COMMENTARY

Readers' and Author's Responses to "Physicians for Sale: How Medical Professional Organizations Exploit Their Members"

Jennifer Quinn, MD, MPH; Robert Coli, MD; Adam C. Adler, MS, MD (c); Lawrence Grouse, MD, PhD

Disclosures

October 09, 2008

To the Editor:

Although I disagree with Dr. Grouse's hypothesis damning "Pharma" as the cause of the outrageous costs of US healthcare, I concede that there are numerous questions surrounding the involvement of Pharma and MPOs [medical professional organizations] in medical education, and perceive no answers in the immediate future. However, I am fundamentally troubled by the gender bias exhibited by Dr. Grouse in two of his 3 scenarios that depict the poor, unsuspecting physician, presumably a male, being accosted by attractive female Pharma reps. Can we leave these underhandedly denigrating images out of a very important debate?[1]

Jennifer Quinn, MD, MPH
JQuinn@interlinkhc.com

Reference

  1. Grouse L. Physicians for sale: how medical professional organizations exploit their members. Medscape J Med. 2008;10:169. Available at: http://www.medscape.com/viewarticle/577178 Accessed September 25, 2008.

Author's Reply:

To the Editor:

Thank you for sharing Dr. Quinn's note about a gender issue in my commentary.

I would first like to point out that my commentary is not damning Pharma as the cause of the outrageous costs of US healthcare. I point out in the essay that Pharma in the United States are legal businesses conducting business activities to maximize the profits of their company for their stockholders according to the law. The article focuses on the role of medical professional organizations in the US healthcare crisis.

Concerning the gender of the individual "meeting and greeting" physicians at the Pharma lunch scenario, the marketing and meeting supervisor for the initiatives that I work on, Ms. Laura Brockwell, confirms that the majority of individuals engaged in this work are women. Further, I am not denigrating their performing such work.

Concerning the gender of the Pharma representative, it is my impression that there is about an even mix of men and women in this role in the United States. These people tend to be very well trained; many are pharmacists or PhDs; and I certainly am not disparaging their business activities or the fictional woman who is employed as a representative in the scenario.

Speaking of presumptions, Dr. Quinn "presumes" that the physician who I am presenting in the scenarios is a man. I had no such thought. I guess that people making presumptions reveal more of their own thoughts than those of others.

Sincerely,
Lawrence Grouse, MD, PhD
Clinical Assistant Professor
University of Washington School of Medicine
Seattle, Washington
lgrouse@u.washington.edu

 

To the Editor:

I agree completely with the valuable content of Dr. Grouse's expose and analysis of these physician-damaging, anticonsumer conflicts of interest that permeate the relationships between MPOs [medical professional organizations] (what used to be called "organized medicine"), KOLs [key opinion leaders], and Pharma.[1] These types of private "arrangements," which also debase medical education, are one of the many structural flaws in the US healthcare system that have served to perpetuate our current antimarket, progovernment mess and have blocked any chance of creating durable, market-friendly, proconsumer reforms.

As a leading healthcare economist and author, Dr. John Goodman points out in "Reforming the Health Care System":

There are two entirely different competing views of health reform. One is where the government takes more and more control over our lives. The other promises to 'do no (more) harm' by giving patients control over the resources needed to manage their own health care. All government health care programs are fraught with perverse incentives that distort choices for individuals. If we could keep government from causing harm, America would have a pretty good health care system.[2]

[According to Meier]:

There is growing objective evidence that past government interventions have often unintentionally caused rising health costs and dysfunction in private insurance markets and that over-reliance on third-party insurance, ill-conceived government policies and disruption of the basic doctor-patient relationship cause us to spend too much on health care.[3]

Many hospital-based academicians are among the 126,000 ACP [American College of Physicians] members and/or 14,000 PNHP [Physicians for a National Health Program] members now advocating a single-payer National Health Insurance program.[4,5] Unfortunately, with this type of antimarket, progovernment reform, the collapse of the destructive system that you have described so clearly would not occur, and these largely hidden relationships between MPOs and Pharma would continue to flourish.

