Thursday, April 24, 2008

Massachusetts Senate Passes Drug Company Gift Ban

On April 18, the Massachusetts State Senate unanimously passed a law that included a complete ban on any gifts from the pharmacetical industry to doctors in the state.

This ban was only a small part of a larger bill to control health care costs in the state, but it is the provision inciting the most controversy by far. At this point, the bill is headed to the state House of Representatives, and then to the governor, so the ban is not yet a fait accompli.

It’s been highly entertaining to see how the issue has been playing out in the blogosphere and in local papers. The first salvo came in the form of this op-ed in the Boston Globe by Christopher R. Anderson, president of the Massachusetts High Technology Council.
Among other things, Anderson argued that a gift ban would hurt the state’s biotech industry by “undercutting biopharmaceutical employers that are expected to create jobs here.”

Boston’s conservative paper, the Boston Herald, then chimed in with this editorial, which quoted a letter from four drug companies complaining that the gift ban would hurt business and implying that drug companies would take their money to other states if it were enacted. The Herald said that the gift ban would “kneecap” the life science industry in Massachusetts.

Wow. How demeaning to both drug companies and doctors. Apparently, the only way to succeed as a pharmaceutical company in Massachusetts is to bribe doctors to use your products. And here I thought business success depended on creating valuable medical treatments that offer real advantages over competitors.

By the way, if companies believe they can flee regulation of their marketing practices by leaving Massachusetts, they’re wrong. Minnesota bans gifts worth more than $50, and Vermont requires public disclosure of gifts over $25. And according to this legislative round-up from The Prescription Project, in 2007 over half of all state legislatures considered bills addressing various aspects of bribery-based pharmaceutical marketing.

Furthermore, m
any of the country's premiere academic medical centers have already banned drug company gifts in their facilities, including Yale, Stanford, University of Michigan, University of Pennsylvania, Boston Medical Center, Vanderbilt University, University of Pittsburg, and University of Massachusetts. The huge University of California system is now in the process of formulating its own gift ban.

There truly is no place for drug companies to hide. A better solution is for the companies to scale back their marketing to traditional and legitimate practices, such as advertisements in medical journals.

At any rate, the Herald then published this perplexing op-ed written by two Boston physicians, supposedly arguing against the gift ban. The perplexing part of the article is that they actually claim to support gift bans in academic medical centers, and furthermore, they readily admit both that the reason drug reps call on doctors is to get them to prescribe more of their drugs, and that cheaper generics are often just as effective as newer, expensive agents, which, they say, "may add only incremental value." Thus, they don’t seem to be arguing against the gift ban per se, but rather they appear to believe that this bill is the first step in a darker liberal agenda: “The real intent of these critics goes far beyond food and trinkets, and its true purpose is to curtail strictly or even eliminate all contacts between physicians and private industry.” Talk about conpiracy theories. There's nothing in the bill eliminating, or even discussing, payments for CME activities or industry funding of research. Come on people, enough with the straw man arguments.

The credibility of the editorial was severely damaged by the conflicts of interest of the writers, which were only partially disclosed in the article. The disclosure noted that Dennis Ausiello is a director of Pfizer, but did not also note that he is on the advisory boards of three other drug companies. Tom Stossel disclosed no COIs at all, despite the fact that he is on Merck’s advisory board and receives payments for various speaking and marketing activities from four other companies. No wonder their editorial, ultimately, fell on deaf ears in the State Senate. You can read more details in two articles in Pharmalot and the Wall St. Journal Health Blog.

Meanwhile, the battle for public opinion has been spiced up by several letters to the editor, including here and here by yours truly, these two pro-bribery letters (one by a physician's husband and the other by the CEO of a promotional products company), and here by Lisa Kaplan Howe of the Massacusetts Prescription Reform Coalition, which is a group I work with.

The fact is that our patients want us to base our prescribing decisions on an objective reading of the medical literature, rathet than a hard sell from professional salesmen. And bribery? It’s time to delete the term from the pharmaceutical industry’s lexicon.


soulful sepulcher said...

