Your doctor could be getting money from pharmaceutical companies and doesn’t have to tell you.
It’s not uncommon for health practitioners to have relationships with industry — companies may be in touch about new drugs, sponsor educational conferences or compensate doctors financially for consultation, for work on advisory boards or in clinical trials.
If your doctor’s in the United States, you can search their name in a public database and find each payment itemized by date, company and amount, thanks to the Sunshine Act, part of the Affordable Care Act.
The legislation requires any pharmaceutical company giving payments or “transfers of value” of any kind or amount to American doctors to disclose them in detail.
Canada has no such law.
Canadian pharmaceutical companies are legally required to itemize all of their payments to doctors in Detroit, Fargo, Spokane and Seattle — but none of their payments to doctors in Windsor, Winnipeg, Calgary or Vancouver.
Disclosures for presentations, not patients
Nav Persaud, a researcher and physician with St. Michael’s Department of Family and Community Medicine in Toronto, wants that to change.
“I think patients want to know that, when they’re prescribed a medication, that it’s in the patient’s best interest,” he said.
“There are requirements to disclose that funding when, for example, you’re giving a talk to your colleagues. What there’s not clear guidance on is whether those gifts or payments need to be disclosed to patients.”
Provincial governments could do it easily, Persaud argues: Ontario, for example, could pass a law requiring all the companies manufacturing drugs covered under the Ontario Drug Benefit to disclose and itemize all of their payments to Ontario health practitioners.
“That could clearly happen in Ontario.”
‘What are we trying to achieve here?’
Russell Williams is less enthused about that idea.
“It would be hugely complicated,” he said.
Williams is president of Innovative Medicines Canada, a pharmaceutical industry group formerly known as Rx&D.
His group’s 10 members have a more modest proposal: They want to start disclosing the total amount of money they give health practitioners — broken down into direct and indirect fees, grants, donations and sponsorships — starting next year.
“I’m hoping that through this exercise we’ll learn the right questions, the right methodology, we’ll share best practices, and I’m hoping we’ll do even better in the next few years,” he said.
Publishing the same information for payments to Canadian doctors his members now publish for American doctors would be “possible,” he said.
“But I’m wondering, ‘What are we trying to achieve here?'”
He’d rather start by just releasing total amounts.
“Let’s see what kind of results we get and then we can have a discussion later on about, ‘Well, do we have to move farther?'”
Williams said Canadian privacy law would prohibit the publication of individual doctors’ information the way the American database does.
“There is privacy legislation that would have to be dealt with … across the country.”
Ontario’s former privacy commissioner isn’t so sure.
“My gut reaction is no, it shouldn’t violate privacy per se because the use of physicians’ names, in the context of the performance of their duties, would not be treated as personal information,” Ann Cavoukian, now director of Ryerson University’s Privacy & Big Data Institute, wrote in an email.
“In the context of work-related activities for which we must be held accountable, there must be openness and transparency.”
Persaud argues publishing the total amount of payments made to all Canadian physicians would be an unnecessary half-measure.
“If you’re going to make a disclosure, why not go all the way?”
‘There needs to be room for appropriate partnerships’
Persaud admits he’s not a fan of these financial relationships, period.
But other doctors argue pharmaceutical companies play a vital role in health care, providing money for conferences, research and education that wouldn’t exist otherwise.
Industry sponsorships make possible “the types of things that the health care budget can’t afford on its own,” says Mary Lynch, a clinician and pain specialist based at Dalhousie University.
“There needs to be room for appropriate partnerships where you’re trying to obtain funding to do good works that are in the interest of patients.”
Pharmaceutical companies have played significant roles in funding pain conferences, education initiatives and associations dedicated to studying and treating chronic pain.
The people with McMaster University’s National Pain Centre tasked with writing national guidelines for opioids have disclosed competing interests relating to their relationships with opioid manufacturers.
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None of this would exist without that funding, Lynch says. And “there are very strict guidelines.”
“Education regarding pain assessment and management is not happening,” she said.
“If there is a conflict, patients should know. But currently we don’t sort of go in and meet the patient and say, ‘Oh, by the way, it’s important that you know that I sit on this board or that board.”
‘We should know what’s influencing the way we’re spending money’
Necessary or not, research indicates these kinds of financial exchanges can change the way clinicians practice in subconscious ways, says Joel Lexchin, an emergency physician and health policy professor at York University.
Research into the nature of that change has yielded mixed results: Sometimes greater interaction with the pharmaceutical industry leads to higher prescribing frequency and higher costs; sometimes there’s no association.
The issue of industry influence has prompted change from other parts of Canada’s medical community: multiple medical schools have sought to distance themselves from insufficiently balanced learning materials, thanks in part to Persaud’s and Lexchin’s research.
Canada’s College of Family Physicians struck a task force to study the health and pharmaceutical industry’s impact on their practice, and to explore the possibility of complete dissociation.
The College hasn’t published its task force’s findings in full; CEO Francine Lemire says they’re still studying the issue.
After the Sunshine Act passed in the U.S., investigative non-profit ProPublica compared the payment database with physicians prescribing database. They found that the doctors who got the most money from pharmaceutical companies were also the ones who prescribed the most brand-name drugs.
It’s important to note, correlation isn’t causation. And no one’s suggesting prescribers who are paid for services by pharmaceutical companies are compromised clinicians because of it.
“The argument that doctors can put forward is that what they’re prescribing is based on legitimate scientific evidence and they’re not being influenced, which may well be true but in that case they should be prepared to justify their prescribing behaviour,” Lexchin said.
“If drugs are being paid for publicly, then we should know what’s influencing the way we’re spending money. … And individual patients should know if their doctors are getting money from drug companies.”
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Health practitioners and industry payments: What are the rules?
Every medical college in Canada has binding rules on its members regarding their relationships with industry. (The Canadian Medical Association also has guidelines; if you’re affiliated with an academic institution, they probably have rules of their own.)
Ontario’s College of Physicians and Surgeons defines “conflict of interest” as “any time a reasonable person could perceive that a physician’s personal interest or relationship with industry is at odds with the physician’s professional responsibilities.”
It prohibits physicians from accepting “personal gifts of any value from industry or industry representatives.” But you’re allowed to accept things that advance disease treatment or education and are a benefit to patients. Meaning, if a company gives you free drugs you have to give them to your patients and not your family or yourself.
When industry representatives want to tell you about a product they’re allowed to buy you and your staff a meal as long as it’s “of modest value.”
Final approval for content of educational events and conferences has to be approved by organizers, not industry sponsors. If you’re presenting at, or working on, a conference funded by industry you can get paid and reimbursed for it “at fair market value and commensurate with the services provided.”
You can sit on a company’s board and they can compensate you for it at “fair market value” and pay for “reasonable” travel and accommodation.
If you get money from industry, if you have investments in industry or if you sit on a company’s board, you have to say so when giving a presentation at an educational event.
You can participate in industry-sponsored research and be paid for it as long as it’s “ethically defensible, scientifically valid, and … complies with relevant national guidelines.”
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