UCD may curb doctors' drug-company freebies

By Dorsey Griffith - Sacramento Bee Medical Writer
http://www.sacbee.com/101/story/32968.html
Tuesday, October 3, 2006

You've seen them in your doctor's office: pens and notepads labeled with the names of leading drugs or medical devices. What you don't see are the free lunches, expense-paid trips and lucrative consulting deals for physician lectures and conferences.

Concerned that the goodies and other tactics by drug or medical device companies can drive medical decisions, the UC Davis Health System is considering strict limits on meals and on payments for doctors to attend meetings or participate in online medical education classes.

If UC Davis ultimately adopts the policies, it will join an elite group of academic medical centers taking the same tack: Stanford and Yale universities and the University of Pennsylvania.

"We need to reaffirm the social contract under which we practice medicine," said Dr. Garen Wintemute, an emergency doctor and UC Davis professor who is leading the charge for reforms. "Our primary responsibility is to the welfare of our patients. Industry marketing practices interfere with our ability to fulfill that responsibility"

The medical center's Pharmacy and Therapeutics Committee, which oversees the purchase of drugs and devices for the health system, voted last week to send three recommendations to the medical center's executive committee for consideration:

• A ban on all gifts, free meals, payment for travel time or time spent at meetings, and payment from drug or medical device companies for participation in online medical education programs.

• An end to the system that allows pharmaceutical sales representatives to give doctors free drug samples for patients. The former arrangement would be replaced with a voucher system to benefit low-income patients.

• The exclusion of any medical professional with ties to drug or device manufacturers from hospital and medical group committees that oversee the purchase of drugs or medical devices.

Four other recommendations aimed at eliminating potential conflicts of interest are pending at the Pharmacy and Therapeutics Committee level. The suggested changes come from a proposal outlined for academic medical centers in a January article in the Journal of the American Medical Association.

One such proposal would prohibit manufacturers from funding medical education programs for health care providers. Instead, companies could contribute to a central repository overseen by the medical center for spending on education. Currently, about 90 percent of funding for physician education comes from industry.

That was obvious last week during a conference on psychotic disorders at the UC Davis MIND Institute. The conference was supported by "educational grants" from four companies that make anti-psychotic drugs. The drug makers had display tables just outside the meeting room, where they handed out pamphlets about their products, free pens and other goodies labeled with their brand names.

In a statement last week, the Pharmaceutical Research and Manufacturers of America (PhRMA) called efforts to restrict such marketing efforts "a serious mistake."

"The general concern we have is that some of these very restrictive policies are not necessary and may in fact cut down on interactions between drug company reps and physicians," said Scott Lassman, senior assistant general counsel for PhRMA.

"This is not good for patients, because the reps have very useful information about the medications."

Lassman added that PhRMA adopted its own code of ethics a few years ago that asked industry members to end lavish gift-giving.

Dr. Tim Albertson, chairman of Davis' Pharmacy and Therapeutics Committee, said the proposals are the most recent in a decadelong effort to re-evaluate drug company ties to the university and to narrow relationships between doctors and the drug and device industries.

Still, any proposed changes pose challenges to the health system. He said drawing a line between marketing and legitimate physician education can be difficult.

"What we are trying to do is bring light to the subject," he said. "We are not going to be police. But if we as an institution make a statement, that has power."

If successful, UC Davis would be the second health system in the Sacramento region to tighten its conflict of interest policies. Two years ago, Kaiser Permanente adopted several sweeping restrictions.

Those limits are working, said Dr. Sharon Levine, associate executive director of Kaiser Permanente Northern California.

"It is protecting professionalism and ensuring our members never have to worry about whose interests are being served when a drug is prescribed or a hip implant is chosen for a surgical procedure," said Levine.

UC Davis medical students have launched their own effort. Second-year student Nelson Conley circulated a petition calling for an end to industry freebies he said are used to curry favor among students when they are most vulnerable to influence.

Even as an undergraduate, Conley said he shadowed a neurologist in private practice and enjoyed free Subway sandwiches, deli platters and Chipotle burritos in exchange for half-hour sessions with drug company reps.

"We will remember who helped us when we didn't have money and we were hungry all the time," he said. "I think it's inappropriate."

Conley has been asked to draft proposals for consideration by the medical school's Committee on Educational Policy.