"A better solution is for the companies to scale back their marketing to traditional and legitimate practices, such as advertisements in medical journals."

Sounds great that these bans are happening/beginning etc.; though in essence doesn't an advertisement in a medical journal have the same potential influence for the doctor? how can one objectively read the journal when the ads are there?

Aubrey Blumsohn has some posts that keep stats on how many ads are in the BMJ which I find quite interesting.

I don't believe the ads should be there. But, I am not a psychiatrist, just an observer.

Daniel Carlat said...

Stephany, I don't have a problem with drug co. ads, as long as there is a reasonable firewall separating the advertising from the editorial side of the journal. How are ads different from drug reps? Less intrusive, and better regulated. In theory, all drug rep communication is regulated by the FDA, just like drug ads, but the reality is that in the give and take of conversation a lot of inaccurate, or at least exaggerated, medical information gets communicated.

soulful sepulcher said...

Thanks Dr.C, good point about the conversations adding more to the equation than the ad,-- that should have been obvious to me.

Supremacy Claus said...

Let's say a journal without ads costs $100 a year to subscribers. A journal with ads costs $10 to subscribers. Don't the ads represent a gift of $90 to all subscribers, even those who do not wish to receive any gift from a drug company, such as Dan?

What if there is an article about a specific condition, and next to it is the remedy in the form of a medication approved for that condition? Is that a bit shady?

Here is the point the left is making. Journals are left wing organs. So paying the left wing organ is not a problem. Clinicians are individuals who directly care for patients. So, they cannot be trusted with a sandwich, for fear of using the wrong treatment after the bribe of a sandwich. Meanwhile, the left wing organ, the journal has received payments in the $millions.

I would appreciate an instance of an article critical of a drug in the same issue as an ad for the drug.

James M. La Rossa Jr. said...

Any physician receiving a free medical journal is part of that journal's "controlled circulation," which means the reader prescribes in such a manner, or is part of a valuable demographic as to attract an advertiser who wants to market to that reader, which, in effect, pays for the cost of the journal, so SC is absolutely correct that the journal is subsidized by advertising. It is, in effect, a gift, but from numerous companies, so there is no ONE COMPANY to feel beholden to. Does this even the playing field and diffuse the issue? DC, I surmise, would say YES. So the FDA's gift provision is diffused in favor of a free market in which anyone can participate.

Let's take it up a notch. It was asked: "What if there is an article about a specific condition, and next to it is the remedy in the form of a medication [advertisement] approved for that condition? Is that a bit shady?"

A study was shown some years ago that the advertisers in Vanity Fair are the subjects of editorial stories at a much higher rate than non-advertisers. Somehow, we live with the contradictions, and good writers and editors occasionally break through and good fashion or science or whatnot is born. But anyone kidding themselves that there is not a reproductive role between advertising and editorial has not given this enough thought.

But this is all window dressing in the great State of Massachusetts. Have we gone so far as to accept that a State Legislator can tell a public citizen what or what not she can accept from a corporation? Are we prepared, in effect, to re-write the state penal code to make that particular gift from this particular company a crime? And what's the crime? Tax fraud? Bribery? Is the doctor being "menaced" by the gift? Have we become this pathetic that the only way to "moralize" medicine is to criminalize gift-giving? Did everyone move to Guantanamo Bay while I was out carousing last night? Justify it all you want -- but Ladies and Gentlemen -- you have just invited a bunch of glad-handing, back-slapping state reps into your waiting rooms to stand in judgment on someone -- that being most of you -- who have survived seven + years of medical school and residency. Are you really this naive (many other words come to mind as well)?

In the 1970s, we virtually gave up the consumer electronics industry to Japan because of ill-chosen government regulation. This century, let's destroy the pharmaceutical industry AND obliterate medicine as a lucrative career and make it a trifecta. I'm not a gambler, so I don't know if I'm using that term correctly. But I do know a bunch of lambs being lead to to slaughter when I see them! You wouldn't be the first intellectuals to lose your minds in the heroic pursuit of tying to save yourselves! And, oh, the irony.

