Do physicians market products? Patients could be unduly influenced

Financial conflict “impossible to avoid”

Although not subject to the provisions of the Physician Payment Sunshine Act, which become effective in September 2014, sales of medications or products in provider offices could unduly influence patients, says Margaret R. McLean, PhD, associate director and director of bioethics at Markkula Center for Applied Ethics at Santa Clara (CA) University.

“As data accumulates regarding the difficulty — if not impossibility — of managing financial conflicts of interest, it seems likely that the Sunshine provisions will reach physician offices,” she predicts. Patients might wrongly assume products sold in provider offices are somehow superior to those available elsewhere. On the other hand, they might wonder whether the physician is getting a “kick-back” on each package sold.

“Financial conflict of interest, in this case, seems impossible to avoid,” says McLean. “And, even if it can be avoided, patient perception that a conflict of interest exists is ethically troubling, as the trust so necessary to good patient care is threatened.”

Acting in the best interest of the patient includes not exploiting the power differential inherent in the physician-patient relationship and avoiding the exertion of undue pressure on the patient, notes McLean. “As patients, we are all vulnerable. We are worried, frightened, confused, and dependent on our doctor’s knowledge and know-how,” she says. “We may feel obligated to buy that vial of eye drops or tube of sunscreen displayed at the front desk, mistakenly believing it to be medically necessary or wanting to please the doctor.”

Remove financial gain

Inherent patient vulnerability mandates that financial conflicts of interest be managed and minimized, if not excised altogether, argues McLean.

“One way to do this would be to erase financial gain from the picture by giving away health-related products to patients or selling them at cost,” she says. McLean says that at a minimum, all office sales should be accompanied by full disclosure, including the financial arrangements between the physician and manufacturer and the availability of the item elsewhere.

“Once again, honesty — in the form of transparency — is the best policy,” she says.

Selling vitamins or skin products for profit and with no clear evidence to suggest medical benefit, clearly places the physician’s profit interest ahead of the medical and financial welfare of the patient, says David A. Fleming, MD, MA, FACP, professor of medicine, chairman of the Department of Medicine and director of the Center for Health Ethics at University of Missouri School of Medicine in Columbia, MO, pointing to increasing oversight and compliance policies.

“As licensure and privileging are regulated by such oversight practices, physicians’ livelihoods might be threatened if practice revenues are in any way dependent on the income of product sales,” he says. “Most will choose not to take the risk, however — nor will they likely be allowed to, by whatever administrative structure controls their practice.”

Benefit to patient

If products are offered at cost as a service to patients for their convenience, solely for the purpose of serving their medical needs, without a profit motive; and if recommendations about purchase are fully informed by what the patient needs based on the shared decisions made by physicians and their patients, then such sales could be considered altruistic and benevolent on the physician’s part, says Fleming.

The only justification for physicians dispensing medical products in their offices is if it serves to benefit the patient, argues Lawrence Schneiderman, MD, professor emeritus in the Department of Medicine at the University of California, San Diego. For example, a rural physician might provide a drug or device that might not be possible for the patient to obtain within a convenient distance, or a patient might not be mobile enough to travel.

“The physician should not seek to make a profit from these activities, unless willing to become a full-fledged pharmacy, meeting all the legal requirements. Rather, the physician should just cover the minimal costs of storing and dispensing,” says Schneiderman.

Ideally, says Schneiderman, the physician should post the wholesale cost paid along with the charge to the patient. The physician should avoid dispensing any drug or device made by a company in which the physician has a financial interest, and at the very least, the physician should clearly reveal that conflict of interest.

“It should go without saying — but unfortunately, in my experience, it needs saying — the physician should dispense only drugs of proven benefit, and not ‘alternative medicine’ nostrums,” he adds.

Reference

1. American Medical Association Code of Medical Ethics. Opinion 8.063 — Sale of health-related products from physicians’ offices (1999). Available at http://www.ama-assn.org/ama/pub/physicianresources/medical-ethics/code-medical-ethics/opinion8063.page.

Sources

• 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: flemingd@health.missouri.edu.

• Margaret R. McLean, PhD, Associate Director and Director of Bioethics, Markkula Center for Applied Ethics, Santa Clara (CA) University. E-mail: mmclean@scu.edu.

• Lawrence Schneiderman, MD, Professor Emeritus, Department of Medicine, University of California, San Diego. Phone: (858) 534-4206. E-mail: ljschneiderman@ucsd.edu.