Public disclosure linked to far fewer payments to physicians
Transparency encourages trust
Many believe that the precipitous decline in industry payments to physicians over the past few years can be attributed to The Physician Payment Sunshine Act, says David A. Fleming, MD, MA, FACP, chairman of the Department of Medicine and director of the Center for Health Ethics at University of Missouri in Columbia. "It has been widely reported that payments from pharmaceutical companies to physicians have gone down as much as 50% to 60%," he adds.
The Physician Payment Sunshine Act, part of the Affordable Care Act, requires manufacturers of drugs, medical devices, and biologicals who participate in U.S. federal health care programs to report certain payments and items of value given to physicians and teaching hospitals. The data will be posted on a public website after September 30, 2014, giving patients access to the information without asking their physician directly.
There is little doubt that the pharmaceutical industry has provided tremendous benefits to patients and to society in general, says Fleming. "New and amazing drugs and other treatment modalities have been introduced over the years, thanks to investment in research and development," he notes.
Physicians have been "invaluable partners in this effort," says Fleming, by serving as consultants for new drug development and enrolling patients in clinical trials. Physicians can also benefit professionally by taking advantage of teaching and learning opportunities provided by industry regarding new forms of treatment that may benefit their patients.
"Unfortunately, however, the healing relationships that doctors have with patients cannot help but be influenced by the monetary and material relationships they may also have with industry," says Fleming. "Such relationships influence the prescribing behavior of physicians." Here are some ways in which this can occur:
• Brand-name drugs are almost always more expensive than generic forms; the difference in cost often comes out of patients’ pockets.
• Physicians may be tempted to deviate from guidelines and known standards of care, such as with off-label use of free drug samples. This, in turn, may pose risks to patients.
• Early adoption of new treatments may lead to as yet unknown complications.
Most physicians adamantly deny that they are influenced in any way by gifts such as drug samples, meals, or money for consulting and speaking. "But even with the best intentions, evidence suggests that prescribing and other professional behavior in the treatment of patients is influenced by such relationships," says Fleming.
Getting information about payments to physicians via a third party, such as the Centers for Medicare & Medicaid Services, "can avoid awkward conversations that both doctors and patients would probably like to avoid," says Genevieve Pham-Kanter, PhD, assistant professor in the Department of Health Systems, Management, and Policy at University of Colorado’s School of Public Health in Denver.
It is unclear whether either physicians or patients will have any incentive to bring these issues up in the context of an office visit, says Pham-Kanter. It is also unclear how patients will react to learning about physicians’ financial relationships.
"We do not yet know how patients will respond to the payments information that will be released, but this will be an important empirical question to answer," she says. "We do hope to be able to answer this question in due course."
Knowing that physicians — either one’s own or physicians in general — receive payments from drug or device firms may result in a loss of patient trust in physicians, and perhaps more broadly in medicine and the medical profession, says Pham-Kanter.
"Research using hypothetical vignettes suggests that knowing that their doctors receive some kinds of payments leads patients to have diminished trust in their doctors," she notes.1,2
Some patients may view payments as a positive sign that the physician is in high demand, on the other hand. "It will be important to keep an eye on how patients actually respond to this information, if they respond to it at all," says Pham-Kanter. "Many patients may not be aware of the payments data release or may not care, especially if they have long-standing satisfying relationships with their doctors."
Fleming says it’s likely that the new regulatory requirement will enhance patient-physician relationships. "Physicians and industry alike have good intentions and are interested in improving the plight of patients and the health of the public," he says. "The Sunshine Act helps physicians and industry remain vigilant."
This level of transparency, he says, is one way that patients can be reassured that their physicians are adhering to their ethical responsibility to assess any corporate relationship. "Transparency encourages trust that physicians are being honest and acting primarily in the interest of their patients," says Fleming.
- Goff SL, Mazor KM, Meterko V, et al. Patients’ beliefs and preferences regarding doctors’ medication recommendations. J Gen Intern Med. 2008;23(3):236241.
- Perry J, Cox C, Cox AD. Trust and transparency: Patient perceptions of physicians’ financial relationships with pharmaceutical companies. J Law Med Ethics. In press.
- David A. Fleming, MD, MA, FACP, Professor and Chairman, Department of Internal Medicine/Director, Center for Health Ethics, School of Medicine, University of Missouri, Columbia. Phone: (573) 884-2013. E-mail: firstname.lastname@example.org.
- Genevieve Pham-Kanter, PhD, Assistant Professor, Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado, Denver. Phone: (303) 724-4469. E-mail: email@example.com.