As Farnkoff notes below, today we're faced with the disappointing news that the House has shamefully caved to the PhRMA industry, stripping the ban on gifts that was in the Senate version, and allowing the industry to “police itself” on gifts to doctors.
Why does this matter? After all, gosh, those gifts are just sandwiches and pens, right? It's only wafer-thin, sir!
The health care law was a great accomplishment, involving a lot of people (even Mitt Romney!) who had to swallow hard to get the deal done. The law's survival will not be ensured in great, sweeping measures, but bit by bit. And conversely, the law's destruction will be sown by seemingly minor concessions to special interests, which in the aggregate will add up to many millions.
The PhRMA lobbyists — and the legislators who do their bidding (hi Chairwoman Walrath) are counting on you not to care. They are counting on your apathy about such a small matter (it isn't). Of course, they sure as hell are not apathetic. And they are not the only special interests at the table, not by far. This health care law is big, big money. And therefore there are any number of groups whose interests are orthogonal to the law's stated goal of providing health care for everyone. And left unchecked, like barnacles on a ship, they will actually impede that goal — if not sink the law outright.
Cost control is the unfinished business of the health care law. And without the strongest possible measures to control unnecessary spending and create incentives for quality-not-quantity, the law will fail. You can absolutely take that to the bank. The law's advocates knew that — they weren't stupid or naive. Terry Murray knew that, and acted courageously to try to wisely regulate certain practices that create bloat in our spending. That courage ought to be honored, not squandered, in the eventual bill that emerges.
What should we think of Chairwoman Walrath's shameful parroting of PhRMA's specious lines of argumentation? Ah yes, it's all about “information” – as if docs have no means of learning about drugs except through their sales reps' goodies. But no one is talking about cutting off communication to docs. That argument is a red herring — and a smelly one at that.
There's no medical justification for pharma companies' gifts to doctors — large or small. Anything that distorts the prescribing process from absolute medical necessity and independent information is flat-out unethical, and wasteful. And medical professionals who imagine themselves to be so brilliant and pure as to be immune to such blandishments — yes, even de minimis things like sandwiches and pens — are ignorant of their own all-too-human nature and behavioral research. (Robert Cialdini's Influence has a whole section on the “rule of reciprocity” as a means of achieving compliance.) Do we really think the pharma companies don't know what they're doing? If they didn't work, PhRMA wouldn't be pushing so hard to protect these practices.
And the fact that they do work demonstrates precisely why they need to be banned. Such sales techniques are commonplace in any number of product areas. And why not? But drugs are not like socks, or cars, or cookies. They affect health — even unto life and death. They are not to be treated lightly. Their use is not to be influenced by extra-medical appeals to reciprocity.
Chairwoman Walrath should agree to put back the ban when the bill goes to conference. No more barnacles on this ship, please.
That’s a good book and an easy read.
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p>Humans are only approximately rational, and there are whole industries devoted to exploiting the non-rational parts.
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p>Gift-giving is but one small example.
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That’s how you sound.
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p>And it’s a ridiculous, elitist concept. “If only it weren’t for pens, go-cups, and the occasional sandwich, we’d have cost-controlled, socialized health care in MA. If only we could ban PhRMA’s gift-giving, why, Beacon Hill could manage our care cost effectively.”
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p>As I wrote in an earlier post …
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p>How ’bout we ask the MDs and medical professionals if coffee mugs and note pads are coercive marketing tools?
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p>I trust my doctor to separate the wheat from the chaff when it comes to Rx meds. One man’s brainwashing promotional product (that means you, Charlie) is another’s communication device — maybe my MD can learn about a new treatment for me using Lipitor. If it takes a free Pfizer-sponsored luncheon seminar to bring it to her attention, terrific! She’s smart enough to read and understand the results of their “research,” and if she’s skeptical, she’ll disregard the free lunch and throw the technical literature in the trash.
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p>Do progressives think highly trained doctors can be coerced by promotional trinkets? Apparently. It boggles the mind how they ever made it through med school (MDs, not liberals.)
