Exploring Human Potential

Note to AMA et al: Transparency and Sunshine Are In Your Own Best Interest

Posted on | July 29, 2016 | No Comments

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Mike Magee

The American Medical Association and its Federation, including the influential American College of Cardiology, took a stand this week – for “non-transparency”.  When it comes to the pharmaceutical and medical device industry paying the freight for doctors’ continuing education, they’d rather the patients and regulators be kept in the dark.

What they are objecting to specifically is a provision in the Sunshine Act of the Affordable Care Act, called OpenPayments, which requires companies to report all  direct and indirect payments, including those made through middlemen CME providers (83% of industry subsidies channel through these intermediaries), for free CME events, trips, textbooks and journals. The value of this hidden support in 2015 amounted to $693 million in subsidies.

In a letter to the Congressional committee considering a bill to exempt doctors from these embarrassing disclosures, the Medical Societies stated quite dramatically that they need relief “to remedy onerous and burdensome reporting obligations imposed by CMS that have already chilled the dissemination of medical textbooks and peer-reviewed medical reprints and journals…” They go on to say, “This legislation would ensure that efforts to promote transparency do not undermine efforts to provide the most up-to-date independent medical knowledge, which improves the quality of care patients receive.”

But, as the Wall Street Journal reported, some CME providers think that’s just preposterous. Daniel Carlat, a CME newsletter publisher and former head of the Pew Charitable Trusts Prescription Project said, “It’s a stretch to view free textbooks and free medical education as being anything other than a benefit to physicians. These are not direct benefits to patients. The only way these would benefit patients is if a drug company gave free books or courses to patients themselves.”

It is perhaps a testimony to the financial dependency and entanglement that exists between medical organizations and industry today that they are willing to make these arguments in the light of day. Just four months ago, ProPublica released a study of 2014 payment records from industry to physicians nationwide. What they found was a strong positive correlation between industry payments and numbers of brand name vs. generic prescriptions written. Internists who took no payments prescribed a specific brand drug 20% of the time, while those receiving more that $5000 in cash or subsidies that year went with branded industry products 30% of the time.

The open source database also found that 90% of cardiologists who had written more than 1000 Medicare scripts in 2014 had received industry payments. For internists and family physicians it was 70%. Payment in the database included “promotional speaking, consulting, business travel, meals, royalties, and gifts, among others.” They didn’t touch research dollars, which is a far bigger issue.

Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School, interviewed in the ProPublica release, said  “It again confirms the prevailing wisdom . . . that there is a relationship between payments and brand-name prescribing. This feeds into the ongoing conversation about the propriety of these sorts of relationships. Hopefully, we’re getting past the point where people will say, ‘Oh, there’s no evidence that these relationships change physicians’ prescribing practices.’ ”

Yet Medical Organizations, and the physician leaders they represent, seem slow to get the message. Making the argument that transparency of such subsidies will slow scientific progress is indefensible. That the AMA and its Federation would expend valuable political capital in such a campaign raises serious questions about institutional independence. As the country continues to struggle with the aftermath of the opioid epidemic, an epidemic fueled by reckless prescribing, which in turn was ignited by fraudulent, medical society endorsed CME and peer review publications, one would expect that the AMA and others would have learned a lesson. And that lesson is – transparency and sunshine are in your own best interest.


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