The AMA, "Prescription Data-Mining," In-Store Clinics, and Patients' and Physicians' Interests

OK - I'm back from Geneva and it's time to catch up.

Last weeek, two commentaries from the US east and west coasts slammed the American Medical Association. From the west coast, in the San Francisco Chronicle, Robert Restuccia from the Prescription Project and Lydia Valas from the National Physicians Alliance criticized how the AMA sells information on individual physicians to be used in pharmaceutical company marketing.

One of the less obvious but more intrusive marketing tools is the drug rep's hand-held computer, which contains a detailed profile of your doctor's prescribing history. Armed with the knowledge of each doctor's individual prescribing habits, pharmaceutical sales representatives tailor their pitches to each physician.

The AMA sells information from its physician "Masterfile" to health information organizations that pair the identifying information with prescribing records from pharmacies and sell the whole package to pharmaceutical companies, a practice commonly called "prescription data-mining."

The AMA profits handsomely from this agreement. In 2005, the AMA made more than $44 million from the sale of database products, approximately 16 percent of its budget.

Despite representing less than 30 percent of all U.S. doctors, the AMA keeps identifying information on all licensed physicians - and sells it all. Even so, only 60 percent of physicians surveyed by the Kaiser Family Foundation were aware of the sale of their information. Once told, 74 percent disapproved. Even a survey by the AMA itself found a 66 percent disapproval rate.

A number of policymakers, physician groups and medical societies have come out against this practice in recent years. Leaders include the National Physicians Alliance, the American Medical Student Association, the Vermont Medical Society and the New Hampshire Medical Society. Unfortunately, the AMA has a financial incentive to keep selling this information without regard to how it is being used or the impact it has on patient care and health-care costs.

By continuing to profit from the sale of physician data, the AMA has shown itself to be at best, slow-to-act, and at worst, opportunistic at the expense of professional boundaries. The AMA should put medical ethics before profits and stop licensing its Physician Masterfile for pharmaceutical marketing purposes.

From the east coast, in the Washington Post, Regina E Herzlinger from the Harvard Business School and the Manhattan Institute, criticized the AMA for spending so much effort fighting in-store clinics, but also had more global criticisms.

Physician incomes, when adjusted for inflation, declined 7 percent from 1995 to 2003, while those of professional and technical workers rose. But unlike other professionals -- lawyers, architects, authors and economists -- doctors' work is dictated by the policies of insurers and governments. Increasingly, independent physicians, accountable only to their patients and the Hippocratic oath, have been replaced by salaried doctors who are accountable to the hospitals or insurers that employ them. Salaried physicians are closely policed for productivity, leading to ever-shorter and more numerous appointments per day.

Meanwhile, academic medical journals routinely publish studies that supposedly document the cupidity and ignorance of practicing physicians while lauding the virtues of single-payer health-care systems, such as those in Canada or Britain, in which the physician is paid only by the government. German physicians unhappy with their salaries and work hours under this kind of system had no recourse against their monopolistic bosses but to go on strike last year.

Small wonder that applications to medical schools have declined by nearly 20 percent in the past decade.

You might expect that the AMA would fight the insurers, hospitals, government bureaucrats and ivory tower academics who have diminished physicians' incomes, besmirched their ethical reputations and compromised their professionalism -- but you would be wrong. No, instead, at its annual meeting last month, the AMA declared war on retail medical clinics....

Unfortunately, while the AMA engages in trivial turf warfare, physicians are increasingly forced to become salaried employees of hospitals and insurers and are constrained by recipes for the practice of medicine that are cooked up by government and insurance company bureaucrats.

The cycle is bringing about the imminent collapse of the medical profession -- which gravely endangers our health-care system. We and doctors deserve better advocates.

In my humble opinion, Prof Herzlinger's criticism of the AMA's concerns about in-store clinics is not well justified. (See our last post on such clinics here.) But her more global concerns are substantive. Clearly, a lot of physicians are disgruntled, and as we have posted repeatedly, primary care and cognitive physicians appear to be an endangered species. The increasing domination of medicine by large organizations, including the hospitals and hospital systems and insurance companies and managed care organizations she mentions clearly has a lot to do with these problems. The AMA has, in my experience, at times stood up to the power of these organizations, but not with much effect.

On the other hand, the increasing power of pharmaceutical, biotechnology, and device manufacturers, fostered in part by the complex financial webs these companies have woven to reach individual physicians, academics and academic institutions, and medical associations, also has a lot to do with the problems of health care. The first editorial suggests that the the AMA, representing only 30% of American physicians, but getting 16% of its revenue from the sale of these physicians' data to be used in part by pharmaceutical marketers, may now be too entangled in these webs to always put the interests of patients and physicians first.

For more on the relationships between medical associations and commercial sponsors, see Chapter 12 of the excellent Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry, by Howard Brody, and Kassirer JP. Professional societies and industry support: what is the quid pro quo? Perspectives Biol Med 2007; 50: 7-17 (see our relevant post here).