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p>PhRMA’s note pads and bulky ballpoints … brainwashing MD’s into prescribing drugs I don’t need? Only in ProgressiveWorld. You cite no study showing the coercive AND negative effects of PhRMA’s gift-giving. You only give your opinion and a reference to a single title on influence (for God’s sake, don’t let that book loose on Beacon Hill.)
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p>Worse still is your absurd notion advocating that politics can — and should! — be employed to control the cost of health care.
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p>No, but is that the standard? As long as we don’t have doctors who are coerced, that’s okay? What about he Doctor who gets a patient complaining about X and asking for Y medicine to cure it? I’m sure after hearing all of these commercials, with people thinking they need all of these medicines, Doctors get tired of it and just don’t put up much of a “you don’t need this” fight. A lot of people die every year from medicines they were correctly prescribed – upwards of a 100,000 or more. That’s probably a pittance to the people suffering from nasty side effects taking medicine they may not need, either because they really don’t need them or because there were other treatments available but the patients either didn’t want them or the doctors were predisposed to giving one medicine over another (and, yes, I think gifts play a role there too.. it’s not just pens and t-shirts they give out, but lavish meals and gifts far more expensive than pens).
Worse still is your absurd notion advocating that politics can — and should! — be employed to control the cost of health care.
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p>Please! Pharma has been buying off politicians for decades (Bernie Tauzin is the best example) so that the government will sculpt the market to favor Pharma’s revenues over ordinary people’s wallets. You act all outraged when ordinary people take the first step to fighting back against Pharma with this gift ban. The majority of people want it. It’s a good idea–even if banning pens & notepads is going “too far” that is hardly any burden on doctors to have to supply their own pens & paper.
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p>Marketing sells people more of a thing than they need. And marketing works. It’s fine for marketing to get people to buy more music than they need, or to go see a Will Smith movie even if it’s not good–but public health is so important that we should set limits on marketing drugs. Moreover, Pharma has profited greatly from our culture’s idea that we need prescription drugs to improve our lives, so they should take the downside of that when we want a law like the gift ban to control costs.
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p>The gift ban is an example of the public good being more important than the profit margins of one industry. If the industry reaction to Sen. Murray’s ban is so strong, then the House should temper the ban and put a limit on it, like $20 or $50–but to drop the ban entirely is equivalent to the House putting one industry’s interest ahead of the common good.
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p>So, who’s to decide the precise amount of stuff we need. I know! The government.
I don’t get it. Don’t drug companies have a right to communicate with their customer base? Is there a freedom of speech issue here?
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p>You make it sound like MDs react like zombies in the face of PhRMA promotional give-aways…they buy “more of a thing than they need.” Prove it. Cite some reports which shows undue influence by PhRMA.
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p>And why not ask the doctors what they think? This is never suggested.
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p>It’s all a big anti-PhRMA campaign with ulterior motives … take the Rx purchase decision away from doctors, and give it to government. This is a small, first step to centralized health care in MA which is what liberals wanted in the first place. And “cost control” is just a code word for “single-payer.”
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p>And memo to you, Joel — “Big PhRMA” has probably saved my life since I suffer from high lipids. I gladly pay $1.00 per day for my Lipitor. If PhRMA profits from that, I’m happy to help. Perhaps those profits will yield a new, better statin for me.
the highest health costs in the world, are the most overmedicated, and yet the US ranks near the bottom in most health and quality-of-life indexes…hmmm I wonder if something is fundamentally wrong with our health care system.
Yeah, gosh, if only groups representing lots of doctors and medical students had taken the initiative to express publicly their views on this.
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p>Oh, wait …
Charley has taken care of that downthread. Be careful what you wish for, if what you’re wishing for is for someone to refute your position. It just might happen!
