Payments to physicians from medical vendors

 A useful rule of thumb when studying the design of markets is that when you see many related rules against something, that something may still be happening.  In yesterday's post I described the code of conduct that speakers at a medical conference are asked to subscribe to, mostly concerning payments received from medical vendors.  Below is a contemporary article about the incidence of such payments, to cardiologists (interventional cardiologists in particular), starting when they are still trainees.

Dhruva SS, Han M, Jing Y, Trock BJ, Hogan SO, Redberg RF. Industry Payments to Cardiology Fellows and Early-Career Cardiologists. JAMA Intern Med. 2024;184(9):1123–1125. doi:10.1001/jamainternmed.2024.3130 

Here's the introduction to the paper:

"Industry marketing payments to physicians may compromise the objectivity and integrity of clinical decision-making, playing a role in nonrecommended care, higher health care costs, and reduced patient trust. Payments to trainees merit scrutiny because these payments may be formative on future practice. The Association of American Medical Colleges (AAMC) recommends policies “that prohibit the acceptance of any gifts from industry by physicians…and trainees.”1 The Accreditation Council for Graduate Medical Education (ACGME) states “promotional activities by industry can seriously compromise the professional relationships that form the substance of medicine.”2 The National Academy of Medicine (NAM) also argues financial relationships do not benefit the educational mission in ways that offset the risks created.3 We quantified industry payments to cardiology fellows and the association of these payments with payments received after training."

And here is a summary of the results:

"During the year before fellowship graduation, 1993 fellows (80%) in procedural intensive subspecialties and 2057 of 3055 (67%) in nonprocedural intensive subspecialties received industry payments. Median (IQR) payment amount per physician in procedural intensive subspecialties was $1801 ($282-$4445; median [IQR] payments, 17 [4-38]). In nonprocedural intensive subspecialties, median (IQR) payment amount received per physician was $198 ($0-$893; median [IQR] payments, 3 [0-13]).

"A median (IQR) of 3 (2-5) years after fellowship, 2385 physicians (96%) in procedural intensive subspecialties and 2483 (81%) in nonprocedural intensive subspecialties received industry payments. Median (IQR) payment amount per physician per year was $1112 ($372-$2870) and $277 ($95-$838), respectively."

Medical conference code of conduct

  Different fields have different conference cultures, and these change over time.  I've agreed to give a talk at a conference that physicians may attend for Continuing Medical Education (CME) credit, and it came with the following list of things for me to attest. Most of them seem to be assurances that my discussion will not be influenced by companies that have paid me in some way.

Attestations

• The content and/or presentation of the information with which I am involved will promote quality or improvements in health care and will not promote a specific proprietary business interest of an ineligible company.
• Content for this activity, including any presentation of therapeutic options, will be well-balanced, unbiased, and evidence-based. Opinions that are not supported by evidence or are supported by limited or preliminary evidence will be so identified. Recommendations involving clinical medicine will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to will conform to the generally accepted standard of experimental design, data collection, and analysis.
• I have not and will not accept any honoraria, additional payments, or reimbursements directly for this CE activity from an ineligible company.
• I understand that my presentation and/or content may need to be peer-reviewed prior to the activity, and will provide educational content and resources in advance as requested.
• If I am discussing specific healthcare products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.
• If I am discussing any product use that is off-label, I will disclose that the use or indication in question is not currently approved by the FDA.
• If I have been trained or utilized by a commercial interest or its agent as a speaker (e.g., speaker's bureau) for any ineligible company, the promotional aspects of that presentation will not be included in any way with this activity.
• If I am presenting research funded by a commercial interest, the information presented will be based on generally accepted scientific principles and methods and will not promote the ineligible company or the funding company

 

Are economist for sale?

 Here's a recent NYT column:

The Justice Department’s antitrust chief thinks conflicts of interest are degrading scholarship  By Peter Coy

"Are the world’s most powerful corporations buying the brains of economists and legal scholars? It certainly sounds that way if you listen to the chief antitrust enforcer at the Department of Justice.

...

"Kanter didn’t exactly say anything about buying brains. That’s my flourish. What he did say was that “all over the world, money earmarked specifically to discourage antitrust and competition law enforcement is finding its way into the expert community upon which we all depend.

”He even said: “Conflicts of interest and capture have become so rampant and commonplace that it is increasingly rare to encounter a truly neutral academic expert.”

...

"Part of the problem is inadequate disclosure, he said. “If a paper was shadow-funded or influenced by corporate money, it can pass that influence and whatever flaws or biases it introduced into the papers that build on it,” he said. “This insidious ripple effect is difficult — if not nearly impossible — to detect.”

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I'm not sure how big a problem this is, but here's the American Economic Association's code of professional conduct

AEA Code of Professional Conduct

Adopted April 20, 2018

The American Economic Association holds that principles of professional conduct should guide economists in academia, government, nonprofit organizations, and the private sector.

The AEA's founding purpose of  "the encouragement of economic research" requires intellectual and professional integrity. Integrity demands honesty, care, and transparency in conducting and presenting research; disinterested assessment of ideas; acknowledgement of limits of expertise; and disclosure of real and perceived conflicts of interest.

The AEA encourages the "perfect freedom of economic discussion."  This goal requires an environment where all can freely participate and where each idea is considered on its own merits. Economists have a professional obligation to conduct civil and respectful discourse in all forums, including those that allow confidential or anonymous participation.

