A Multi-Dimensional Web

The important article in the Annals of Internal Medicine on the stealth marketing of Neurontin (see post here) was accompanied by an editorial (Henney JE. Safeguarding patient welfare: who's in charge. Ann Intern Med 2006; 145: 305-6.)

Its author, Dr Jane Henney, put the onus on physicians to address conflicts of interest involving pharmaceutical companies.

Steinman and colleagues' article provides numerous examples of conflicts that arise when physicians receive compensation or other benefits from manufacturers in exchange for assistance with the marketing of drugs for off-label uses. The burden of managing these conflicts is the responsibility of the physician. The first and foremost principle of conflict management is disclosure. Whether the audience is a single patient or a group of fellow physicians, when the physician has accepted financial or other support (for example, slide preparation) from a manufacturer and has not told the audience about the arrangement, then that physician has gone over the line.

Steinman and colleagues' article on gabapentin marketing and promotion points out in stark detail that no patient is well-served when a manufacturer engages in practices, whether inside or outside the law, that involve physicians in activities in which conflicts are present. But physicians are not passive participants: They can say 'No.'

We have recently posted about arguments that disclosing conflicts of interest in health care may not be sufficient to manage all their ill effects, and could possibly even enhance such effects.

Ironically (a word that I seem to be using a lot), Henney's editorial itself illustrates the ambiguities created by disclosure. In her introduction, she discloses, "I have been privileged to serve in a variety of roles, including that of oncologist, principal investigator, study manager, senior academic administrator, Commissioner of Food and Drugs at the U.S. Food and Drug Administration (FDA), and as board member for 3 Fortune 500 and Global 500 companies (AstraZeneca PLC, 2001 to present; AmerisourceBergen Corporation, 2002 to present; and Cigna Corporation, 2004 to present). "

This disclosure immediately raises questions about why the solution she advocated for the problem of stealth marketing indicated by the Neurontin case was merely disclosure, rather the abolition of particularly important conflicts of interest. Was she speaking as an academic leader of a medical center, or as someone with ficuciary responsibility to the stock-holders of a large pharmaceutical company (Astra-Zeneca), a company that acts as a middle-man between pharmaceutical manufacturers and patients and providers, including hospitals and academic medical centers (AmerisourceBergen), and/or a health insurer/ managed care organization (Cigna)?

Furthermore, all the organizations she leads ostensibly have conflicting interests, forming a multi-dimensional web. The role of these conflicting interests in controllling costs is at the heart of arguments for market based health care. In theory, pharmaceutical companies to maximize their profits want to maximize drug prices and prescribing volume. Companies that convey drugs to users and providers want to maximize profits by minimizing drug prices. Academic medical centers want to maximize their surpluses by minimizing the prices they pay for drugs and other goods and services, while maximizing their reimbursement from insurers. Insurers want to minimize reimbursements for drugs and reimbursements provided to hospitals. In theory, the competition resulting from these competing interests should control costs.

However, Dr Henney is one example of how the leadership of organizations with such ostensibly competing interests overlap. Does this mean that these organizations are not likely to negotiate as vigorously as the theory suggests? Does this suggest a reason why health care costs have not been controlled by the market model? And does this suggest that US health care diverges even more from an ideal free market than was heretofore believed?

Inquiring minds want to know.