Well, they’re everywhere. From JAMA:
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p>Another from JAMA:
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p>Anything else you’d like, Shep?
http://www.vaccinetruth.org/ph…
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p>In 2000, the drug industry sponsored more than 314,000 events for physicians – everything from luncheons to getaway weekends – at a cost of almost $2 billion. On top of that, many doctors accept speaking and consulting fees that link them to drug companies.
The Chap 58 law is most certainly not the success that the law’s main architects–led by the state’s largest insurance company MA Blue Cross and Blue Shield–would have you think. I’ve posted here on BMG a long time ago about Rep. Walrath’s public comment to a group of 7 health professionals who met with her about the health insurance law as it was in the works and she stated that “…no bill passes the health care committee without the approval of the health insurance industry…”. It should come as no surprise that you can substitute “the pharmaceutical industry”…
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p>Re Charlie’s misplaced accolades for MA health insurance law: Lots of smart, well informed health policy professionals, clinicians, reform advocates, as well as hundreds of thousands of state residents who remain uninsured, remain unable to afford insurance, and who are getting tax fines instead of getting healthcare, see the facts of the MA mandated commercial insurance law and come to a VERY different conclusion.
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p>For example, here’s a comment from a recent political discussion with a PhD in comparative health policy about MA activists impact on national healthcare reform. The discussion was about the fight for single payer (see http://www.Healthcare-Now.org ) vs. a “hybrid” approach (see http://healthcareforamericanow… ) that would expand Medicare as an option for all and also lets private insurance co’s remain under strict gov’t regulation. Make sure you get to the final sentence:
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p>Walrath and the Lege got away with the Chapter 58 fake “reform” law, so why should they think they can’t get away with caving in to Pharma?
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p>BTW Chap 58, the mandated private insurance law, is ALREADY a failure; how else would you describe a program that in its first full year is hundreds of millions of dollars over budget, while hundreds of thousands of our neighbors, friends and co-workers in the state are still uninsured, while most of the rest of us continue to be crushed by sky-high health insurance and “uncovered” healthcare costs?
when sales reps wear professional business attire to their sales pitches it exerts a subtle influence on doctors who will think of them as knowledgeable and capable and the doctors judgment will be subverted, so we need a bill to ban PhRMA sales reps from wearing anything but sweat pants and t-shirts. And I think that when sales reps show up on time that doctors will think of them as efficient and professional and the doctors judgment will be subverted, so we need a bill that will assign each PhRMA rep a random number of minutes late that they must be to all their events that week. And I think that when the temperature in the room is set at a comfortable level that the doctors will relax and their judgment will be subverted, so we need a bill to ban any sales pitch in a room with a temperature between 63 and 82 degrees Fahrenheit. And I think that when reps have carefully put together powerpoint presentations that doctors will think of them as knowledgeable and professional and the doctors judgment will be subverted, so we need a bill that requires at least 5 typos and 3 misplaced slides in each presentation.
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p>I mean, its common practice for PhRMA reps show up on time in professional attire to present clever power point slides in rooms with comfortable temperatures, so they must know that they are subverting the wills of the doctors with such trickery. Post hoc ergo propter hoc.
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p>And, as we all know, doctors are some of the most easily swayed people around. They can’t be trusted to rely on their extensive background and education to exercise judgment when making medical decisions. We need to have laws to protect their fragile minds from the ruthless and evil PhRMA sales reps. I mean, we’re talking about a person’s health.
Using Spanish in a post is very elitist and Obama-like of you. THIS IS AMERICA! We use English.
is not Spanish. Its actually Czechoslovakian, the most non-elitist language of all.
Why is it that standard operating procedures for salesmen in other fields that are widely accepted as being the way business is conducted turn into something evil when conducted by PhRMA reps? Trinkets and coffee and bagels and cookies are just a part of all sales meetings. I don’t understand why they need to be stripped out of a standard sales pitch only for PhRMA reps. Of course health care is vitally important and lives depend on it. But thats also the case for automobile brake pads, and rollercoaster harnesses, and elevator cords, and flotation devices, and electrician wiring services, and train tracks, and many other items that are bought and sold every day. Why can’t we trust doctors at the same level that we trust all those other buyers to make the right decisions when human lives are on the line?
