Tuesday, June 3, 2008

Unintended Silliness: Free Lunches get a New Cheerleader

The law banning pharmaceutical gifts to doctors continues to pick up steam, having already been passed by the Massachusetts State Senate, and now being considered in the House Ways and Means Committee. You can get a quick education on the issue by watching this NECN debate between myself and Harvard's Tom Stossel.

I recently learned about an unintended putative victim of this bill: companies that specialize in catering all those free lunches. Kevin Abt, CEO of Restaurants to You, has written this letter to his state representative complaining that not only will his business suffer, but that caterers state-wide will lose $40 million if the bill is passed.

The letter, along with 22 entertaining comments, is posted on the political blog Blue Mass Group, which bills itself as "reality based commentary on politics and policy in Massachusetts and around the nation."

Please go to this great site and read. Here are snippets from some of my favorite responses to Mr. Abt-the-caterer's concerns:

1. "Just because a drug rep isn't paying doesn't mean the doctors won't be eating lunch. This isn't going to be $40 million just disappearing from our economy. It's going to be shifted around some. I bet non-catering deli counters in the vicinity of hospitals will be thrilled to have the gift ban passed. I don't mean to be insensitive to the plight of Mr. Abt and other caterers who have made a business out of catering lunches between doctors and drug reps, but businesses are forced to adjust and adapt all the time for any number of reasons."

2. "So, let's not ban lunch-n-learns. In fact, there's no request to do so. Let's just let the doctors buy their own lunch. After all, at only $8-$20, it wouldn't be a burden on the doctor. Doctors gotta eat. So, it's not about foodz4u.com, it's about who pays for foodz4u.com. This bill wouldn't allow the drug companies to buy the food for the doctors."

3. "By his logic doctors will just go hungry if they don't get free lunches from PhRMA companies. The doctors I know, including my wife, are getting their lunches from the small local restaurants he is claiming will lose money. Of course, the last thing this guy wants is for health care workers to walk to their local restaurants instead of eating catered lunches. More and more hospitals are banning such practices in any case, so whining about it to the legislature is probably not going to do all that much good in the long run."

I might add that Mr. Abt's pulled-out-of-the-air estimate of $40 million cuts both ways. From his point of view, it is $40 million lost from the pockets of a niche food business. But from the consumer's point of view it reminds us of the enormous scale of the pharmaceutical marketing endeavor. The drug industry was once considered an important engine of research and development. But the dirty little secret is that pharmaceutical companies spend more on promotion than on research--much more. The latest analysis, published in PLOS Medicine, estimates that in 2004, drug companies spent $31.5 billion on R & D, dwarfed by the $57.5 billion they spent on marketing and promotion.

I suggest the Mr. Abt begin marketing his tasty offerings directly to physicians--I doubt he'll go out of business.


Anonymous said...

This is a great post. We have these places in California, including one shameless place known as Dr. Lunch!

I for one think we oughta be buying lunch out of our pockets for the gals, and I am pretty generous with the corporate credit card for yummies if we have to work through lunch. Come on, people. Three pizzas can feed an office for about $40, and they deliver! If someone wants to drive to get the food, you can treat the whole office to Chili's for $65. Nice! We aren't breaking the bank here.
Are we really so pathetic that we can only arrange a catered lunch if a rep does all the work? I don't know about the rest of us, but if I can make it past Dr. Walker and internship, I can certainly figure out how to have a nice lunch in the office without a rep.

Anonymous said...

When the drug reps provide lunch, it is usually for the doctors and staff. Assuming an office of 5 physicians and 10 staff, the cost of lunch is probably closer to $100. Annually, that would be $25,000. If you a private practice psychiatrist, charging at least $200 an hour on a cash basis, buying your own lunch may not seem like a big deal. But if this practice is a 5 physician family practice office, struggling to make ends meet with high overheads and low payments from insurance companies, the $25K annually is more than appreciated. Also, primary care physician who take insurance often run so behind schedule trying to squeeze everything into a 15 minute visit, that there is very little time for a lunch break. The catered meal is a time saver as well as a cost saver. Part of the willingness of primary care physicians to accepts lunches and pens is due to the difficulty of maintaining a primary care practice.

soulful sepulcher said...

This is fascinating!

Daniel Carlat said...

