Sunshine Act: Are Doctors Still Enjoying Free Lunches From Drug Reps?

Leigh Page

Disclosures

November 21, 2017

In This Article

Lawmakers Are Getting Involved

Lawmakers are also bearing down on drug reps, often noting that some reps promote brand-name opioids at a time when illegal use of opioids has reached epidemic proportions.

The Chicago City Council, citing the opioid crisis, passed an ordinance in November 2016 that requires drug reps to have licenses. In Chicago, drug reps must now keep detailed lists of the doctors they visited and the materials they provide them, according to a report[7] on the new ordinance.

Meanwhile, Vermont has made it unlawful for drug reps to provide meals, and in 2017, the California Senate passed a bill that would restrict drug companies from providing travel, speaking fees, meals, consulting payments, entertainment, and other economic benefits to providers.[8] The bill is now in the California Assembly.

Free lunches weren't supposed to be the major target of the Open Payments system, according to Sullivan. "People are more concerned about taking doctors out for a round of golf or an expensive dinner," he says.

The chief concern, reformers say, are the physicians who get five- and six-figure consulting fees. According to the report to MedPAC, a very small group of doctors get an immense amount of money from industry through consultancy arrangements and the like. Looking just at general payments to doctors—which includes everything from free meals to paid consultancies, but not money for research or ownership—the report showed that 86% of industry spending went to just 5% of listed doctors.

Free Lunches Get a Bad Rap

Free lunches didn't use to be such a big deal. The old American Medical Association (AMA) ethics code[9] on industry gift-giving, written in the 1990s, actually condoned free lunches. "In an office or hospital encounter with a company representative," the old AMA code stated, "it is permissible to accept a meal of nominal value, such as a sandwich or snack."

But a rewrite of the whole AMA code,[10] adopted in June 2016, doesn't get into any specific situations in which physicians may and may not take gifts from industry. Basically, it states that an in-kind gift should be of "minimal value" and "directly benefit patients, including patient education."

This changes things. Some say that it's hard to argue that a catered meal staff and colleagues in your office directly benefits your patients. When the AMA issued a media guide[11] in 2015 that listed three specific examples of permissible interactions with industry—CME sessions, journal reprints, and some sales rep visits—it didn't mention lunches.

The latest bit of ammunition against free lunches came in a study[12] based on data from Open Payments reports that was published in August 2016 in JAMA Internal Medicine. The study found that even a single meal with a drug rep who talks about the company's expensive brand-name statin makes it more likely that physicians will prescribe the brand-name product rather than a less expensive generic statin.

The Ethics of Gift-Giving

Many physicians simply don't believe that food can cloud their objectivity. "There is no better way of getting CME than having it come to you along with a delicious sandwich, especially when many patients also benefit by getting up to half of their treatment for free through samples," an oncologist commented after reading a 2014 Medscape article[13] on the topic.

An allergist commenting on the same article disagreed, however. "You may not think a sandwich and a slap on the back can influence you, but why degrade yourself," he wrote. "You make decisions for your patients based upon what is best for them, not you or some drug company."

Say what you like about the movement against conflicts of interest in medicine, but it is not doctrinaire. Rather than expecting doctors to abandon all ties with the drug and device industries, proponents want them to carefully pick out the relationships that make sense and abandon the ones that don't.

Relationships with industry, the AMA Media Guide notes, "drive innovation in patient care, contribute to the economic well-being of communities, and provide significant resources for professional medical education, to the ultimate benefit of patients."[11]

What Constitutes Conflict of Interest?

The movement challenges doctors to think about what are good relationships and what are not. The current AMA code states, "Gifts to physicians from industry create conditions that carry the risk of subtly biasing—or being perceived to bias—professional judgment in the care of patients."

Applying basic principles regarding conflicts of interest to real-life situations is not always easy. In a 2012 poll,[14] 15% of doctors were "not clear at all" about what constitutes conflict of interest in physician/industry relationships, whereas 42% were somewhat clear and 43% were very clear.

As the movement against conflict of interest continues, some ways of doing things are fading away, such as handing out tchotchkes displaying brand names of drugs as a reminder to doctors to prescribe them.

The drug industry itself backs these changes. Drug reps shouldn't distribute "non-educational items, such as pens, mugs and other 'reminder' objects adorned with a company or product logo," advises the Code on Interactions with Healthcare Professionals[15] of Pharmaceutical Research and Manufacturers of America (PhRMA).

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