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p>And where was all this animosity towards PhRMA companies when Gov. Patrick was handing them millions with his “life science” grants and tax credits?
Let me say this topic is far off my radar of expertise and I’m not up on the details of the bill.
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p>But if I take this issue of sales pitches as part of the larger context of:
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p>then the idea of doctor payola becomes not the problem itself, but a symptom of a much larger issue.
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p>Clearly, it would be best if our highly-trained doctors were making pharmaceutical decisions based on the best science available. That’s what I want as a patient. But the waters have been muddied at every layer to the point where a smart patient/consumer should have doubts about the process by which medicines are chosen for their conditions, or doubts if the medicines are even necessary in the first place.
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p>There will always be an element of salesmanship-over-science in the big Pharma game. But as a consumer and a patient, I’d like to see the growth of the nfluence of salesmanship curbed and reclaim some of that real estate for science. This is a basic consumer protection goal and if we chip away at the influence of salesmanship, we increase consumer confidence. To me, real science is far more critical to the chemicals prescribed for my body – especially if we’re talking long term health and life and death situations – then brake pads and electrical wiring. Let’s un-muddy the waters and make science a more influential factor in doctors’ decisions to prescribe drugs.
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p>You may be right in saying that this bill is useless and the trinkets and bagels have little effect on the doctors. I don’t know. But I think it’s hard to dispute the principal behind the bill, that flash, salesmanship, and outright bribery is far too pervasive in Pharma sales and science is being subverted and suppressed. I see a need to chip away at the non-scientific influence held over doctors when it comes to my and everyone else’s health. Maybe this bill isn’t a pragmatic solution (maybe it is?), but it sends a message to the medical industry and consumers that this bought influence needs to be checked and balanced.
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p>In light of the context above, even if you can’t agree that this is a good bill, can you see why some people find it necessary to want to curb the power of the marketing and sales arms of big Pharma, and perhaps see why selling Lipitor or anti-psychotics to kids is different than brake pads and elevator parts?
That is the most thoughtful and honest answer I’ve read anywhere on this blog as to the reasons behind supporting this bill. As you rightly point out, there are some larger ethical problems in the industry and there are some reasons to suspect that the process has been compromised. And of course it would be best if doctors made their decisions based 100% on scientific evidence.
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p>However, I get the sense that many supporters of this bill, including yourself, are very upset at some overall industry practices and are merely throwing up their hands and throwing away common sense in order to support a bill that finally does something. I support the idea of a gift ban, I just don’t see why it can’t have an exemption for de minimis gifts.
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p>And maybe I don’t understand the industry enough, but why haven’t the insurance companies stepped in to prevent this? If costs are really being increased by doctors proscribing unnecessary medicines, then aren’t the insurance companies, who have to pay for the unnecessary medicines, in the best position to stop the practices? Do insurance companies deny coverage for particular unnecessary drugs? Shouldn’t they?
I know some plans have a maximum yearly prescription benefit payout, like say $2000, so it doesn’t matter to the insurance co which drugs you get, they’re only on the hook for the max. For an added premium, the insurance company will sell you an “unlimited” benefit.
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p>I also know that certain providers refuse to cover certain name-brand prescriptions forcing the consumer to only use generics.
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p>Like you, I don’t know enough to say with authority how the insurance industry manages prescription costs, but it seems they have quite a few protections in place and also probably pass along any additional pharmaceutical costs to the consumers via higher premiums.
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p>As to the idea that some supporters of the bill are throwing their hands up, it might be true. Some support might just come from vindictiveness and the opportunity to lash out anyway available. But the way I’m looking at it – and again my understanding of this topic is superficial and I have done little to educate myself about the bill – is that this is a first step in the incremental processes of fixing the larger ethical problems of the Pharma industry.