My wife made a great suggestion: instead of drug companies spending $40 million on lunches for Massachusetts doctors, why don't they donate the money to food banks and soup kitchens, such as the Greater Boston Food Bank? She is a pediatrician who runs a small practice and maintains it as a drug-rep free zone. They have a small kitchenette with a fridge. The nurses and other staff bring in their own food or go out to local restaurants and pay their own way. Nobody complains about it because this is the way it has always been.

Psychiatrist in Iowa said...

One thing that my colleagues and I noticed after banning drug reps was that we lost weight...seriously!

It can be difficult to stop free lunches and snacks if your staff members (including clerical staff) have grown accustomed to it. We encountered quite a bit of resistance at first. This is one of the insidious effects of the free lunch: Staff members are won over.

Anonymous said...

People may be missing the big picture of the benefit of the ban....

You Have Now Been Sampled (Drug Reps, Part 2)

While the pharmaceutical industry’s image and reputation has suffered, and has been complicated with their declining profits due to a few reasons, these companies still apparently insist on keeping most of their gift- givers on board. Known presently as simply drug reps today, this job has become a vocation void of a sense of accomplishment, which will be described below.
So they may be named at times in different ways, these promoters will be referred to as drug reps, which number close to 100,000 in the U.S. presently, it is believed. The cost to the pharmaceutical industry of these employees is around 5 billion dollars a year. Income for each rep grosses close to or above 100,000 grand a year on average, along with great benefits and a company car, as well as stock options as they gladly work from their homes.
The main function these days of drug reps, I believe, is primarily to offer doctors various types of inducements of a certain value. The drug sampling of doctors may be considered an inducement, and a rather valuable one for the drug rep, as many believe that these samples are what ultimately influence the doctor’s prescribing habits over anything else, including statements from drug reps. This may be why the drug industry spends around 20 billion every year on samples.
While historically drug reps have used their persuasive abilities to influence the prescribing habits of doctors in an honest and ethical manner. However presently, most health care providers now simply refuse to speak with them, or have banned all drug reps permanently from their practices for a number of reasons, including the recommendations from their colleagues. It is possible that this may be due to the following reasons:
1. The doctors lose money. Doctors are normally busy, so their time is valuable. As a drug rep, you are a waste of their time. Yet they will accept your samples still. The credibility you possibly have as a rep is not considered anymore to be present in your vocation due to various controversies associated with the pharmaceutical industry, it is speculated.
2. Most drug reps in the U.S. are hired for their looks and their personality. As a result, many are somewhat ignorant in regards to anything that is clinically relevant to a medical practice, so doctors seem to know this and have responded in such ways. Most drug reps have college degrees that do not correlate with their profession as a drug rep, which is to say that the clinical training of drug reps is limited. In fact, many consider this of such a serious nature that an Act is presently being considered called the SafeRx Act that would certify pharmaceutical reps, and this would be mandatory. One main reason would be to ensure personal accountability for their tactics and statements, I believe, which may improve the quality and safety of their function in the medical community.
3. Many drug reps, it is believed, are void of any ethical considerations due to ignorance of what they are coerced to do or say to prescribers by their employer, and this allows them to embellish the benefits of their promoted products at times in addition to offering inducements to doctors. This is usually due to the rep being unaware of the consequences of their actions at times, yet at other times what reps say is with premeditated intent for potential financial gain for such a drug rep. Worse yet, due to pressure to keep their high-paying jobs, they always are anxious to please their superiors, who require them to offer various types of inducements to physicians that are designated targets of a particular drug company. Such tactics are especially true with the larger drug companies. These reps are in fact coerced to spend these individual promotional budgets assigned to them by their employer. While legally risky, the drug companies continue to dispense to their reps these large budgets reps have been forced to be responsible for dispensing, and are required to spend these budgets. In fact, so much emphasis is placed on this promotional spending, there seems to be an association between the money a rep spends and the progression that occurs with their career working for their pharmaceutical employer. Disclosure laws are being considered presently to mandate the release of all funds dispensed from pharmaceutical companies, which is to say to allow others to see where their money goes and who it goes to, as it is presently very secretive, overall. It is not unusual for a big drug rep to spend 50 thousand dollars a year for clinic lunches alone. In addition, drug reps hire doctors as speakers for certain disease states, and they find many other ways to spend this money they are required to spend.
4. Another issue is what is referred to as data mining. The American Medical Association sells this prescribing data on individual doctors to pharmaceutical companies, which allows them to track the scripts a doctor writes, and the data is free of the patient names. Yet the names the products prescribed are well illustrated and available to the drug reps. This allows reps to tailor their tactical approach with any given doctor, if they see the doctor at all during an office visit. Worse yet, doctors who greatly support the promoted products determined by this data allow reps to reward those doctors who favor the rep’s products that they promote, and this could be considered a form of quid pro quo. Laws are being considered presently to prevent this practice of allowing reps to have this data. Doctors are opposed to the data the reps have as well about them for privacy and deceptive reasons, so they say.
5. Overall, reps can be best described as far as their function goes with their profession is to, whenever possible, manipulate doctors with remuneration or other forms of inducements, as they also continue to sample such doctors along with others their promoted meds. Also, frequent lunches are in fact bought often for doctors’ offices and their staff as a method of access, primarily, as stated earlier with the money reps spend earlier for this type of function. Essentially, because of the income and benefits the drug reps receive that they would likely not be able to obtain with any other job, they are compelled to do such unethical if not illegal tactics mentioned earlier that they perhaps normally would not do in another setting. Usually these drug reps rarely refuse to implement such tactics encouraged to them by their employers.
6. Samples keep the prescriber from selecting what may be their preferred choice of med due to cost savings from samples left with a medical office by a drug rep. In addition, doctors are now being paid by prescription providers, which are called pharmacy benefit managers (PBMs) that are typically owned by a managed care company to have a doctor switch their patients to generic substitutes, if they exist, and this is often not disclosed to such patients. Apparently, these PBM companies are doing this in response to the activities of the branded drug companies, as they continue pay doctors often for various reasons, which are questionable in themselves.
It is likely that most drug reps are good and intelligent people who unfortunately are coerced to do things that may be considered corruptive to others in order to maintain their employment, ultimately. It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps that exists, with their encouragement, which forces the reps to do the wrong thing for the medical community, possibly. Clearly, greed has replaced ethics with this element of the health care system, which is the pharmaceutical industry, as illustrated with what occurs within these companies. However, reversing this misguided focus of drug companies is not impossible if the right action is taken for the benefit of public health. Likely, if there are no drug reps, there is no one to employ such tactics mentioned earlier. Because authentically educating doctors does not appear to be the reason for their vocation. This is far from being the responsibility of a pharmaceutical sales representative.