However, I believe that the damaging role of MPOs and their leaders on US healthcare would be minimized if a free-market, value-driven, patient/consumer-directed solution could be implemented with established transparency on the pricing, quality, and financial conflicts of interest and restoration of the traditional doctor-patient relationship.

As outlined by Greg Scandlen, Director of Consumers for Health Care Choices at the Heartland Institute, there are at least 10 promising milestones heading in this direction that are already under way. Not one of these developments has required any new legislation.[6]

What could prove to be another key milestone in this same patient-centered direction is a grassroots reform effort by individual physicians that was started on January 29, 2008 by Sean Khozin, MD, MPH, with the Sermo platform.[7,8]

Robert Coli, MD
rdcolidisco@yahoo.com

References

  1. Grouse L. Physicians for sale: how medical professional organizations exploit their members. Medscape J Med. 2008;10:169. Available at: http://www.medscape.com/viewarticle/577178 Accessed September 25, 2008.

  2. Goodman JC, Matthews M Jr. Reforming the U. S. Health Care System.Washington, DC: National Center for Policy Analysis; 1999.

  3. Meier CF. What is free-market health care? The Heartland Institute Web site. September 1, 2002. Available at: http://www.heartland.org/Article.cfm?artId=10333 Accessed September 25, 2008.

  4. Physicians for a National Health Program (PNHP) Web site. Available at: http://www.pnhp.org Accessed September 25, 2008.

  5. American College of Physicians (ACP) Web site. Available at: http://www.acponline.org/about_acp/who_we_are/ Accessed September 25, 2008.

  6. Scandlen G. A health care revolution is underway... no thanks to government 'help.' The Heartland Institute Web site. August 1, 2008. Available at: http://www.heartland.org/Article.cfm?artId=23591 Accessed September 25, 2008.

  7. Doctors unite. Sermo Web site. Available at: http://www.doctorsunite.org Accessed September 25, 2008.

  8. Sean Khozin, MD, MPH. Available at: http://www.seankhozin.com Accessed September 25, 2008.

Author's Reply:

To the Editor:

I thank Dr. Coli for his kind words and his interesting ideas.

I am not a health economist and am not qualified to analyze the outcomes of different healthcare funding and reimbursement plans.

I have read the 10 milestones described in Dr. Coli's reference above, and I am unsure that medical savings plans, concierge medicine, and medical tourism are the way in which our healthcare system needs to go. I do agree that improvement in information technology would be valuable, but I don't agree that providing generic-only medications would benefit US healthcare.

The free market in the United States has certainly been at the heart of our economic achievements, as Dr. Coli indicates, but I believe that without government supervision of the fairness of the economic results of the market, our national ideals cannot be realized.

The consequences of the current supercommercial, superexploitative, superexpensive marketplace in the United States can be seen in the recent meltdown of our entire financial system. The same overcommercialization of healthcare is leading to medical meltdown in the decline in US public health, the loss of continuity and comprehensiveness of US medical care, and rising inaccessibility of care due to cost. The burden to families of this superexpensive healthcare is bankrupting many and turning many treatable illnesses into fatal ones.

Unfortunately, advanced medical care does not follow the free-market rules of cost and demand. For this reason, I advocated in my commentary the establishment of a mandatory primary care base of medical care and a scaling-back and increased regulation of specialty care, the excesses of which I believe have resulted from the activities of the medical professional organizations (MPOs).

By what combination of free-market and government regulation this goal can be achieved I do not know. Our country has to make a major financial commitment to reestablishing a comprehensive, fair, and high-quality healthcare system, and our profession has to make a commitment to working in a realistic system that is within the means of our country and that adheres to the principles of medical ethics.

Sincerely,
Lawrence Grouse, MD, PhD
Clinical Assistant Professor
University of Washington School of Medicine
Seattle, Washington
lgrouse@u.washington.edu

 

 

To the Editor:

Every patient in the United States has been to a doctor's office that appears to have been newly decorated by the drug reps. I have been to offices in which almost every visible thing has some pharmaceutical or drug's name plastered all over it. It could not be argued that acceptance of a free car or vacation or a large sum of money is unethical, but is taking a free pen overboard?

