By Paul D. Thacker, Aaron S. Kesselheim, MD, JD, MPH, and Eric G. Campbell, PhD, MA
The federal government recently unveiled a website called Open Payments that provides details about payments made by pharmaceutical and medical device companies to physicians. Initial news stories noted some interesting details. During the last 5 months of 2013, these companies paid physicians almost $3.5 billion in speaking and consulting fees, with some physicians earning more than half a million dollars in that period.
The Open Payments site was immediately criticized for multiple problems, including the difficulty people have in navigating the site and the fact that there might be misattribution of some payments. Government officials said they plan to improve the site, and later introduced a search tool, making it easier for consumers to find their physician. Meanwhile, drug and device manufacturers and physician groups continue to complain that patients might misinterpret the data on the site.
A Clear Need for Transparency
The need for transparency in medicine is clear. The legislation creating the Open Payments site was initiated after Sen Chuck Grassley (R, Iowa) and then-Sen Herb Kohl (D, Wisc) uncovered numerous examples of companies paying undisclosed sums of money to physicians at almost a dozen academic institutions, including Harvard University, Stanford University, Emory University, and the University of Wisconsin. These cases received wide media coverage and are believed to have encouraged numerous medical schools and academic medical centers to change their policies on their physicians’ outside financial relationships.
Patients are right to be curious about some of these payments to physicians, because studies show that certain financial relationships can affect physicians’ medical practices, leading to nonevidence-based prescribing or unnecessary spending on expensive drugs when less-expensive ones would work just as well. And in numerous surveys, patients have made their voices clear: they support the greater transparency of physicians’ financial relationships with outside companies that the Open Payments site provides.
Starting a Conversation
Open Payments has the potential to help strengthen physician-patient relationships by increasing patients’ trust in the recommendations their physicians provide. Thus, instead of focusing on the limitations of the website, the medical community should be helping patients understand how to interpret these payments. We can think of 4 ways patients might start that conversation.
1. Patients who see their physicians listed on Open Payments should ask them what the transactions were about. Not all financial relationships between physicians and industry are bad; in fact, funding for research can help spur medical innovation. Although the federal government funds billions of dollars every year for basic research, drug and device companies support the majority of clinical trials, often through contracts with physicians at research universities. Therefore, payments for research can be socially useful and a marker of physician expertise within a field. But without clarification from the physician receiving the funds, it may be difficult for a patient to know if a payment was for research or for other useful endeavors.
Marketing payments, such as when a manufacturer pays a physician to give promotional talks about a product, are more worrisome. These talks are presented as educational events, but tend to favor the product being discussed. Sometimes, the manufacturer even requires the speaker to follow a script provided by the company. Patients should be skeptical about physicians who are frequent promotional speakers who earn substantial additional income for promoting drugs or devices used in their care.
2. Patients should ask their physician whether they have any industry relationships that are not listed on the Open Payments website. Because Open Payments currently covers only disclosures from the last 5 months of 2013, payments could have been made in the months before. Also, a substantial number of payments have been withheld from the site because they relate to an experimental drug—or a new use for an existing product—or because the government is still clarifying the correct physician involved.
3. Patients should also ask their physician if someone oversees their outside financial relationships, particularly those related to the drugs or devices that they commonly use in patient care. For example, some physicians receive large sums of money from device makers as royalties if they helped invent a medical device, such as a hip implant or a cardiac stent. In these situations, representatives of the physician’s hospital or university should be working with the physician to oversee the clear conflicts of interest that such payments create.
The goal of these questions would be to help reassure patients that their physician’s outside financial relationships are insulated as much as possible from their clinical choices. Not all physicians support the idea that patients should be informed about these payments, and thus may be reluctant to provide details. However, patients deserve open and truthful answers to such questions.
4. As with all things in a market-based economy, the costs of pharmaceutical and medical device promotion, which includes lunches that physicians (and their staffs) may receive in their offices or sponsored dinners that they attend, are ultimately passed on to the patients and payers in drug or device prices. Patients who are uncomfortable indirectly paying for these lunches and dinners should to let their physician know how they feel.
Despite some flaws with the Open Payments rollout, the United States is the first country to make information about these payments systematically available to the public. We are, therefore, in uncharted territory, and it is difficult to predict how this information will change medicine. The Open Payments data hold the promise of counteracting the negative effects that certain types of conflicts of interest can have on health care delivery.
But transparency itself will not be enough. To help the Open Payments site contribute to making medical decision making more unbiased, patients should begin to ask physicians about their outside financial relationships, and the medical community should not shy away from this open dialogue.
About the authors:
Paul D. Thacker is a journalist and consultant to nonprofits. He has written for the Christian Science Monitor, Salon, The New Republic, Science, JAMA, and was an editor for the news section of Environmental Science & Technology. For almost 4 years, he was an investigator for Sen Charles Grassley of Iowa on the Senate finance committee. While on the Committee, he led several high-profile investigations into corruption and conflicts of interest among academics at American universities, leading to reforms at the National Institutes of Health and passage of the Physician Payment Sunshine Act.
Aaron S. Kesselheim, MD, JD, MPH, is an associate professor of medicine at Harvard Medical School and a faculty member in the Division of Pharmacoepidemiology and Pharmacoeconomics in the Department of Medicine at Brigham and Women’s Hospital in Boston. He leads the Program On Regulation, Therapeutics, And Law (PORTAL), an interdisciplinary research core focusing on intersections among prescription drugs and medical devices, patient health outcomes, and regulatory practices and the law. In 2013, he was named a Greenwall Faculty Scholar in bioethics by the Greenwall Foundation, which supports innovative empirical research in bioethics.
Eric Campbell, MA, PhD, is a professor of medicine at Harvard Medical School and director of research at the Mongan Institute. Over the past decade, his research has focused broadly on professionalism in medicine and has empirically examined issues related to conflicts of interest, self-regulation, care for the poor, and participation in civic activities. Campbell received a master’s degree in education, with a specialization in adult education, and a doctorate in higher education policy from the University of Minnesota.
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