“What you don’t do can be a destructive force.” --- Eleanor Roosevelt

Dan Abshear

Anonymous said...

Thanks for this terrific post and the great comments. The Massachusetts Prescription Reform Coalition has been reaching out to our state leaders in support of the gift ban. To learn more about the coalition and to join in our efforts please visit www.hcfama.org/mprc or email me at lkaplanhowe@hcfama.org. Also, please consider contacting your state representative and senator to urge them to support the gift ban. You can easily send them an email here - http://capwiz.com/hcfama/issues/alert/?alertid=11423511&type=ST&show_alert=1.

The legislature is considering the gift ban now - it is more important than ever that we reach out to our state leaders about our concerns with pharmaceutical gifts.

soulful sepulcher said...

I think the donating to local food banks, shelters etc. is a great idea. I've spent hundreds of hours as a food bank volunteer, and many times brought items in myself for the clients because shelves were sparse. After so many psychiatric hospital & medical bills due to to my daughter, I am now qualified to use a food bank. Imagine if Pharma funded that!

I can imagine having catered and free lunches would become a habit, as with anything free. This represents far more than the lunches at stake.

Psychiatrist in Iowa said...

One of the interesting quotes from the ex-rep who wrote "How Drug Reps Make Friends and Influence Doctors" was this:

During training, I was told, when you're out to dinner with a doctor, “The physician is eating with a friend. You are eating with a client.”

Supremacy Claus said...

Iowadoc: Cite an instance of your prescribing a medication because of industry sponsorship of an activity, or a trinket. Dan, do the same.

What was the outcome?

Anonymous said...

As a big pharma rep not long ago, I averaged close o 40 thousands dollars a year as an individual rep with such companies. You do the math.

David Behar, M.D., E.J.D. said...

Anonymous: You would have done far better mowing my lawn.

What math are you talking about?

I still await an instance of adverse patient outcome caused by undue industry influence. Iowa Doc, Dan, Dan's wife, Therapy First. Even Stephany is welcome to cite an instance. I am getting desperate here.

