For Financial Conflicts of Interest, Size Is Not All That Matters
“It seems plausible that very large payments warrant greater concern about conflict of interest causing bias and undue influence.”
Physician financial conflicts of interest depend on more than just the size of the industry payments they receive. In a recent issue of JAMA, two experts argued that evaluating whether and to what extent an industry-physician payment is problematic should also take into account the purpose and ultimate impact of the payment.
“It seems plausible that very large payments warrant greater concern about conflict of interest causing bias and undue influence,” noted lead author Bernard Lo, MD, president and CEO of the Greenwall Foundation, a biomedical research organization in New York. “The degree of concern will vary, however, according to the type of financial relationship and the nature of the physician's advice or activity.”
The Open Payments database, which publicly reports the amount and type of physician payments from drug and device companies, indicates that the 5 physicians who received the largest industry payments between 2013 and 2015 were given more than $28 million each. That amount might be concerning, but some of these individuals are inventors, the authors note.
“Payments for inventions leading to treatments, for developing effective new therapies, and for valid research serve the primary interest of patients for effective and safe therapies, and as such should be encouraged,” they say.
More concerning is an Open Payments database figure showing that some physicians received as many as 207 payments from 27 companies over the same period for speaking, training and education.
Physicians engaging in these types of paid activities should be excluded from voting on guideline committees. They should, however, be invited to share their views so that their expertise is not left out, the authors say.
Additionally, physicians who receive industry payments and speak at accredited continuing medical education (CME) programs should undergo “particularly careful review.” Accrediting bodies and audience members should ask whether these speakers “inappropriately recommend enlarging the population to be treated by a drug,” “overstate the clinical significant of the drug's benefits,” or “underemphasize adverse effects,” for example.
Speaking fees, where the presentations are prepared primarily by the company, present an ethical dilemma for medical schools, the authors note.
“[This] contradicts the expectations for students and trainees to think critically and receive credit only for work to which they made significant contributions,” they write. While several medical schools do not permit faculty to join speakers' bureaus, the authors urge that the ban become universal.
Physicians receiving smaller amounts from industry raise fewer concerns, but “some very small gifts also matter enough to justify restrictions,” the authors argue. They pointed to research showing that a single $12-$18 meal that is paid for by a drug company can increase prescribing of the company's promoted branded drug, even when equivalent generic drugs are available.
“A small gift to an individual physician may influence prescribing by only that physician, but such gifts are ubiquitous,” the authors write.
Given the complexity of the relationships between industry payments and physician behavior, the authors called for more mining and analysis of the Open Payments database to tease out other “policy-relevant information.”
Lo B and Grady D. “Payments to Physicians: Does the Amount of Money Make a Difference?” JAMA. 2017;317: 1719-1720. doi:10.1001/jama.2017.1872