Prescribing Above the Influence
Brody, on the other hand, will be among those watching to see whether industry influence waters down the bill to a degree that would render it ineffective. “The fact of the matter is that if you follow the track record of the pharmaceutical industry, they almost always get their way in Washington,” he observes. “And they don’t get their way by shouting and screaming and making noise…. So you always have to be very careful and very cautious with any legislation.”
Under the Influence?
The entire ethics debate begs the question: How much influence does a pen or a notepad—or even a slice of pizza—really have on a health care provider’s prescribing habits, anyway? Obviously, there are what Brody calls “high rollers,” the physicians (predominantly) who receive consulting fees totaling millions of dollars in exchange for lending their expertise as “key opinion leaders” on behalf of pharmaceutical companies. But what about the average clinician?
“It’s true that it’s a very large industry, and there are always kids who will throw spitballs in class,” Powell admits. “But it’s a bit like saying, ‘OK, we’ve all lost our recess for the week because Johnny misbehaved.’”
The Massachusetts law “does not convey a lot of faith in the people of these professions to prescribe based on the research and the standard of care,” in the opinion of MAPA President Jillian Crowley, PA-C. “Personally, I cannot think of anyone who would be influenced to prescribe a drug based on a pen—or even remember the pharmaceutical company that produces the drug!”
MCNP President O’Rourke echoes that assessment, calling the Massachusetts code “almost like a slap on the wrist and ‘Big Brother is watching’ kind of stuff.” Her professional viewpoint, she says, has always been to go with the evidence-based data, with the acknowledgment that “pharmaceutical studies are usually skewed in some way. So you take the information and you prescribe what’s appropriate for the patient—not because of the pharmaceutical rep. I think I could say that probably 99.9% of the NP and medical communities feel that way. I think the law didn’t take that into consideration.”
But Brody cautions against assuming that any individual is immune to marketing. He recalls a pharmacist colleague from the hospital where he taught in the family practice residency program, who used to say: “There’s never any doubt in my mind when a drug rep has just come through, because there’s a spike in the prescriptions for the drug that that guy markets.”
“Smart people, profitable people, don’t waste money to the tune of billions of dollars in the US with a marketing strategy that does not work,” Brody argues. “The point is to recognize that we’re all human and we’re all susceptible to these kinds of influences.”
Powell points out that the focus on the pharmaceutical industry overlooks other potentially influencing factors. “When you talk to prescribers, they consistently say that the largest influence on their prescribing decisions is the formulary that the patient’s health insurer establishes,” she says. “But nobody regulates their medical decisions. And in fact, some insurers are paying prescribers to switch patients’ medications, which for a pharmaceutical manufacturer would be a violation of the Anti-Kickback Statute.”
Powell also says that companies have “an obligation” to disseminate relevant information about medications to health care providers. “It’s vitally important that everybody in the health care system have the most current information about new medicines and medicine where there has been a change in the labeling,” she says. “Without that information, prescription medicines can’t be used effectively.”
Brody, on the other hand, says that every health care provider “should have a source of information they know they can go to and they can say, ‘I know that the drug companies are not controlling the information that I’m getting from this source.’”
Money Better Spent
Clearly, the conversation about interactions between pharmaceutical sales reps and health care providers will continue for the foreseeable future. But for PAs and NPs like Crowley and O’Rourke in Massachusetts, the bottom line is really that the money pharmaceutical companies (used to) spend on wining and dining them and their colleagues—an estimated $7 billion annually across the United States—could certainly be put to better use.
Crowley thinks there should be “some regulations on the amount of money [pharmaceutical companies] spend on advertising, so that we cut down on the costs that need to be relayed to the consumer… I think a balance needs to be obtained between the pharmaceutical companies and the state to achieve education for providers and marketing and the lowest cost of the drug to consumers.”
