Wednesday, March 29, 2006

A New Species of Conflict of Interest in Health Care

This topic warrants an interim summary.

Early this year, we posted about how an article in the Journal of the American Medical Association (JAMA) about conflict of interest in health care provoked considerable discussion (see NY Times editorial, and USA Today editorial). (Brennan TA et al. Health industry practices that create conflicts of interest: a policy proposal for academic medical centers. JAMA 2006; 295: 429-433.) The article posited conflicts of interest as a major threat to physicians' core values. Its exclusive focus was on conflicts of interest involving physicians and pharmaceutical and device manufacturers. It proposed a ban on many possible relationships between physicians and these companies. It asserted that even small gifts, such as pens and coffee mugs with company logos, could influence physicians' decision making. Therefore, it proposed an absolute ban on any gifts of any type to physicians. It also proposed absolute bans on physician service on company speaker bureaus and participation in ghose-written articles. It proposed that all financing of academic activities by pharmaceutical and device companies go through appropriate offices at academic medical centers.

Only a few days later we stumbled across a case of a species of conflict of interest that seemed to be more significant than those discussed in this article, yet had never been discussed in the press or the medical literature (see post here). The case was that of the Marye Anne Fox, Chancellor (equivalent to president) of the University of California - San Diego, and hence the person to whom the University of California, San Diego School of Medicine and its acadmic medical center report. The conflict was between this position, and her service as a member of the board of directors of Boston Scientific, a medical device manufacture, and the board of directors of Pharmaceutical Product Development Inc., a contract research organization.

Medical schools and their academic medical centers and teaching hospitals must deal with all sorts of health care companies, drug and device manufacturers, information technology venders, managed care organizations and health insurers, etc, in the course of fulfilling their patient care, teaching, and research missions. Thus, it seems that service on the board of directors of a such public for-profit health care company would generate a severe conflict for an academic health care leader, because such service entails a fiduciary duty to uphold the interests of the company and its stockholders. Such a duty ought on its face to have a much more important effect on thinking and decision making than receiving a gift, or even being paid for research or consulting services. Furthermore, the financial rewards for service on a company board, which usually include directors' fees and stock options, are comparable to the most highly paid consulting positions. What supports the interests of the company, however, may not always be good for the medical school, academic medical center or teaching hospital.

So, to return to our first example, leaders of the UCSD Medical School must decide whether to purchase medical devices from Boston Scientific or its competitors, perhaps whether to do research concerning such devices, and perhaps whether to cooperate or compete with research done by contract research organizations such as Pharmaceutical Product Development Inc. Yet they also must report to a leader who has a fiduciary duty to and is paid by Boston Scientific and Pharmaceutical Product Development Inc.

Thus alerted, I kept my eye out for other examples of this sort of conflict. To my surprise, they were easy to find.

For example, Dr Ralph Horowitz, Dean of the Medical School at Case-Western Reserve University, was recently appointed to the board of UK based GlaxoSmithKline, although his appointment was then rescinded after the company found he had written an article criticizing one of its products (see post here).

Also, Donna Shalala is President of the University of Miami, and hence the person to whom the University of Miami Leonard M. Miller School of Medicine and its academic medical center reports. President Shalala is on the board of directors of UnitedHealth Group, a large, for-profit managed care organization and health insurer.

I also found a sub-species of this conflict: influential academic leaders of health care research and health policy research who serve on the boards of directors of health care companies whose interests are relevant to their research. This is in some ways similar to the more widely discussed conflicts that may be generated when an academic consults for, serves on a speakers bureau for, owns stock in, or receives research funding from a health care corporation. However, again, service on a board, while it is often well paid, also entails a fiduciary duty to protect the interests of the company and its stockholders. Three examples of this sub-species appeared this month.

Professor Joseph Newhouse of Harvard University was the senior author of an article in Health Affairs about whether oncologists decide which chemotherapy drugs to used based on how they are reimbursed for these drugs. Professor Newhouse, a health care researcher with an international reputation, serves on the board of directors for Aetna Inc., a large for-profit managed care organization and health insurance company. Although some of his previous articles have disclosed this relationship, this one did not. (See post here.)