Psychiatrist in Iowa said...

"Iowadoc: Cite an instance of your prescribing a medication because of industry sponsorship of an activity, or a trinket."

I don't go to infomercials, don't allow reps in our facility and don't accept gifts in the mail. And I use generic Walmart pens. So your premise is flawed. However, I have read papers suggesting that even very small gifts can influence prescribing behavior.

If these trinkets and programs are not having any impact on prescribing (as you seem to be suggesting), then the coroporations who invest in them must have all collectively made a massive miscalculation...and they keep making it year after year.

I know lots of people who work for big corporations and it has been my general impression that they tend to stop investing millions in marketing schemes that don't pay off.

So either physicians ARE being influenced, or every single drug company on the planet is wrong; which do YOU think is more likely?

Supremacy Claus said...

Iowa: There is not a single fact in response to the question in your reply. Just a bunch of demeaning suppositions about doctors.

Tell us your first drugs of choice for newly diagnosed major depression, mania, schizophrenia, and ADHD. Better yet, you are newly diagnosed with each of these conditions. Your psychiatrist states correctly, the data show no superior medication within classes of drug. You know psychiatry, pick one for yourself."

We can compare your choices to those of doctors in the pocket of drub companies.

Psychiatrist in Iowa said...

SC: If I was trying to spin this whole thing in favor of Pharma, I would probably frame it this way: That criticisms of Pharma were really attacks on physicians. And these attacks suggest that physicians aren't capable of thinking for themselves. Yes, that might just have legs!

Facts or no, you can't deny that there is a certain logic to my position. It I'm wrong, and physcians are impervious to their marketing schemes, then why would Pharma keep spending millions on such futility?

David Behar, M.D., E.J.D. said...

Iowa: You are prepared to starve your staff rather than allow any undue influence in your clinical decisions.

You are going to receive an anti-psychotic. You have good evidence that perphenazine is as good as any, and far cheaper. Outside of the CATIE study, first generation meds have the same discontinuation rate as modern meds, across the board. Tell us what psych med you would want in your body.

You are manic. You hear voices. Your psychiatrist says, they all have the same success and acceptability. You get to pick your drug for monotherapy, and you intend to continue working full time. You cannot be dopey looking or acting.

I trust your honesty, because you are a left wing ideologue. You are all supercilious, goody two shoes. If you answer, I know it will be honestly. It requires a single name.

Give us the name of the neuroleptic you want prescribed for yourself in 2008.

Anonymous said...

A well-managed newsroom absolutely prohibits free lunches for reporters. It has always stunned me that this has been okay for physicians.

There's some essential human sense of reciprocity that instinctively demands graciousness when one has been fed. It's too personal a connection to deny--which is probably why the companies sponsor them.

Psychiatrist in Iowa said...

SC: One of the reasons that I am no longer a registered Republican is that I grew weary of dichotomous thinking. You are either with them or against them. If you don't agree with them on one issue, you are a left-winger.

You don't know me, so I fail to see how you are qualified to label any my global political leanings on the basis of one issue.

In my travels I have found that the average American usually embraces a variety of positions all over the political map. The only true idealogues are found in the media or in politics.

Now back to your question: You are obviously not a psychiatrist, because any psychiatrist would know that you should never indulge a patient who is trying to goad you into a pointless argument.

And no one on my staff is going to starve. In fact, it would do some of them well to lose weight. And I should lose a couple of pounds myself. But thank you for your conern.

David Behar, M.D., E.J.D. said...

Iowa: you are free of undue industry influence. You have to ingest a neuroleptic for some reason. Give us the name.

If you select a first generation one, for yourself, that is based on science and cost.

If you select a current brand name second generation, then that outcome, free of undue industry influence, is the same as the choice of 90% of psychiatrists in this country, all in the pay of industry, according to you.

This is a test of left wing hypocrisy. The neuroleptic is entering your brain, which one do you pick? If you refuse to answer, that implies you pick a heavily promoted second generation neuroleptic, good enough for you, but too good enough for others, according to the left wing hypocrite.

Next, do you use any product advertised on free TV shows? What brand of car do you drive, and how did you select it?

Supremacy Claus said...

Iowa will not answer which neuroleptic he would ingest if he had to. I assume, it is a heavily promoted second generation, extremely expensive kind. His choice is the same as that chosen by doctors for their patients, with or without industry sponsored programs.