Public Trust Matters: Keeping the Big Pharmaceuticals In Line

In my previous post and following Google’s announcement to launch a personal medical record service, I raised the hope that the United States will eventually have a national health information storage system that will help deliver better care, lower costs, and reduce medical errors, in spite of some initial resistance. I believe such resistance can be overcome over-time since the American society has a good track record of embracing internet technology. Underlying that optimism is that public trust remains unshaken by the conduct of health care community – care providers, the pharmaceutical industry, and health insurance companies. Big, publicly-traded drug companies are powerful players in the health care community because of their financial resources as well as their control over the new drug supply. Unfortunately, they do have a questionable reputation through years of careless product launch, aggressive marketing tactics, and to a lesser extent – overcharging the public and the government. Although these companies are financial giants, they can be nudged into building better public confidence, as some of their perceived influence could be exaggerated.

The latest confidence-shaking incident involved Merck and Schering-Plough, who manufactured the drugs, Zetia and Vytorin, a combination of Zetia and Zocor, to treat high cholesterol. Worldwide, about five million people are now taking the drugs, according to a New York Times report. A two-year clinical trial that ended April 2006 raised questions about the medicine’s effectiveness and about the behavior of the pharmaceutical companies. The trial was meant to prove that Vytorin’s combination of Zetia and Zocor would reduce the growth of fatty plaque more than Zocor alone. Instead, the plaque actually grew almost twice as fast in patients taking the combination. Due to the drug’s significant contribution to their profitability, it aroused suspicions that the companies had deliberately delayed the release of data two years after the trial ended. The House Energy and Commerce Committee is investigating the delays.

Reflecting the general public suspicion about the drug companies' marketing activities, there are many articles written about their influential relationship with physicians. Part of the $671 million settlement, which Merck announced on February 8, 2008, was related to charges that it gave doctors freebies and gifts to induce them to prescribe its drug. As reported in the New England Journal of Medicine (November 2007), Eric Campbell, the co-author of the survey report, disclosed that over 90% of physicians take something from drug companies. The most common freebies are food and drug samples, which about 80 percent of physicians reported receiving, a smaller percentage (25-35 percent) of physicians reported receiving substantial payments in the form of reimbursement for professional travel, consulting, and servicing on speaker’s bureaus or advisory boards. According to Eric Campbell, "Although most physicians deny that receiving free lunches, subsidized trips, or other gifts from pharmaceutical companies has any effect on their practices....companies wouldn't spend $19 billion each year establishing and maintaining them [if this strategy didn't work]."

It is unrealistic to expect the big drug companies will not aggressively market their products, having invested a large sum of money on research and development. According to the Congressional General Accounting Office (GAO), the pharmaceutical industry spent about $30 billion on R&D, and about $20 billion on marketing and advertising. About half of the $20 billion is accounted for by the free medicine provided to doctors. The big drug companies maintain their relationship with the physicians through the large army of drug representatives, who are, by and large very intelligent and good at cultivating personal relationships. I believe such contacts or relationship is necessary and helpful, if it is limited to carry out informational programs. Today, a physician, especially a general practitioner under the network of a HMO, has limited time for a constant product update. I am not disputing that each physician should keep abreast of any new drugs launched, and our internet-delivery system can make such attempt an easy task. However, physician's continued learning can always be enhanced in a one-on-one “tutoring” session, when a drug representative visits. Due to complexity of new products, drug representatives could play an important role to disseminate results of this post marketing studies. It is also likely that through these calls, some of the beneficial drugs which are under-prescribed can be brought to the physicians’ attention. I believe such relationships can be beneficial to new drug developments. Many of the drugs currently on the market simply would not exist if it were not for such close relationships whereby physicians enroll patients in manufacturer’s clinical trials, and provide valuable advice on the drug development. Some think that such marketing call may result in a physician giving preferential treatment to the drug which the visiting drug representative promotes. In reality, and in our intense competitive environment, physicians do see other representatives from the other manufactures. Competition among manufactures itself will offset the effect exerted by the other drug representatives. Further physician’s prescriptions could be subject to the insurance company’s approval. An insurance company may request that the dispensing pharmacy to substitute a branded drug with a generic one whenever it is available. I do not see how giving physicians drug samples is an issue, since the samples are not for sale. Some physicians may use free drug samples to help low-income or uninsured patients, especially if the sample is of a new, expensive drug, which would treat patient’s condition. While the influence of the freebies on physician's behavior is real, it is limited.

The health care community is doing a good job in constantly bringing this freebie issue alive for discussion. This is part of the effort in keeping the powerful drug companies in line with certain standard of ethics. Within the professional body, in limiting the undue inference, the American Medical Association has recommended physicians not to accept gifts over $100. The industry has always been working toward upgrading a set of codes of conduct. Even Congress, which is thought to be heavily influenced by lobbyists from big drug companies, introduced legislation last fall to make drug companies disclose how much they have spent on gifts to medical practitioners. For now, we may rely on people like Cynthia Fitzgerald (as pictured above) in the health care community to be a willing whistle blower as another form of deterrence. With all these efforts acting collectively, and despite all the happenings and discussions, I do not feel we have a fractured trust that will end our health care reform hope.