Will drug reform work?
The first time I went to a drug company bash, my jaw dropped: everywhere I looked there were freebies -- pens, pads, equipment, jackets, briefcases. I worked in television at the time and was accustomed to fairly lavish hospitality, but this was something on an altogether different scale. Just for attending a short and unremarkable talk about beta blockers, I could walk away loaded with goodies. And apparently my event was understated; I didn't get the cheerleading team to persuade me that branded drugs beat generics -- if only because generics don't come with pom-poms.
But all that is about to change. One of the provisions of the new health care reform law calls for drug companies and device makers to disclose anything they give to doctors, be it meals, pens or paperclips. And the legislation has muscle. Failure to report a gift can result in a penalty of up to $10,000 per omission.
The intent is clear: to make transparent the commercial relationships between medical professionals and pharma and device manufacturers, and to remind all participants of the exact nature of their relationships. Laws like this have been in force for some time in Massachusetts and Vermont. Has it worked there? David Ring is one of the country's leading orthopedic surgeons and a champion of transparency in every aspect of medicine. Does he think the reforms will change behavior?
"Given the powerful influence of a gift, I do think it has some merit," Ring told me. "Orthopedic surgery just went through a huge overhaul where all the major companies were investigated by the Department of Justice, found to be doing some nefarious things with their consulting, and they underwent deferred prosecution agreements. The changes to the industry have been very positive in my opinion. I think the way we do things now is better and the younger surgeons are much more aware of the potential problems with conflict of interest."
In the past, the onus of disclosure has been on physicians, not drug companies. Dr. Lindsay Nicholson, who has worked in the U.S. and in Europe, agrees that the new reporting obligation is a step in the right direction.
"It means you can see the correlation between payments and prescribing," the doctor says. "Americans pay much more for their drugs than Europeans, in part because marketing brands, which are more expensive, leads to their prescription over generics, which are cheaper. So the hope is that the patient benefits from cheaper drugs and cheaper health care."
Both Nicholson and Ring are thoughtful critics of the role of money in U.S. medicine, so I take their endorsement of the legislation seriously. On the other hand, I can't help but notice that the patient is still left out of the equation. You and I won't know who our doctors have been wining, dining or vacationing with. We won't know which device companies have their reps standing in our operating rooms. And this matters because the psychological effect of money is insidious. We may believe, or hope, that we aren't swayed by it, but the evidence runs very much to the contrary. And it's human nature that we like people who like us. Should they choose to demonstrate that affinity with gifts and hospitality, it's hard not to think well of them.
When the legislation is enacted (and assuming it doesn't get hopelessly watered down), what we have to hope for are two things. First, we should expect some rigorous examination of the correlation between marketing spend and physician choice. Emerging trends will tell us a great deal about whether or not the law is working. Watchdogs and whistleblowers should be on the lookout for the big spenders.
And second, we have to hope that we all have physicians we can trust. It would be nice if we could legislate for that, but so far, no one's figured out how.