Although there are no simple solutions and no clear place to draw the lines, I would agree that some degree of reform is overdue. It is great to see that states, such as Massachusetts, are taking stance to limit the incentives provided to the healthcare community. If we are to maintain the highest quality of care for our patients, we must tailor the approach to each individual without outside constraints.

I believe that one of the main problems lies in Pharma-sponsored drug trials as well as peer review conducted by Pharma "employees." In the wake of the Avandia disaster, we must remain vigilant of how and who is allowed to scrutinize our work. We would not allow students to grade their own exams and papers, so can we allow those who make the drugs to test and grade them? Unfortunately, in the era of clinical trials, the cost of testing new drugs can be astronomic. Patients enrolled in trials must receive benefits, such as basic care, continuous monitoring, testing, evaluations, and surveys along with payment for any complications that can arise -- at no cost. It seems to me that it would be very difficult to find another source of funding for these trials. Without adequate funding, newer medications would be slower to come to market if at all. Who should we permit to pay for these investigations? Without Pharma money, advances in medicine would cease, ultimately harming patients.

The author claims that "Pharma" subsidies physicians from outside of the United States to attend medical conferences, another way in which they contribute to the revenues of the MPOs [medical professional organizations].[1] True, although this may cause a problem of physician indebtedness to these companies, it remains a fact that many of these physicians are from countries where medicine is much less lucrative, and they would not be able to attend these conferences otherwise. Membership in these MPOs is not mandatory; as a highly intelligent group, it is up to the individual to decide whether and where to belong.

One thing remains a fact: Physicians' prescription writing history must be kept confidential to avoid outside pressures from being relayed. Above all, we must protect the doctors' ability to maintain the highest level of patient care.

Adam C. Adler, MS, MD (c)
Rappaport Faculty of Medicine, Technion Israel Institute of Technology
adamcadler@gmail.com

Reference

  1. Grouse L. Physicians for sale: how medical professional organizations exploit their members. Medscape J Med. 2008;10:169. Available at: http://www.medscape.com/viewarticle/577178 Accessed September 25, 2008.

Author's Reply:

To the Editor:

Dr. Adler makes a number of points, most of which I agree with, and I only have a few additional comments.

A principle of human interaction that has been well recognized since the time of Confucius is reciprocity. Somebody gives things to you and you have an obligation to give something back. Pharma uses this approach very successfully, and physicians who think that they are immune to this effect should consult Solomon's view of vanity to better understand their point of view.

Of course, the power of this effect is proportional to the value of the gift that is provided, which is why in my commentary I emphasized that the influential KOLs [key opinion leaders] who receive substantial personal benefits from Pharma, which represent a major part of their income, are the ones to be most concerned about. Is it a surprise that these are the same people who serve on FDA [US Food and Drug Administration] advisory committees, participate in Pharma clinical trials, present at Pharma-supported CME sessions, and act as peer reviewers?

I don't completely agree with Dr. Adler's comment concerning clinical trials that "Without Pharma money, advances in medicine would cease, ultimately harming patients." I believe that most Pharma studies are efforts to seek documentation of product advantages over competitors and are not as reliable and projectable as they should be. Obviously, most Pharma have to fund some studies just to achieve licensing and approval of their products in countries to market them, but I believe that landmark clinical trial studies by institutes, such as the NIH [National Institutes of Health] NHLBI [US National Heart, Lung, and Blood Institute] did much more to provide guidance on clinical care for physicians than those funded by Pharma.

I agree with Dr. Adler about restricting access to physician prescribing information, and I would emphasize that physicians need to shine some bright lights into the dark corners of their MPOs [medical professional organizations] to expose practices that need reevaluation.

Sincerely,
Lawrence Grouse, MD, PhD
Clinical Assistant Professor
University of Washington School of Medicine
Seattle, Washington
lgrouse@u.washington.edu

 


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