Anonymous said...

Thanks for blogging on this issue. It's in line with an article we ran on the GNIF Brain Blogger. Recently, Dan Abshear divorced himself from "big pharma" and joined our writing team. He now reveals the corruption involved with drug development, research, and approval in order to get to our medicine cabinets. Thank you.


Anonymous said...

read Albert Fuchs' op-ed piece in the LA Times (exact date it ran I do not know-it was run in The Baltimore Sun paper, opinion section).
titled No More Middleman, note the comment in middle of paragraph 6:
", a doctor has only one route to more income: increased volume."
Or, drug whore. I read between the lines.

Hope this is of interest to the readers of this blog.

Supremacy Claus said...

The left wing hypocrites need to cancel all subscriptions to journals carrying advertising by drug companies, including JAMA and that Commie rag, the NEJM. The ads have subsidized their reading by factors of 10 times higher than the subsidized subscription price.

The same goes for those Commie rags, the SF Chronicle and the Baltimore Sun.

Supremacy Claus said...

I invite this form of legislation in my state. I would have standing to sue the state in Federal court for violating the Free Speech Clause, not to mention the Dormant and the Awake Commerce Clause. Even to get my suit dismissed on first pleading would cost the Commies running it $1 million. The state does nothing well nor efficiently except collect the rent.

Anonymous said...

It's saturday night, I've had a long week, as I was at a conference on psychotherapy today for 8 hours, and I come on this blog site and read the same crap from the same people.

This has become f#*&*%g chat room banter, folks. So, let's get back to the point at hand, and that is responding to the posting that Dr Carlat makes each few days that addresses inappropriate behaviors by various idiots who allegedly represent people of authority and medical discipline.

By the way, Dr Carlat, where would you be if people like me did not subscribe to your newsletter? It's a question I have pondered these past few days. You need rebels and invested colleagues to keep this publication afloat, so don't take us for granted. Just remember what a radio talk show host repeats every so often on his show: don't believe your press too much, or you'll become a footnote. I respect your work, just stay grounded!

To you people who challenge me for my postings on this commentary: you are irrelevant to me at this point. Further postings from me are to educate and direct to more important comments from others. I'm done with this chat room BS!!!

What is with this word verification stuff anyway!?

Supremacy Claus said...

TF: Did you pay for the full cost of this conference on psychotherapy and get CME credit? What did you learn that you did not know before?

Anonymous said...

As noted, I will offer quotes and sources to educate and enlighten.

1. from Severed Trust, by George Lundberg, MD; page 153:
"In the end, however, we have to wonder whether less isn't sometimes more in medicine. Sometimes the best medicine may be to advise cautious waiting. Often, as Archie Cochrane so eloquently pointed out, the recuperative powers of the body are indeed more powerful than medications. Sometimes the very best therapy comes not from pills or procedures but from professional attention to a patient's distress."

2. from Cynthia Geppert, MD's column in July 07 Psychiatric Times, page 78:
"If medicine continues on its present path and evolves, or should I say devolves, into a business, it will represent the first time since the Hippocratic revolution that those entrusted with the care of the sick and weak are not members of a profession with all the virtues and values this implies. However effective and even equitable the future business of medicine might become, the authentic practice of medicine as a healing art will no longer be possible, since the essence of doctoring is the exercise of compassion in the relief of suffering."

So what do these two citations have to do with this blog? You allow people who have no true investment to enhance care be the deciders of treatment interventions, passive acceptance if not flagrant support by physicians is guilt by inclusion. Waiting for politicians to set policy is failure, because politicians are as much if not more corruptable than physicians as a group could ever be. So Dr Carlat may be hopeful such legislation would be of value, but it still takes decisions out of our hands.