"I'm hoping it's the beginning of a tide shift," he said. "It's a very slow process."

Conley and other proponents of policy changes say many medical students and doctors don't believe they can be swayed by the marketing tactics in question.

"They have almost always a universal view that none of this has an influence on them because they are scientists and accustomed to evaluating data objectively," said Jerome Kassirer, former editor of the New England Journal of Medicine and author of the book "On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health."

"That's a lot of baloney," he said.

Several studies in recent years have found that the rate of drug prescriptions by doctors increases substantially after they see sales representatives, attend company-supported meetings or accept free samples, according to an article published earlier this year in the Journal of the American Medical Association.

Daniel Weintraub: Breaking free from employer-managed health care

By Daniel Weintraub -- Bee Columnist
From the Sacramento Bee
Published 2:15 am PST Tuesday, February 21, 2006

Imagine for a moment that your employer was required by law to buy a plan to manage your nutrition needs - rather than simply paying you a wage, out of which you buy the food you want to eat.

Or suppose the government required your employer to pay for a housing plan, rather than paying you and letting you decide where and how to live.

Finally, consider what it would be like if the company you work for was mandated to design and finance a transportation plan for you, with a list of options for how you could get to work and back home each day.

Each of these scenarios brings a few things to mind.

First, you'd probably get paid a lot less than you do today, because your employer would be diverting much of your current wages to pay for these plans instead.

Second, you would have less choice than you do now, because your employer would have to standardize these food, housing and transportation plans to fit the needs of many workers.

Third, the service you would get from your local grocery store, landlord or automobile dealer would probably be worse, since your relationship with each of them would now be muddled through the entry of a third party, your employer. Your local grocer would have a greater incentive to try to satisfy his real customer - your boss, or worse, the food management company your boss chose - than to serve your needs.

Fourth, the costs of each of these goods would tend to rise over time - especially if you and your fellow employees were able to eat as much as you liked, or live in any size house or drive as far as you wanted within the choices provided. While large employers might be able to use their superior bargaining power to drive down costs a bit, their power in the marketplace would be outweighed by the increased cost of providing food, housing and transportation in quantities unlimited by the discipline that comes when a consumer pays for something out-of-pocket.

Finally, as the costs did start to rise, you would feel less secure about where your next meal was coming from, or whether you'd have a place to live tomorrow or a car to drive to work. With the management of these essential items in the hands of a third party, you'd feel vulnerable, worried about whether they might cut back on your choices or on the quality of the offerings in order to save money.

Sound like a good deal? Well, that's exactly the kind of health care system we have today. While individuals once managed their health insurance themselves, paying for it out of their wages, employers began doing that for them during World War II as a backdoor way to increase compensation in an era of government-imposed wage and price controls. The custom stuck, the government rewarded it with tax breaks and today more than 60 percent of us have our health care managed through work.

Not coincidentally, health care is the one essential in our lives that is most often described as being "in crisis." While some people have access to better food than others, nobody in America goes without food today, thanks largely to food stamps, which give people a chance to obtain essential nutrition without involving employers or the government (too much) in managing their choices.

Some of us certainly live in better housing than others. But that's no business of our employers. To the extent that the government has decided that some people need help paying for their housing, we have provided vouchers for rent, with minimal regulation on how those stipends can be spent. The housing the government provides directly, in contrast, is mostly in lousy neighborhoods, crime-ridden and poorly maintained.

Finally, while some of us drive nicer cars than others, our employers are not responsible for this, and neither does the government inject itself into the equation. The state does provide public transit and subsidizes it from tax revenue in part to enable the poor to have access to transportation.

Now comes a national movement to require employers, especially large ones, to spend a certain amount of money on health insurance for their workers or pay a tax to the state to cover their care. In California, a state senator says she plans to introduce a version of this bill.

It's odd that just when the informal system of having employers managing their workers' health care is in danger of collapsing from the weight of the problems it created, some politicians want to lock that system, with all its flaws, into place with a new law.

Shouldn't we instead be looking for alternatives? Maybe, instead of trapping us into having our health care managed by others, we should emulate the ways we have more successfully provided food, shelter and transportation to almost everyone who needs it.

Individual choice. Individual responsibility. Voluntary transactions. And targeted help for the few who cannot afford to buy what they need on the wages they earn, with the burden of financing that assistance falling on all of society, not just on a few.