In the last presidential election, Democrats and Republicans each spent nearly a billion dollars in campaigning. The National Rifle Association, AIPAC, the AARP, and other political action committees also pour billions of dollars into Washington to influence legislation. In 2013 alone, lobbyist groups spent $3.24 billion dollars. Many former politicians also eventually become lobbyists for financial groups, a trend Senator Elizabeth Warren (D-Mass.) chided as the “Washington to Wall Street revolving door.” Some have gone as far in criticizing the current political system to claim that America is now an oligarchy controlled by the wealthy; most would agree that money talks in American politics.
Here is a scarier concept: money also tries to influence one of the most trusted groups in society—physicians. Drug company lobbyists outnumber congressmen two to one. Pharmaceutical companies and medical device manufactures spent nearly $3.5 billion on doctors and teaching hospitals in merely five months. Although much of this spending goes to beneficial education for physicians, the prescription drug industry nevertheless has pull in Washington. Only in the United States and in New Zealand do drug companies advertise directly to consumers. In other words, no other countries would allow Viagra commercials to chime in during every Super Bowl timeout.
However, a provision in the Affordable Care Act, formally named the Physician Financial Transparency Reports and now referred to as the Sunshine Act, works to derail lobbyists from colluding with physicians to champion their products. Through transparency, the Sunshine Act works to ensure that all, not just most, of physician-company relationships remain professional.
Sunshine
Many drug companies invite physicians to attend conferences regarding new products, and these companies often provide physicians with promotional material, gifts, meals, consulting expenses, and sample products. The Sunshine Act requires pharmaceutical and medical device companies to report “payments or other transfers of value” made to physicians and teaching hospitals to the Centers for Medicare and Medicaid Services. Further, these companies must report any investments or any interest physicians may have in their companies.
Beginning September 30, the information became publicly available on an online database established by the CMS. This information includes each physician’s contact information, the amount of the payment, and the form of the payment. Co-author of the bipartisan bill, Senator Chuck Grassley (R—Iowa) hopes the bill will “help inform the public about the finance relationships between the drug and medical device industry and doctors.”
Granted, many, if not most, relationships between physicians and pharmaceutical companies are not with insidious intent, rather the opposite. In an interview with the Harvard Political Review, former Head of the Office of External Affairs at the U.S. Department of Health and Human Services Anton Gunn suggested that physicians attending conferences with drug companies can be and often is beneficial for consumers. At these conferences doctors find out “what the best technologies are, the best resources are, [and] what the best things [they] have available to [their] patients.” He further implied that doctors wholeheartedly care for their patients and “focused on … getting the information that’s going to help [their] patients.”
The Sunshine Act ensures that physicians maintain professional relationships with drug companies through transparency. In an interview, Don Berwick, the former administrator of the CMS, believes the Sunshine Act will have a “salubrious effect on their relationship.” He adds that “if nothing untoward is going on, transparency reassures people, and if it’s something that shouldn’t be going on, then transparency is a way to make people aware of it so it decreases.”
Clear Skies
Much of the information made public through the Sunshine Act has been available for individual hospitals, but not in the public domain. Dr. Sanjay Saini, a professor of radiology at Harvard Medical School, concluded that making the information public will likely have little to no effect on how patients view their physicians because “the data is going to be so large that from an individual patient’s point of view it will be impossible to decipher how to make meaning of it.” Moreover, Gunn asserted that as long as the demand for drugs and medical devices exists, there will be “people who turn a blind eye to how much [companies] are spending or what stocks they pick on a trip, or what perks they got, as long as they continue to produce a product that people demand.”
However, as Dr. Berwick put it bluntly, “Transparency matters a lot.” He adds that public transparency likely will lead to “the chance of unwise relationships go[ing] down.” Further, Gunn argues that the availability of records in the public domain will impact the existing dubious relationships between physicians and companies: “What you’ve done in the dark allows you to continue to move in ways that no one knows about, but when you bring those things to light when there is some public availability and accountability… it does change the practices of some people.” The transparency and clarity forces a sense of accountability for physician, by providing data and analytics for the public to hold physicians accountable.
Some critics of the Sunshine Act argue the legislation fails to make a significant impact on the issue. Massachusetts State Senator Jamie Eldridge (D-Acton) argues that the Sunshine Act legislation became “very watered down” and does not go far enough in tackling the problem. In an interview, Senator Eldridge advocated for legislation similar to the Massachusetts Gift Ban Law, which prohibited Massachusetts physicians from accepting many forms of payment from pharmaceutical companies. However, the restaurant industry of Massachusetts lobbied the state legislature into overturning much of the legislature and allowing physicians to accept meals from pharmaceutical companies. Senator Eldridge further implied pharmaceutical companies demand influence on physicians. When asked if pharmaceutical companies also played a part in this undermining of the legislation, the Senator said, “I would cynically say that [it] was a very good strategy to have restaurants be the face of the issue … but I have no doubt [pharmaceutical companies and restaurants] were working together on it” because the ban was “limiting their influence.”
Ultimately, transparency in itself is not likely to change how much money is spent by drug companies and medical device manufacturers. Again, much of this money can be beneficial in making physicians more aware of available medicine and technology. Yet, shady relationships between physicians and companies will exist, and this legislation will help weed those out. Physicians will be more diligent and careful in their professional relationships, and publications will hold them accountable by digging through the data and pointing out any outliers.
Raining on the Parade
As with the unveiling of the ACA’s website, healthcare.gov, technical difficulties might undermine the effect of the Sunshine Act. Harvard School of Public Health profess John McDonough stated that the effectiveness of the Sunshine Act “depends on the credibility of this site. In other words, if they mess it up and get the data wrong or present it in ways that people just don’t get or understand or agree with, [the act] could be delegitimized.” Unfortunately, the act has experienced some hiccups in its implementation thus far.
In early August 2014, the American Medical Association called on the CMS to delay implementation of the Sunshine Act in order to give physicians more time to review and verify the information. AMA President Robert M. Wah affirmed in a press release, “In order for the Sunshine Act to be effective, physicians need enough time to review and correct any inaccurate data that may be reported.” However, the CMS went through with the act and implemented it in late September 2014. Consequently, the report remains incomplete and potentially inaccurate. For example, the CMS already had to remove physicians’ personal information from about 40 percent of data because of potential inaccuracies in the information.
Once the CMS solves the technical problems, it will enable the Sunshine Act to accomplish its goal of increasing transparency and discouraging companies from wrongfully influencing physician behavior. The Sunshine Act likely will not greatly affect the mutually beneficial relationship many physicians and companies have. However, it will help weed out those underhanded relations aimed solely at boosting sales and sharing profits. According to Anton Gunn, transparency in these relationships “is important for consumer protection issues and important for the public” so that patients have ensured full faith and trust in the unbiased advice of their physicians. Image from The Economist