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p>With our Constitutional government, change comes slow, especially when the target of change is a financial juggernaut like Pharma. It’s rare that big systems are shaken up from the top down and the people who are profiting from current conditions have the resources to resist change. If someday we are to get this right, meaning that patient-consumers are being treated only based on the best scientific data while drug manufacturers are allowed to perform for their shareholders, then finding the winning approach to reform and compromise is critical. No matter how much I’d love to charge in like a bull and mandate an overhaul where everything would be ethical, my pragmatic side knows that method is doomed to failure. I know that banning de minimis gifts is a drop in the bucket, but it is a small first step – if you can’t do what you want, do what you can. Start from the bottom of the bottom and work up. Re-shape these practices incrementally.
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p>Perhaps there is a better solution, but this seems to be the only solution being offered now. If something better came along that gave consumers better protection but still allowed salesmen to take doctors out to lunch and give them mugs, I’d probably be for that.
My story is illustrative. When I had my first exam by an OB/GYN I was told I was anatmoically abnormal, and to ask my mother if she had been prescribed DES.
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p>Fortunately, her OB/GYN was still alive and got the records out of storage. The answer was yes. She had prescribed DES for my mother, who was of the generation to “do what she was told” – because the Pharma rep convinced her to do this with all patients with any history of spontaneous misscarriages…tragic, really.
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p>The DES had been sold to the OB/GYN by a Big Pharma rep, complete with gifts as “preventing miscarrauige”. As subsequent lawsuits [I was a plaintiff in one} showed, Big Pharma knew that DES not only did NOT prevent miscarriage but did cause birth defects.
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p>See: http://www3.interscience.wiley…
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p>So, yes, this failure to regulate disgusts me, and places you and I and everyone we know at risk.
As I would have come and told my story and rooted up other DES daughters and sons to do so as well. Unlike Thalidomide, the birth defects are “invisible” but still life changing from DES.
I am going to look at this from a fifferent perspective. First I hope doctors aren’t selling us out for a free lunch.
No one has talked about the impact this has on the restaurant & catering industry, which is already suffering because of George Bush’s economy.
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p>I know a great many restaurant owners. This would hurt them severly. Some of them relay on this business and up to 30 % of some restaurant business comes from drug companies.
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p>Let’s take a balnced approach to this. maybe a phase in, so that we aren’t hurting a segment of the economy that no one is looking out for.
You were conspicuous in your absence.
Let’s do some linkage… the Pharma companies can stop having lunch with the pols when we completely eliminate lobbying. All the bullshit arguments about Doctors not needing to go to lunch to get information about drugs can be used against Senators and Representatives not needing lunch, airfare, hotels, boat rides and all the other stuff they get from lobbyists to get information for their “causes”.
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p>I would feel a “shitload” better about a highly paid Doctor getting a pen from the likes of Pfizer then what our wonderful politicians get A lobbyist link in congressmen’s visits to Cape. And don’t even try to compare what the Doctors prescribe improperly with all the pork that gets paid for from our hard earned tax dollars to lobbyist’s projects. Now that is criminal!
Either way, the law to ban lunches and pens will have no impact on Mass. healthcare spending. If you really want to save some money for the state, figure out a way to recycle the hundreds of millions of dollars of drugs that the nursing home industry is forced to flush down the toilet every year. Ask any nursing home nurse or administrator what I am talking about. Drugs are ordered in 30 day amounts. All drugs not used (the patient died, went to the hospital, had an allergic reaction, etc.) are flushed. Not used by the patient in the next bed who happens to be on the same med. Not donated to a neighborhood health center for the poor. Not sent overseas to developing countries. The drug companies want them to buy the drugs again.
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p>The same is true for state prisons. Hundreds of inmates are on expensive triple therapy for AIDS/HIV. When the prisoner suddenly gets transferred to a different prison, the meds are left behind and flushed. Then they are reordered at the next prison.
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p>Forget the pens and sandwiches. There’s some real money at stake for the drug companies here.