To determine the risks of policies restricting physicians’ access to drug reps, Chressanthis et al. (2012) studied the prescribing decisions of 58,647–72,114 physi- cians. Decisions were statistically analyzed using prescription data from IMS Health. A consulting firm database was used to determine access-to-reps levels for 300,000 physicians. (Reps have a strong financial incentive accurately to log this data because their pay is linked to it.) Physicians were sorted into four categories of access: very low, low, medium, and high. Only high-prescribing doctors of diabetes and lipid-lowering drugs were studied. Low prescribers were ruled out because drugs reps rarely target them.
The drugs were:
• An innovative drug for type 2 diabetes (Januvia-sitagliptin)
• An older diabetes drug with a new FDA-required black box warning for cardio- vascular safety (Avandia-rosiglitazone)
• A combination lipid therapy that had reported negative outcomes in a clinical trial (Vytorin-simvastatin+ezetimibe)
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The authors found:
• Physicians with very low access to reps had the lowest overall adoption of new, first-in-class therapy and took 1.4 and 4.6 times longer to adopt than physicians with greater access.
• In responding to the FDA’s boxed warning for Rosiglitazone, physicians with very low access were 4.0 times slower to reduce their use of this treatment than those with greater access.
• Physicians with very low access to reps were significantly slower to change their prescribing based on negative industry news about combination lipid therapy.
• Overall, cardiologists were the most responsive to information changes relative to primary care physicians.
The authors conclude that limiting access to reps can have the unintended effect of reducing appropriate responses to negative information about drugs just as much as responses to positive information about innovative drugs. When new information became available, primary care physicians who had reduced access to drug reps were more likely to prescribe less effective and potentially more dangerous drugs.
A survey of 2996 physicians found that >50% are working in organized provider systems. Forty-two percent of those reported never seeing industry reps (compared with 25% of independent practitioners). Of those physicians working in organized provider systems who never see reps, 80% report that not seeing reps was due to organizational polices (Quantia and Capgemini Consulting 2014).
Supporters of restrictive drug rep access policies might object that reps have seeded physicians’ information environment with so much bad data that their mak- ing apparently beneficial compensatory updates appears attractive. Perhaps it is bet- ter to cut off the whole desultory exercise with a “nudging” social-distancing policy (Thaler et al. 2006) guided by principles of “libertarian paternalism” (Sunstein and Thaler 2003). The premises of these thinkers have received harsh criticism (Wright and Ginsburg 2012). A fuller discussion of freer versus more restricted information markets goes beyond my purposes.
Conclusion
Appreciation for physicians’ competing interests is not new. About 2500 years ago, Plato observed that the physician “professes medicine,” but he practices an addi- tional art not professed by him—the art of getting payments. Everyone practices the latter art—because no one takes on the troubles of strangers, to straighten them out, but everyone expects payment for that—for the opportunity cost thereby incurred, to use the language of economics.
Plato’s analysis recognized that money payments are not the only kind in which people take an interest. Indeed, money payments, while most common, are the low- est kind. Payments additionally include social recognition/status, affirmation from social sources that matter. Professionals commonly have accepted a payment
L.K. Stell
mix—money but also high status, patient approval, social appreciation for pro bono services, and self-approval for doing good, removing harm, and at least avoiding inflicting needless harm. Plato also mentioned the type of payment required to moti- vate the best of the best—those who had lost interest in money and in further social recognition. Such person could only be motivated to service by avoiding having less qualified, less excellent persons serve in their stead. These exalted souls could not live with themselves were they to allow that to happen. Thus the ultimate sanction and payoff was avoidance of self-disapproval for what one allowed to happen.
The COI cascade seriously misfires by fixating on monetary payoffs while ignor- ing all the other things that people care about, things that can bias their judgment and lead to wrongdoing. Wrongdoing should be the focus, not the temptations and motivations that sometimes result in it.
Today, more than 50% of physicians are practicing within some type of health- care system. Their compensation is tied to various performance metrics—process measures, outcome measures, patient volume, and satisfaction measures. They have much lower access to drug reps than in the past. More than 1/3 of physicians are part of an integrated health network, the most restrictive environment for rep access.
Seventy percent of physicians who have been out of medical school for 10 years or less are employed by an organized health system. More than 50% of physicians have their prescribing decisions constrained by a formulary and a care pathway or require prior authorization. Prescribing restrictions are greater for in-patients than out-patients.
Conversations with drug reps, where allowed, are rule-constrained. It is not enough for a physician to be convinced about a drug’s appropriateness to have it dispensed successfully to a patient. The drug must be on formulary and listed as available on the patient’s electronic health record. It is not easy for a physician to discover which drugs are on formulary. He will receive notification in the event he prescribes off-formulary. Nor may a rep detail a product to a physician if it is not already on formulary. Suggestions for formulary additions must be submitted to a Pharmacy and Therapeutics Committee, not to an individual physician. Lobbying an individual physician to submit a formulary addition request is a violation which carries a campus-exclusion penalty for the rep—as long as 90 days.
Corruption fears have resulted in social-distancing policies of drug reps from physicians, and they have given us sharply constrained information markets. There is some evidence that this may be disadvantageous to patients. Information market restrictions do promote powerful political and corporate interests. Interests that can- not reach these levers of power are disadvantaged. Whether there are compensating benefits in reduced expenditures on drugs and devices, which account for roughly 10% of healthcare expenditures, remains to be seen. The prices of some generics have increased sharply. We can only hope that our institutional policies eventually will be revised in a manner that better respects physicians as sophisticated consum- ers of product marketing and holds them accountable for their choices not their motivational states.
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Acknowledgment I am indebted to Thomas P. Stossel, MD, for the PowerPoint slides and to David Barton for the Excel spreadsheet chronographing the COI cascade.
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