Sunday, May 15, 2011

Last Week's Hearing on Virginia's Health Care Lawsuits

(Originally posted on the National Physicians Alliance Virginia Local Network page, May 15, 2011)


Last week, two Virginia lawsuts against the Patient Protection and Accountable Care Act (PPACA) were heard in the United States Court of Appeals for the Fourth Circuit.  The 3-judge panel heard appeals for two different cases: one case brought forward by Liberty University (in which the PPACA was upheld), and one case brought forward by Virginia's Attorney General Ken Cuccinelli (in which the PPACA was found unconstitutional).  This is the next step on what will be the PPACA's inevitable review by the United States Supreme Court.  Last Tuesday's hearing begins a string of appeal hearings across the United States.

As of right now, it does not sound as though the hearings went very well for AG Cuccinelli.  Kaiser Health News summarized much of the news coverage of the hearing, and most analysis indicated that the panel appeared inclined to uphold the PPACA.  Some of the news reports indicate that the panel might even determine that the Commonwealth of Virginia has no standing to sue the Federal government regarding the PPACA.  Despite this apparently unfavorable early response from the court, AG Cuccinelli is making no indication of changing his approach even though the panel seemed to reject his claim that not buying insurance was inactivity (as opposed to activity) and therefore could not be regulated.

Obviously, every single person (unless incredibly lucky) will need to access health care during our lives, so this is a necessity and not a commodity.  So long as healthcare expensive (which it is) and largely paid for by for-profit insurance companies (which it is), people will need to have access to health insurance.  And as long as we require Emergency Departments to provide treatment for everyone, regardless of their insurance status (which we do), then it is fair to ask everyone to pay into the system that will pay for their care when they need it.  Currently, it is estimated that $1,000 of each family's health insurance policy costs result from cost-shifting for uncompensated care.  It is reasonable to expect all of us to pay our share, and to help those who seek insurance but cannot afford it.

A decision from the 3-judge panel is expected in the next few months; whatever happens, another appeal will follow.

How the Medical Industrial Complex Influences Physicians

(Originally posted on the National Physicians Alliance blog, May 15, 2011)


One of the National Physicians Alliance (NPA)'s key issues is that of integrity and trust in medicine, and the greatest focus in this area has been that of physicians' conflicts of interest with the pharmaceutical (PhRMA) and medical device industry.

There is an already-developing literature showing that increased physician contact with industry impacts the decisions that physicians make and the nature of the care that we provide.  Articles have advised that physicians should refuse to see pharmaceutical sales reps as the evidence suggests that increased contact with PhRMA results in medical decisions that do not necessarily benefit our patients.  Other articles have indicated that PhRMA contact changes physicians' prescribing patterns; that physician/PhRMA contact affects prescribing and professional behavior; that PhRMA funding affects research decisions, seems to affect the way research results are reported, may affect the content of continuing education (CME) programs, affects medication sales and formulary decisions, and negatively effects physicians' prescribing decisions in that physicians exposed to advertising tend to use newer medications inappropriately (or excessively), and that physicians tend to underestimate the effect advertising has on their practice (link here); that even unintended or unrecognized bias may affect patients' trust in physicians; etc.

As the evidence continues to build, PhRMA has developed a voluntary code of conduct (pdf) that is intended to guide its members' interactions with health care providers.  This code of conduct addresses such issues as gifts and meals PhRMA reps can provide to physicians, the way in which industry interacts with corporate consultants and speakers, and how industry will support CME programs.  The American Academy of Family Physician's summary of this updated code of conduct can be read here.  The end result of this update appears to limit the risk of bias and influence as industry sales reps interact with health care providers.

In response, it appears that PhRMA and medical device companies are starting to look elsewhere to exert influence.  As public scrutiny of industry/physician relationships increase, industry appears to be exerting influence at higher level.  ProPublica recently reported on the nature of industry relationships with medical societies.  This influence is of great importance, both because influencing professional medical societies can lead to downstream influence of that society's members, and because these societies are often involved in writing and/or endorsing practice guidelines that influence the way thousands of physicians practice.  For example, ProPublica has reported that nearly 1/2 of the money the Heart Rhythm Society collected in 2010 came from makers of medical devices and cardiac medications.  As a result, at one of the Society's recent meetings, industry ads were seen on the carpet, on the bus used to transport attendees, and in attendees hotel rooms.  In addition, ProPublica found that 12 of 18 of the Society's directors have received money from industry sources, and this does not appear to be something limited to this one organization.  The article continues to describe the ways in which professional societies and industry have worked together to influence is frightening and very much worth reading.

In a related article, ProPublica has reported that the Society for Cardiac Angiography and Interventions received 57% of its revenues in 2009 from the medical device industry.  This took place even as over 50% of patients who received stents did so before receiving optimal maximal therapy, which is counter to the recommended course of care of maximizing medical treatment before using stents to treat coronary artery disease.  The United States Senate's Finance Committee has released a report indicating that the professional societies that represent interventional Cardiology have done little to address this issue of over-treatment.

The professional societies usually defend their interactions with PhRMA and medical device makers by arguing that the industry funding makes educational programs less expensive, that the funding can be used to provide training programs for physicians, and that without disseminating this information physicians will be unable to keep up with new developments in their fields.

I would counter by arguing that, as physicians, it is our professional obligation to keep up on new developments without depending on industry-funded "education".  We need to recognize that any information that is affected by industry funding is likely to demonstrate some level of influence, and we need to seek sources of information that do not use any industry money.  If this involves paying more money for subscriptions, memberships, etc, then so be it.  If we are reading a journal or attending a conference that includes industry ads or exhibits, we can choose to ignore them and pass them by.  Our professional societies need to work harder to remove industry influence from any educational events they sponsor: make funding and conflicts of interest transparent, move any industry exhibits to an area that does not require conference attendees to pass through them in order to get to the conference rooms or any academic exhibits, and continue to search for other funding mechanisms that can reduce industry's influence.

Unfortunately, it appears that the medical profession is not yet at the point where we are willing to take on this increased responsibility.  In a recent study, physicians noted their concern that industry support can bias medical education, but that less than 1/2 of those who responded would be willing to pay more to remove industry influence and only 15% felt it was necessary to eliminate commercial support for CME. So: we acknowledge the risk of influence, and yet decline to do anything to reduce it.

We should be better than this.  We should be asking our professional societies to disclose exactly how much of their funding comes from industry and how that funding is used.  We need to push those who organize CME events to reduce the opportunities for industry influence, and to make any financial conflicts of interest public--both at the level of the event and for each of the event's speakers.  We can discuss these issues with patients, and encourage patients to ask their physicians if they take industry money...or encourage patients to find out for themselves by using this resource. We can join the NPA's Unbranded Doctor campaign, and/or take the No Free Lunch pledge.

We must do better.  Our patients' health and wellness depends on it.