Doctors, when surveyed, say they are opposed to the very idea of skewing their prescribing practice in favor of companies giving them money. The problem is, they still take lots of money in the form of honoraria, speaking fees, research grants, and outright gifts from pharmaceutical and medical device companies. Research suggests they can then fail to recognize that they’ve been influenced.
Psychologists George Loewenstein and Don Moore argued in a 2004 paper that while people consciously think about their professional obligations, the other half of a conflict — self-interest — is “automatic, viscerally compelling and often unconscious.” That theme keeps returning in more recent research.
As MD turned ethics professor Sunita Sah of Georgetown University concluded in a review paper, even if doctors don’t recognize what’s going on, those in the pharmaceutical industry understand social psychology and know what works. Reciprocity is a part of human nature, and field studies have shown that doctors change their practices to reciprocate gifts and favors. Those who ultimately lose in this game are the patients, who are at risk of prescriptions that are not entirely in their best interest.
Every once in a while an extreme case leads to a dramatic downfall. That happened recently when a New York Times/ProPublica story revealed that Memorial Sloan Kettering Cancer Center’s chief medical officer Jose Baselga had accepted millions from industry and then written numerous scientific papers without disclosing financial ties to the companies whose products he was studying.
He resigned within days. The larger problem remains: Conflict of interest is the norm in medicine. According to a 2007 survey, 94 percent of physicians had some sort of industry ties. And as Sah and other social scientists have shown in their research, this can bias their behavior even as they insist they are above it.
Sense of entitlement is a big factor in physicians’ acceptance of industry money. In one study she co-wrote with Loewenstein, doctors were more likely to agree they would accept industry payments when they were reminded of their sacrifices — years of medical school, debt incurred, sleep deprivation when on call. She compared the attitude to that expressed in the famous commercial for L’Oreal hair products: “I’m worth it.”
In addition to the lure of money, pharma and medical device companies can appeal to physicians’ egos by anointing them “key opinion leaders.” In one of her papers, Sah quotes one such leader, a psychiatrist, saying: “It strokes your narcissism. … The first thing they do is take you to a really nice hotel. And sometimes they pick you up in a limo, and you feel very important, and they have really, really good food.”
In another study, which examined conflict of interest and bias across professions, Sah and Lowenstein showed that people were less likely to offer biased, self-serving advice when they worked with individuals, known by name. In experiments, subjects designated as advisers could guide advisees in a number estimation game — the adviser having access to more information than the advisees. The advisers could benefit from causing advisees to make an overestimate, while the advisees benefited from getting the number right.
When they were giving advice to individuals, advisers were less likely to act selfishly. When dealing with groups, self-interest became a bigger factor, though subjects weren’t aware of the change. They reported afterward that they were unbiased and gave good advice. In interpreting the findings, the researchers suggested that in doctor-patient relationships, empathy might guide decisions. But people have more trouble feeling empathy toward nameless groups, as they would in, say, making clinical guidelines or public health recommendations. Grants for studies also appears to create a bias. Industry-funded studies are more likely than independent ones to show a product is effective, according to a 2017 review.
Disclosure rules are supposed to limit the damage, but other studies show they don’t help much. In a 2005 paper, researchers argued that advisers feel “morally licensed and strategically encouraged” to give even more erroneous or exaggerated advice once a conflict was disclosed. In another paper, Sah and colleagues showed that patients were just as likely to take advice after a conflict-of-interest disclosure. Some thought that if a doctor owned a stake in an imaging center, for example, then he or she must have expertise. Others reported they felt awkward about refusing. After a conflict-of-interest disclosure, she said, “advice can be harder to turn down because it suggests you think the doctor is biased and corrupt.”
The main benefit is that disclosure rules can discourage providers from taking money that creates a conflict in the first place. There is hope, however, that doctors can be more principled than other kinds of advisers. In a recent study, volunteers were asked to play the role of either doctors or financial advisers and were placed in a conflict situation where they could make money at the expense of advisees. Those who were reminded of their responsibility as doctors gave less selfish advice, and those reminded of their role as financial advisers gave more selfish advice. When researchers carried out the same experiment with real doctors and financial advisers, Sah said, they got pretty much the same result.
So maybe doctors are a little special after all, in that they work by professional standards that put patients’ well-being above fancy dinners, prestige and the almighty dollar. But with drug companies and others cleverly playing to doctors’ selfish desires, they may sometimes need a reminder.
1. Healthcare, given that we have 325 million-plus people in the U.S. with an aging and growing population that is living longer, is a very complex problem.
2. When I hear any executive, technology person or sales person look at an audience and say, “If everyone would just use this type of coaching app for diabetes or behavioral health, we would cut billions of dollars in costs,” I cringe, scoff, laugh and tend to get angry. I recently heard this in a speech I listened to.
3. Healthcare at its core is really taking care of individual patients. I see the theories behind population health and preventive health but I’m skeptical that it’s a fix-all.
4. When people say there should be no fee for service, I tend to think they’re representing some constituency. I assume at some level someone will still need to get paid to do something.
5. Hospitals and physicians and many providers will struggle as they become more reliant on governmental pay and as commercial patients are siphoned off. Government reimbursements will soften.
6. I’m not so dumb as to not see the irony in the campaign signs that said “get the government’s hands off my Medicare.”
7. Notwithstanding No. 6, whenever the government does place fingers on the scale, they are often wrong, and it often has massive unintended consequences.
