anderson stated, "Our view is not to pass judgment. We wanted to paint that landscape of how diverse these sorts of relationships are. Some may be quite beneficial and some might be quite concerning, but until we really understand what relationships exist, it is hard for the medical and academic community to have a good discussion about what we should do to minimize the risks and maximize the benefits of these collaborations." He continued on, noting that a one-size-fits-all approach will not work to manage all of the relationships, but instead, a more open approach is warranted to avoid losing the public’s trust.

Anderson thinks that the way the Sunshine Act solely focuses on physicians and attempts to expose their minute financial interests might be misguided and results in oversight of academic professionals and their loyalties. The study focused on the fact that academics who sit on the board of a for-profit company have duties of loyalty both to the academic organization that employs them, as well as to the shareholders of the company whose board they sit on. The concern of the study and the researchers behind it are that those loyalties have the opportunity to conflict at times, placing the academic board member in a precarious position.   

The study acknowledged that “there is no doubt that collaboration between academic institutions and industry has led to profoundly important clinical trials, drug development, and translational research initiatives, although the role and necessity of academically affiliated directors in facilitating these projects is unclear and undocumented” and that academic institutions can benefit from having their staff members and faculty as representatives in corporate board rooms, forging fundraising or research partnerships.

The study further recognized that one of the difficulties in developing guidelines to monitor the competing interests is that the potential harms vary depending on the individual’s primary academic duties. Certain academics may be in a position, both academically and professionally as a board of director, to balance the potential conflicts of interest and will successfully benefit both organizations with their knowledge and expertise.

However, because the end result of the study advocates for “additional review, regulation, and, in some cases, prohibition when conflicts cannot be reconciled,” it is worth keeping an eye on potential movement in this area. It is likely only a matter of time before someone, or a group of people, speak up and ask for more strict regulation on academics who serve as a member of the board of directors for for-profit companies.   This would be unfortunate as both organizations can benefit from the other in expertise and developing much needed cures.

October 05, 2015

Conflict of Interest Rules in Medical School Might be Changing

Rules

Harvard Medical School has been known to have some of the most stringent conflict of interest rules in the nation. Several faculty members, however, have not been shy about questioning whether stricter rules could be damaging innovation, one professor noting, “If there were conflict-of-interest policies so that Thomas Edison couldn’t be involved in the company he formed to create the electric light, we’d still have gas lamps.”

In light of faculty discontent, changes in the medical field, and additional research on conflicts of interest and how they affect physicians, Harvard Medical School is starting to take some steps back from the strict conflict of interest rules they set out five years ago. The school has started to discuss with faculty some changes that can be made to protect the integrity of the medical field while also promoting new innovation and creativity. One of the policies they are reviewing is the “research support rule,” which bars faculty from receiving research grants or contributions from a company they hold equity in. Another strict rule under review, which is believed to be unique to Harvard, is the “clinical research rule,” which prohibits faculty from conducting clinical trials on products if the faculty has equity or earns at least $10,000 in income from the company who produces the product.

The viewpoint Harvard has held for the last several years gives credence to the thought that if you have a financial stake in a particular product, it is hard for you to accurately evaluate it. They believe that these rules protect patients against self-serving doctors who are solely focused on making as much money as they can with disregard for patient health and safety.

However, it has been found that while small gifts may influence the activity of physicians, it does not necessarily follow that greater financial stakes have a large impact on the activity and decisions physicians make. Dr. Lisa Rosenbaum has done some research on the topic and believes that conflict of interest rules have been so entrenched in the medical field that at this point, keeping them is a matter of indignation, not a matter based in reality. She believes that a shift toward a conversation that “better accounts for the diversity of interactions, the attendant trade-offs, and our dependence on industry in advancing patient care“ will be a more beneficial way of looking at things for all parties involved.

Dr. Rosenbaum also has concerns about the accuracy, reliability, and relevance of the data that has been considered to be the impetus behind the strict conflict of interest rules around the country. She does believe that while patient health should never be compromised by a physician’s desire for financial gain, “the extent to which physicians’ primary and secondary interests actually conflict, under what circumstances, and at what cost are unknown.” She also highlights the fact that neither the benefits, nor the harms, of these regulations attempting to expose or mitigate these conflicts are clear.

In her research, Dr. Rosenbaum poses several questions about the suggestive data that has been relied upon to create these conflict of interest rules. Some of these studies have been somewhat self-serving, in that they specifically go out to find instances of potentially negative industry influence and wind up successful. However, just because industry influence exists, that does not mean it is harmful to the patient. Just because a doctor attends a symposium funded by a drug manufacturer and ends up prescribing that drug to a patient does not mean the patient is harmed. Just because a doctor receives drug samples or a lunch from a drug representative and then goes on to prescribe that medicine does not mean the patients who receive that medicine are harmed by those interactions between the physician and the pharmaceutical industry.

In all, while there have been many studies done on the relationships between physicians and the pharmaceutical industry, there have not been many studies done on the effects of those connections to patient health. There are two sides to this coin, but if conflict of interest rules prevent physicians and others from creating the next “big thing” in medicine, that could very well be doing more harm to patients than a doctor who has contacts with a pharmaceutical company.

It will be interesting to keep up with the progress of this Harvard Medical School review and see if any changes are made to their policies, and consequently, to any other medical schools who may have similar rules. 

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