Physician conflict of interest has been a concern since the time of Hippocrates. However, as the for-profit healthcare industrial complex continues to grow (soon to be the largest government expenditure), physician conflict of interest concerns have grown exponentially. Relationships between physicians and the pharmaceutical industry seem to receive the most public interest. Recently, a piece from the NY Times called “Paid to Promote Eye Drug, and Prescribing It Widely” drew a lot of attention.
At issue are two drugs made by the same company. Both are used to treat a common eye disease called wet macular degeneration, which can lead to blindness. One drug, Avastin, approved to treat a variety of cancers and effective in macular degeneration treatment, costs $50 a dose. Lucentis, which is essentially the same drug but is FDA approved for macular degeneration, costs $2,000 a dose and is Medicare’s most expensive medicine, costing about $1 billion a year. And the Times reports that the top prescribers of Lucentis were highly paid speakers and consultants of the product’s manufacturer.
Physicians’ Role in Pharma Product Success
While the Avastin issue is mainly a regulatory issue, the broader issue of conflict of interest merits discussion. Unlike most industries whose products go directly to customers, the pharmaceutical industry’s products can only be dispensed by physicians. Physicians are also needed for both the required research and government approval of products. Due to their important role in product success, physicians are engaged by companies to consult on matters from research to marketing or to speak on their behalf about their product. Pharmaceutical representatives also interact directly with prescribing physicians, often offering product samples or a meal if an educational program is being provided.
It should be clear to all that interaction between the industry and physicians influences prescribing. Marketing works—companies would not spend billions to influence buying if it didn’t. This influence is likely to be greater when physicians have direct financial relationships with industry, such as serving on speaker’s bureaus. However, the real question is: Do these relationships influence physicians to inappropriately prescribe their products at increased cost and/or potential harm over other lower cost products that might be equally as effective and/or safer?
The fact is that harm and cost may be valued differently by physicians, patients and payers. Also, cost is complex and can refer to average wholesale cost, cost to the payer/government or cost to the patient. In the Avastin/Lucentis example, both the physician and the patient might not see prescribing Lucentis over Avastin as problematic—Lucentis may offer small benefits at no additional cost to the patient. The government and other payers likely have a different perspective.
Physicians are obligated to provide the safest, most effective treatments with costs determined by the patient’s insurance. Even if I speak for a drug company on behalf of one of its products, I can’t prescribe that product if it is not covered. More importantly, physician and industry interactions are necessary—drug companies produce almost all pharmaceutical research and provide most of their product information. I would welcome research (including comparative effectiveness studies rarely done by the industry) and education from an unbiased third party. To my knowledge, this does not exist.