Mary O'Neill Mundinger, Dean of the School of Nursing of Columbia University, wrote a book chapter in a new book on primary care advocating advanced practice nurses as comparable or even superior to physicians. Dean Mundinger serves on the board of directors of UnitedHealth Group. The book chapter, and some of her previous articles advocating advanced practice nursing did not disclose this relationship. (See post here.)

Professor Uwe Reinhardt, an internationally known health economist at Princeton University, wrote a letter which challenged an op-ed in the New York Times which had decried the effect of business management practices, and of managed care on the doctor-patient relationship. Professor Reinhardt is also on the board of directors of Boston Scientific, on the board of directors of Triad Hospitals, a for-profit hospital network, and on the board of directors of Amerigroup, a for-profit managed care organization. His letter, and his recent articles in JAMA, Health Affairs, and the British Medical Journal did not reveal these relationships. (See post here.)

The ease with which I found examples of conflicts of interest generated by service on a health care company's board of directors suggests that these conflicts may be quite common. Because such service entails a fiduciary duty to protect the company's interests and those of its stock-holders, such conflicts may be quite important. Yet I have found no discussion of this sort of conflict in the media, or in the health care or medical literature. It makes no sense that such conflicts have been ignored while we worry about physicians receiving pens and coffee mugs with company logos. We ought to start paying some attention.


Anonymous said...

While I agree that Roy's digging into conflicts of interest has unearthed some telling tidbits, it's important to remember that just because somebody has a conflict of interest does not mean their findings or opinions are wrong.

Take Uwe Reinhardt's comments in response to an op-ed ("The Doctor will see you FOr Exactly Seven Minutes")that appeared in the Times. Reinhardt may be financially entangled with managed care, but even so, not one thing he said in his letter is untrue. Physicians' share of healthcare dollars did indeed rise in the nineteen-nineties. Maybe some primary care physicians saw their incomes go down, but in the aggregate, physicians saw an increase.

What fell is the per-visit reimbursement to primary care physicians. Managed care didn't require shorter visits; primary care physicians made the decision to see more patients per day in order to maintain their incomes.

In this regard, I found Peter Salgo's op-ed rather disingenuous. He lays the blame entirely at the feet of greedy managed care companies and health insurers. Let's call a spade a spade. The seven minute office visit was a response to shrinking reimbursement. Physicians have every right to object to seeing their reimbursement go down, and it is certainly unfair that primary care has felt the sqeeze far more than proceduralists. But don't blame the loss of time with patients on the insurer. There were other ways to respond to less money per visit and maintain the patient-doctor relationship, including taking a cut in income.

Roy M. Poses MD said...

Reinhardt perhaps also was being disingenuous. See my comments on the details of his arguments (as well as the details of his "entanglements" with corporate health care) below:

Anonymous said...

Funny no one said anything about Brian Strom from the University of Pennsylvania, who not only serves on Medco's Board of Directors but also, it seems, profitted mightily from Medco stock (as in at least 6 figures), based on SEC filings. Why is he exempt from criticism?

Roy M. Poses MD said...

My first attempt at systematic research in this area revealed almost 200 people on faculty or in the leadership of US medical schools who are also on the boards of directors of S+P 1500 health care companies. And I'm sure there are hundreds more who are on the boards of smaller companies, companies who have major health care operations but are not listed as health care companies, health care companies outside the US, and privately held companies.
See our abstract here:

So I have only been able to blog about such people who make it into the news media.

We at Health Care Renewal unfortunately do not presently have the resources to do our own investigative reporting.

Medical Writing Experts said...

While I concur that Roy's delving into irreconcilable circumstances has uncovered some telling goodies, it's critical to recollect that since some person has an irreconcilable circumstance does not mean their discoveries or assessments aren't right.

Roy M. Poses MD said...

Medical Writing Expert,

And did I ever state that if someone has such a conflict of interest everything that person says is not right?

However, conflicted persons' discoveries and assessments may warrant a bit more skepticism, especially if they skew in a way consistent with their conflicts.

By the way, you might want to look into what we have written about conflicts of interes since 2006...