Having once been ostracized for taking a stand against poor care decisions, why the hell can't we as a group stand up to, what I hope is, the minority of whores and cowards that feed at the pharmaceutical trough and ostracize them.

As a reader of Spiderman as a kid, I love the quote: with great power comes greater responsibility. that is what we as physicians have to accept.

Supremacy Claus said...

TF: Many psychiatric conditions are episodic. One could withhold treatment until the passage of an episode. The patient could rage on in a state hospital, use cold sheets to calm, an all natural remedy. Once improved in 6 months, release.

But that's the care of 1950. It also promotes something in your interest. It promotes psychotherapy for catatonic or manic patients, as used to be done in 1950. One has to be seen daily at $300 an hour, for the duration of the episode, even if mute or rigid.

So you are promoting your own brand of care. It's from 1950.

The public has made its choice for something else. There is evidence for the brain protective effect of early and steady treatment. If allowed to go untreated, patients get more episodes, more severe episodes, more prolonged episodes, more treatment resistant episodes. If you decide to dispute this settled idea, provide data, not quotes from people who do not see patients, and are devoid of credibility. These are left wing ideologue paper shufflers.

What is indisputable is the cost comparison of prolonged untreated illness and adequate treatment with medication. It includes the deaths of 10's of 1000's of additional undertreated patients by suicide, at the peak age of productivity and responsibility.

Not even veterinarians take the proposed path.

Anonymous said...

While I loathe to respond to you, SC, your comment on April 27, 7AM, has to be addressed.

Yes, I paid for it, as it was NOT funded by a pharma org, and why should it be as it was on psychotherapy and not meds, and I received CME credits, as I should as it was for 6 hours.

More annoying was your question as to did I learn anything. Yes I did, I pursue CMEs as I continue to learn things to this day and beyond. CMEs are in place to insure the humility that you as a doctor don't know it all and need to keep up to date and refresh concepts that you may not practice on a daily basis.

Bringing it back to this blog site, CMEs need to be regulated and monitored so people do not get false information, or skewed information, or minimal information.

Your role in this commentary site is beyond bizarre. Again, either tone down your rhetoric or find somewhere else to practice your niche philosophies. Or, just view me as irrelevant and ignore my postings here, since you don't seem to ever give any feedback I am a support or value to you.

Have a nice day!

this word verification is to stymie people from replying?

Supremacy Claus said...

Was there advertising of any kind, for books, for services, perhaps by faculty? If there was, then your cost was reduced by the value of the advertising, and you were bribed by that discount.

The word verification is very hard for the old people. Designed to keep spam ads away, it frustrates the old people. It is a type of rudeness by Dan. He should just delete the Viagra ads daily.

James M. La Rossa Jr. said...

Do you have an opinion on the issue of medical/physician over-regulation, TF? I did not think I was banging the same drum.

SC: While, I surmise, you are an experienced blogger and I am a relative novice, we all spend time here in the hope that someone will find something important in what we have to say. How we "say" it is important, as well. I don't think that referring to the Sun, the SF Chronicle, JAMA and the NEJM as "Commie rags" furthers our community goal. You have every right to write those things, of course, but please note that a valuable contributor could assume that we are NOT engaged in a serious debate when they read such broad and dismissive language about four very different publications. When I look at past postings here, it seems that the best debates have multiple commentators, who stay "on point" however difficult it might be for them to hide their personal animus. More later. Best, j.

Anonymous said...

I have no further interest in this chat room banter bs, as James' point to outside readers exposed to "we are not engaged in a serious debate" will not participate when they read remarks that are not focused on the points to this blog site. I've said this before, and I appreciate James saying it in a nicer but direct way.

I'll give you, SC, the right to ask to clarify if there were other incentives for participation by the audience. I didn't see any; no books, no referrals to contacts outside the conference, no sales pitches. I listened to 6 authorities who were educating a group of different providers: MDs, RNs, therapists, residents, who wanted to know about CBT, IPT, EMDR, and other techniques to work with patients. It was a good conference, because the goal was to learn and have some time to interact with others, on a Saturday, in a more relaxed environment. Hard to believe there wasn't a sales pitch in there somewhere, Hmmm SC?