8. The system costs with 325 million-plus people in the U.S. are crazy and insurance costs per family are insane.
9. Both parties are tone deaf as to the needs of the American people. Simply stated people that are poor need healthcare, and people that aren’t poor need affordable healthcare. These people are both Republicans and Democrats.
10. Given the quasi-monopolies of insurance companies in certain areas and the lack of insurance options, it’s likely we will need some sort of public option at some point.
It’s not all bleak and this is part of a larger talk on healthcare as a zero sum game. But here are 11 headwinds facing systems.
1. Pharmaceutical costs particularly non-generic.
2. Payers expanding into providers and combining with providers.
3. Payer market share.
4. Health IT and cybersecurity costs.
5. Labor costs and a labor intensive business.
6. High costs of bricks and mortar.
7. Medicare as a larger percentage of health system revenue and Medicare reimbursement softening now and over time as federal deficits rise.
8. Slowing overall healthcare inflation as hospital costs rise.
9. Siphoning off of better paying commercial patients.
10. Siphoning off of profitable ancillaries.
11. Entry of big technology firms into healthcare.
|The politics and substantive rules of the road for the Affordable Care Act are more stable now than they have been in years. But chaos is never far away.
What to watch: The upcoming ACA enrollment season, which starts Nov. 1, will be the first one with the Trump administration’s agenda fully in place, and it will test just how effective that agenda is.
This period of relative certainty could come undone in court.
The bottom line: We’re either adjusting to the new normal, or in the calm before the storm. A federal judge in Texas and a six-week enrollment period will tell us which. — Sam Baker
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Seven things to know:
1. The ballot initiative, initially filed in May, would place a 15 percent cap on the amount Palo Alto-based hospitals can charge in excess of direct patient care costs. Hospitals, medical clinics and other providers in Palo Alto would have to refund payers for charges exceeding the 15 percent cap within 180 days of each fiscal year.
2. The Service Employees International Union-United Healthcare Workers West sponsored the measure. It represents healthcare workers at Stanford Health Care — which has a main campus in Palo Alto.
3. Stanford University announced its opposition to the measure in a Sept. 28 statement.
The measure “would threaten Stanford Health Care’s ability to provide top-quality healthcare to patients from Palo Alto and across the region,” officials said.
“Such a policy is estimated to reduce Stanford Health Care’s budget by 25 percent, requiring significant cutbacks and the possible closure of many services and programs that are essential to high-quality healthcare in the local area.”
4. Union spokesperson Sean Wherley argued the measure will provide accountability for local healthcare providers and the city, according to the report.
“This is about transparency [and] letting people understand how much [they] are being charged, and why [they] are being charged so much more than the clinic down the street or in the neighboring community,” he told The Stanford Daily. “This is our chance as an organization to get healthcare costs under control.”
5. The union has also taken issue with Stanford Health Care’s profits, but the system said these are necessary resources to maintain its specialists, facilities and community benefit program, and that the system invests all its profit margin.
6. Palo Alto City Council members voted this summer to oppose the measure. According to the report, they attributed the decision to not having adequate bureaucratic infrastructure to regulate healthcare charges from local providers.
7. As of Oct. 3, the political action committee of the union and the opposition committee — Protect Our Local Hospitals and Health Care — had spent a combined $1.8 million on the measure.
Senate Republicans turned back a Democratic bid Wednesday to kill President Trump’s plan to expand the sale of health plans that fall short of Obamacare’s rules, saying Americans who buy insurance on their own need more options, not fewer.
Sen. Susan Collins, Maine Republican, sided with Democrats in the 50-50 vote, though the resolution needed a majority to advance.
Its defeat was never in doubt, really, though the vote allowed Democrats to paint Republicans as “junk plan” peddlers who don’t care about people with preexisting conditions who might pay more for robust coverage, as healthier people who cross-subsidize their costs ditch Obamacare for skimpier options.
“This administration wants to let these junk insurance plans run rampant and let people be duped into thinking they’re having insurance when it covers almost nothing,” Senate Minority Leader Charles E. Schumer said. “They are a massive risk to any family who purchases them, and worse, they cause rates to go up for everyone else.”
Democrats are elevating their defense of health coverage for sicker Americans this mid-term season, citing polling that shows GOP threats to undo Obamacare’s protections for preexisting conditions are unpopular.
Sen. Tammy Baldwin, Wisconsin Democrat facing re-election, pushed Wednesday’s resolution under the Congressional Review Act, which gives Capitol Hill a chance to veto new rules and regulations.
She targeted a Trump rule, finalized in August, that would allow companies to sell “short-term” health plans that fall short of Obamacare’s full coverage menu, and to allow Americans to hold the plans for up to a year.
President Barack Obama himself allowed consumers to hold short-term insurance for a full year until 2016, when he capped short-term plans at three months.
Republicans were quick to point that out, although Mr. Trump’s regulation would let consumers renew for an additional two years.
The administration and its GOP allies say Americans have been priced out of Obamacare’s market, so invalidating Mr. Trump’s attempt to extend a lifeline would be cruel.
“Surely, they must have a better answer than snatching away one of the remaining options that some Americans still prefer,” Senate Majority Leader Mitch McConnell said.
“Our constituents deserve more options, not fewer,” he said. “The last thing we should do is destroy one of the options that still is actually working for American families.”