The National Coalition on Healthcare recently held a discussion on the Physician Payments Sunshine Act. The discussion featured insight from Rodney Whitlock, who currently works for Senator Chuck Grassley (R-Iowa) as the Health Director of the Senate Finance Committee. Dr. Adriane Fugh-Berman, associate professor at Georgetown and the director of Pharmed-Out, Allan Coukell, the senior director of the Pew Charitable Trust, and Dr. William Jordan, President-Elect of the National Physicians Alliance provided their views on the Sunshine Act and the pharmaceutical industry as well.
Whitlock started things off by noting that Senator Grassley believes that generally “more information available to the public is in the public interest.” He reiterated, however, that the Sunshine Act approaches financial transactions between companies and doctors from a transparency perspective, rather than an “absolutist approach” of condemning these interactions, or suggesting they are illegal. That is an important distinction, and one Whitlock repeated throughout the discussion in order to draw a line between Senator Grassley’s position and the opinions of the other panel members.
Grassley’s ultimate goal, stated Whitlock, is for both patients and doctors to be comfortable looking at the Open Payments data and having an open discussion. He notes that while the Sunshine Act was only meant to get the data out there, now it is up to the research community to use the information to inform public policy. Open Payments combined with the Medicare payment data will provide a lot of insight into payments and patterns of practice, he notes.
Panelists Take on the Sunshine Act
Adriane Fugh-Berman, MD, associate professor of Pharmacology at Georgetown and alternative medicine specialist, whose organization, PharmedOut, advocates against pharmaceutical marketing influence in medicine, believes the Sunshine Act is not doing enough to weed out pharmaceutical company influence. She stated simply: “patients shouldn’t see doctors who see drug reps.”
She points to what she believes are deficiencies in the Sunshine Act’s reporting requirements. Open Payments “only picks up about 20 percent of what is required to be reported,” she stated. “Some states or non-states [referring to DC’s AccesRX Act] have reporting laws that are even more stringent, and I would make a plea for keeping them.” Additional requirements imposed by these laws include reporting payments to nurse practitioners and physician assistants. Fugh-Berman also points to the influence of social workers and receptionists, and even a doctor’s social contacts. If a physician doesn’t see drug reps, pharma reps will find out who “their kids play baseball with” and “who are their spouse’s best friend” in order to target those people to try to get the marketing message to the physician, she states.
“Pharmaceutical companies will always try to affect whoever is affecting market share,” be it a doctor, patient, or payor. She targeted cost-effectiveness studies on the payor side—for example, if a company has a “terribly expensive” drug, they may point to the fact that the treatment will save hospitalizations or save money down the line.
Fugh-Berman is also very cynical about disease awareness programs. “Pharma’s getting involved in a very scary way in disease management,” she noted. “There is a lot of partnering with government agencies, medical groups, professional organizations, specialty groups, and also with consumer advocacy groups,” which Fugh-Berman argues are often invented or created by companies. Companies also “fund TVs in waiting rooms that have fake news on them,” Fugh-Berman says, which are “possibly pharma ads but often the messages are incorporated into the fake news stories.” As a final warning, she stated: “I think what we should be watching for is the establishment of the new definition of specific conditions…pharmaceutical companies have actually invented some conditions wholesale.” She argues that some offenders are female sexual dysfunction, acid reflux disorder, and pediatric bipolar disorder.
Allan Coukell, senior director for health at the Pew Charitable Trusts speaking on the Prescription Project, made predictions about what he believes to be the future of the Sunshine Act. He predicts both that the process of submitting data will be streamlined, and also that CMS will refine the way it presents this data–from improving the interface and search tool, to adding more context including physician specialty, geographic location, and time trends. Coukell hopes that the Sunshine Act streamlines the descriptors around payments going forward. He believes certain classifications–be it consulting, marketing, meals–are overlapping and potentially confusing. Coukell suspects that companies are using these terms in different ways, and that this harms the utility of comparing the Open Payments data across the industry.
Dr. William Jordan targeted free drug samples, a practice he believes is a major gap in transparency. “There is good data that banning samples increases prescribing of first-line drugs like the most appropriate drug for that patient,” he noted. “I would say overall free samples are misdirected and unsafe.” He encourages all patients to ask their doctor about alternatives to samples, and also to press them about the costs involved. Fugh-Burman chimed in to recommend that whenever a doctor offers you a free sample, to just say no. “It would be worth it to see the look on the doctor’s face when you hand back a sample and say ‘I’m sorry can I have an older time tested medication please?’ And really it would be the best thing for your health.”
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An audience member asked the panel why the Sunshine Act had a dollar threshold of $10, an amount that many consider both extremely burdensome and of limited utility. Fugh-Burman stated: “I’ll defend the $10; in fact I believe it should be $1 because what social sciences shows us is that small gifts actually have a larger impact than large gifts.” Fugh-Burman argued that “nobody likes to think that they’ve been bought off by a small gift.” When you change your opinion after a small gift, you think it’s just an independent change, she said.
Another member of the audience tried to get a clear answer about whether the Sunshine Act was drafted to discourage independent CME and other meaningful relationships between companies and doctors. Addressing Whitlock, he noted: “You said this was legal behavior, but it is very clear that we are parsing this into ‘legal but immoral,’ or ‘legal but disdainful’ behavior.”
“I reject associating that with my comments or my boss’s work here,” replied Whitlock, speaking for Senator Grassley. “We are not rushing to pass judgement.” In distancing his own opinion from that of the panel, Whitlock stated: “I realize I am sitting next to judgment here, and we don’t necessarily agree with those things.”
Whitlock added: “I cannot wait to go to my wife on our upcoming anniversary and tell her ‘I heard that little gifts were more meaningful, so I’m just saying maybe this snickers bar verses dinner….'”
View a replay of the conference from CSPAN 3 here: http://www.c-span.org/video/?323780-1/discussion-physician-payment-sunshine-act