Physicians urged to disclose magnitude of industry relationship to clarify bias

Baltimore-Efforts at reform notwithstanding, the relationships between physicians and pharmaceutical companies continue to be perilous because pharmaceutical companies have such strong incentives to influence physicians to use their products, said John T. Thompson, MD, a retina specialist in Baltimore and past president of the Maryland Society of Eye Physicians and Surgeons.

"There is nothing wrong with physicians being rewarded for helping to develop a new drug or device. Physicians and patients both benefit when new treatments are better than existing treatments," Dr. Thompson said.

"However, when the physician speaks about this or competing products at a meeting, the audience deserves to know more about the potential bias of that physician based on the amount of money the physician has received for his or her work or the value of stocks held in that company," he said.

As currently stated, guidelines tend to be effective at identifying physicians who have no commercial interest or support but are inadequate to address the different types of arrangements that many academicians and speakers at major meetings have with industry, he added.

Specifically, he suggested that disclosure should be graded for any financial relationship (e.g., consultant, speaker's bureau, stock ownership) by the magnitude of that relationship over the past 3 years. Currently, some physicians can slip through a loophole by receiving a payment for 1 year but not the next, so there is nothing to disclose for the second year, Dr. Thompson said.

Financial disclosure scale

He proposed a scale for financial disclosure of CME activities to provide information about the extent of an economic relationship. A low-level relationship would be one in which the physician received $10,000 or less, a mid-level relationship one in which the payment was between $10,000 and $100,000, and high would be payment greater than $100,000.

The often-convoluted relationships between physicians and industry stem from the strong incentives companies have to influence physician use of their products. Pharmaceutical companies are not price controlled, unlike other segments of the health-care industry, and can charge whatever the market will bear for new drugs that can help save lives or preserve sight, Dr. Thompson explained.

To cite a few examples of the amounts at stake, he noted that the cost of drugs for subfoveal choroidal neovascularization alone averages $6,000 to $12,000 for the first year in a newly diagnosed patient, depending on the treatment chosen and the patient's response to therapy. From another perspective, payments for verteporfin (Visudyne, Novartis) and pegaptanib sodium (Macugen, OSI/Eyetech Pharmaceuticals) alone exceed $800,000 a year in Dr. Thompson's two-person retina practice.

He also noted that rapidly increasing drug costs for physician-administered drugs in Medicare patients cause a negative shift in reimbursement for other ophthalmologic services. "The net effect is to shift money away from physicians and toward the pharmaceutical companies," he said.

At its most basic, the economic formula of pharmaceutical companies is based on convincing physicians to prescribe their drugs. While a substantial percentage of costs occur during the development of new drugs, and many of the drugs in the pipeline will never reach the market, there is a significant opportunity for profit from the sales of drugs that are successful in clinical trials and fall under patent protection.

Pharmaceutical companies understand that physicians' prescribing habits are influenced by education about a drug and their subsequent experiences with it, Dr. Thompson said. "Physicians then become creatures of habit, and they use the same drug for the same condition, especially if they are happy with the results," he said.

While trying to ensure that physicians continue using certain drugs, the pharmaceutical companies also invest heavily in informing physicians about new drugs and encouraging greater usage of these new products. They have also devised sophisticated systems for tracking prescriptions and can measure the impact of their interactions with a given doctor.

Doctors target of marketing

And while pharmaceutical companies increasingly target a segment of their marketing directly at consumers, doctors remain the focal point.