James, I'm not sure I understand your question about medical/physician overregulation.
In a broad way, we are subjected to so much oversight and accountability, you have to wonder why anyone would go into medicine in this millenium. I have no qualms saying if I could choose a profession again, knowing what I know now back to the age of 25(which I am not close to now!), Medical school would not be considered. But, you can't throw away 12 years of work and start over again with a family, plus I like providing the care I was trained to do, when I have the chance.

This is chat room crap, so I'll leave the above in place but get back to the point: we as doctors let managed care, big pharma, and politicians direct our interventions, we have failed our patients. My quotes from others on Sunday are the start of reflecting what are healthy impressions in my career. I would like to hear others, especially new ones, chime in and dialogue about the importance to this blog.

this word verification is a step above hieroglyphics !!!

Supremacy Claus said...

TF: How much did the 6 hours of CME cost you, including travel time, and any lost income?

Anonymous said...

Sir, you are inappropriate and are incapable of reasonable discussion.
I do not have to answer to you, and I have made the final mistake in trying to respect your random chance of fair dialogue (yes, it does average out to 1/20 comments I gave some credibility to accept).

Hopefully you will deem me as irrelevant as I deem you.

Supremacy Claus said...

TF: Your cost is relevant to this blog. It gives an idea of the cost of unsponsored, pure CME.

Also name a new idea you learned if there was one.

I would like to calculate the total cost and divide it by the number of new ideas you learned. This would be real world calculation.

Anonymous said...

Why will I regret giving you an answer? Because you prey on my instinct to be fair and reasonable, and hold hope you will respect it in turn.

$160 for 6 CMEs.

This discussion is over for me. I am interested in the posting today.

Do me and you a favor: move on!

Supremacy Claus said...

Did they provide lunch?

Daamn. That CME requirement is one expensive unfunded mandate by the left wing ideologue rent seeking Commies running the license board.

Supremacy Claus said...

Jim: Self-dealing redistributionists, redistributing mostly to themselves, are rent seeking, incompetent, inferior competitors in the CME market. They attack clinical care in bad faith. Civility is inappropriate.

There is also likely to be a correlation with their opposition to direct to consumer advertising. The left wing ideologues are just maintaining their rent seeking turfs, without disclosing their self-dealing conflicts of interest.

I am a patient, and have patients in my family. And, I feel personally threatened, as a patient, by these left wing ideologues, by the land pirates, and by government over-reaching regulators. I would not be here without the products of these companies. I support the formation of patient advocacy direct action groups that would just apply self-help to the left wing ideologue. Pay a visit to the Macy Foundation. To deter.

James M. La Rossa Jr. said...

The "Land Grab" for CME dollars, as SC uniquely put it, was always there, I guess, but it it began to get completely out of control in 1999/2000 -- when the APA began to heavily restrict rights to anything said or done at its own meetings, so that ONLY the association could benefit economically. Speakers were required from that point on to sign away copyright on their own slides to the APA. (I've gone on record many times as having said that this is patently illegal and completely unenforceable as a matter of law ... but that's not my point.) Clearly, the APA wanted the pharmaceutical money for themselves.

Considering how aggressive the APA was in protecting its turf from outside MED-ED companies, I will be curious to watch how the association divorces itself from industry sponsorship, as it has announced. I know you may disagree, but they made a daring good faith first move by electing Carlat to the Association's leadership. He, of all people, knows this matter well.

My point is to illustrate that this issue of competing for CME dollars was "sanctioned" by the most powerful association in psychiatry -- which now may be in a unique position to reverse the trend -- not to invite criticism of DC. Let's hope my press credentials are not suddenly "lost" at the meeting. -j

soulful sepulcher said...

"Go to the APA Meetings in Washington the next week or so and watch and listen to the hierarchy of this organization. They are so out of touch with the reality of this field, it is beyond embarassing. And this is from a doctor who has been harassed, threatened, and hounded by these "old guard people" because they are truly threatened by someone like me who stands up to poor standards of care and efforts."--therapyfirst

Thank God for this statement! Do you know how many of them I have met in the last decade? that refused conversation of intelligence, referencing their "30-35 year" "I'm the doctor" "If you want to become a psychiatrist then do it".? just to name a few arrogant comments said to me in board rooms, and in the end, they all had no idea how to treat my daughter and in the end one psychiatrist, no make that 2 have thanked me and told me I was a fierce advocate because "you saw something in your daughter ALL of them didn't" and that is why she is not in a state institution to this day. Me.
Sorry this is off topic, but TF, I highly suggest you go to blogger, sign up and start your own blog--"Therapy First" and start your writings. I am serious, link up to this blog and I will send over my readers to yours. You have a voice that needs to come out of this comment section, as much as I appreciate this blog, yours would be regarded the same. Informative, refreshing, and standing up for what you believe in.
Get over the word verification, it keeps the spammers down and in essence challenges your mind, and tests your patience, which is needed in your line of work, yes?
Thanks for your rants, because they are interesting and I've been reading with amusement at your word verification frustration, and how SC has got you under his thumb, let it go.
Just another "sociology psych major" with hands on experience inside of 6 psych wards, as a mother who listens A LOT.

Anonymous said...

Dr Carlat:

If you are going to delete a comment entry, I think you are obligated to acknowledge the entry was deleted and perhaps give at least a short explanation as to why it was removed. I sensed you might remove my comments about what the leaders of the APA are about because I used an obscenity in the entry, but if that was so offensive, I would like to hear your explanation to why what others continue to write in here, that is fairly inappropriate as well, remains in place.

Censorship may be a right in one's own blog site, but without accountability, it will not encourage participation. Otherwise, it could be interpreted as being as inflexible and rigid as the issues you claim to be fighting to rectify. That would seem to take the wind out of the sails you hope to ride on, eh?

I hope you will at least consider this perspective.

soulful sepulcher said...

TF: is it your comment that has this in it?
"Go to the APA Meetings in Washington the next week or so and watch and listen to the hierarchy of this organization. They are so out of touch with the reality of this field, it is beyond embarassing. And this is from a doctor who has been harassed, threatened, and hounded by these "old guard people" because they are truly threatened by someone like me who stands up to poor standards of care and efforts."--therapyfirst"

Because I did respond to that comment, and it does now not make sense in the comment thread where I was able to quote you.

But, yes blog authors have the right to delete comments.

Anonymous said...


That quote was from me, but it was censored for R rated terms. Dr C did provide a disclosure in his most recent posting section, so notice has been served.

Catch you in later postings, if any made soon that are of interest to comment on. My interest here is to pass on the words of others who have written on this quest by Dr C now. Big pharma is a demon, do not underestimate its control of the medical discipline. Physicians won't give up their paydays if we don't slam managed care for their role in crippling our efforts to pursue the worth of our craft. I'd like to say it the way it needs to be voiced, but I'm not interested in being deleted again.

Be cautious in your words!

Maybe word verifications can be used as censors.

Psychiatrist in Iowa said...

I have heard SC make a couple of references to a concept that merits further consideration: There was a question as to how many new ideas were actually learned at a conference. This is an excellent point. An even more important question is this: Why do we really go to conferences? Do we go learn new info, or is it really a recreational experience? I have often thought that these presentations could eaily be held in a hospital auditorium rather than an upscale hotel. And would it really kill up to buy our own lunches?

The debate often centers on who should pay the bill, rather than the activity itself. We act as if we are entitled to pompous surroundings in exotic places. Some of the best programs I have attended were right here in Iowa put on by local experts in hospital auditoriums. One reason that I stopped going to drug company junkets is I always felt at the end like it was just a big infomercial of very limited clinical usefulness. That, and I felt like I needed to take a shower when I got home...