The AEA seeks to create a professional environment with equal opportunity and fair treatment for all economists, regardless of age, sex, gender identity and expression, race, ethnicity, national origin, religion, sexual orientation, disability, health condition, marital status, parental status, genetic information, political affiliation, professional status, or personal connections.

Economists have both an individual responsibility for their own conduct, and a collective responsibility to promote professional conduct. These responsibilities include developing institutional arrangements and a professional environment that promote free expression concerning economics. These responsibilities also include supporting participation and advancement in the economics profession by individuals from all backgrounds, including particularly those that have been historically underrepresented.

The AEA strives to promote these principles through its activities.

 

About the AEA Code of Professional Conduct

In October 2017, then-AEA President Alvin E. Roth formed an Ad Hoc Committee to Consider a Code of Professional Conduct, and charged it with evaluating various aspects of professional conduct, including those which stifle diversity in Economics. The ad hoc committee, composed of John Campbell (chair), Marianne Bertrand, Pascaline Dupas, Benjamin Edelman, and Matthew D. Shapiro discussed an interim report and draft code with the AEA Executive Committee at its meeting on January 4, 2018, and provided an update to the AEA membership at the Annual Business Meeting on January 5 in Philadelphia. The interim report and draft code were circulated to the membership in January 2018 with an invitation to submit comments. The draft code was revised in response to more than 200 comments received, and the AEA Executive Committee voted on April 20 to adopt the revised Code. The committee thanks all members who offered feedback on the initial draft and would like to emphasize that it read and considered carefully every comment that was submitted. 

To review the interim report from the ad hoc committee, click here.

To review the final report, click here.

Conflicts of interest in caring for candidates for kidney transplants

Harvey Mysel has posted the following (reproduced in its entirety) here:

How Conflicts of Interest Negatively Impacts a Patients Chance to have a Kidney Transplant

Patients who need a kidney transplant expect their dialysis clinic and/or their transplant hospital to provide them with information on the best medical options available. CMS (Centers for Medicare and Medicaid Services) requires dialysis companies and transplant hospitals to provide this information. These companies may “technically” abide by these rules however, the information is often vague and not very useful.

The Conflict for Dialysis Companies
CMS requires dialysis companies to ask: “Has the patient been informed of kidney transplant options?” A Yes/No box needs to be checked. A dialysis company’s mission is to dialyze patients, not to educate them about kidney transplants. It’s a conflict of interest for the dialysis company. Once a patient receives a kidney transplant, they don’t need the services of the dialysis company. What company will educate their customer to an option that will result in losing their customer?

From the statistics you can see there is a problem in the dialysis community. There are over 400,000 people on dialysis but only 98,000 are on the kidney transplant waiting list. By some estimates, 10% of all dialysis patients die every year. Many dialysis patients were good candidates for a kidney transplant when they first started dialysis, but after years of treatments their health deteriorates and the majority is no longer healthy enough to recover from a kidney transplant.

The Conflict for Transplant Hospitals
CMS requires transplant hospitals to tell their patients they can register at more than one transplant hospital. The primary reason to register at another transplant hospital is to be on a shorter waiting list. Providing this information to their patients is a conflict of interest for the hospital. A hospital might tell their patients they could register somewhere else, without letting them know the benefit of doing so. There are regions in the U.S. where the wait for a deceased donor kidney is 5-­-10 years, while in another area, which might only be a 1.5 hour drive, the wait time is only 12 months.

There’s another conflict that can develop for the transplant hospital. Patients are given excellent advice and encouraged to find a living kidney donor. There are many benefits of a living donor kidney versus one from a deceased donor.

The biggest benefit is a kidney from a living donor lasts on average twice as long as one from a deceased donor. Statistics show about one-­-third of all potential donors who are evaluated are not compatible with their intended recipient. Potential donors could have an incompatible blood type or the recipient has certain antibodies, also referred to as being sensitized that will result in rejecting this person’s kidney. High levels of antibodies can develop as a result of a previous transplant, a blood transfusion or for some women giving birth.

Better anti-­-rejection drugs and Kidney Paired Donations (KPD) also called paired exchanges, chains or swaps allow these incompatible donors to help their intended recipient by donating to another recipient who also has an incompatible donor. KPDs have the potential of adding thousands of kidney transplants a year if a centralized national program is developed and all incompatible pairs are registered in the same pool. Unfortunately there isn’t one centralized program, but many different KPD options. To read more about KPDs go to: www.lkdn.org/LKDN_Paired_Exchanges.pdf

Since there are many KPD programs, the likelihood of being matched with another incompatible pair is increased when you join other KPD programs. It’s a numbers game. There are exceptions to this, if there are many pairs with rare blood types or when a pool contains many difficult pairs to match due to the recipient being sensitized. To read more about the paired exchange conundrum go to:http://www.lkdn.org/LKDN_The_Paired_Exchange_Conundrum.pdf

Here’s the conflict. Hospitals are under no obligation to tell their incompatible pairs about the benefits of registering with other KPD programs. This could result in a patient going to another hospital to receive a transplant. What company will educate their customer to an option that will result in losing their customer?

Kidney dialysis and kidney transplants are very profitable for these institutions. It costs approximately $83,000 a year to provide dialysis services for one patient and a kidney transplant can generate approximately $125,000 for a hospital.

What could be done to help patients understand their options and remove these conflicts of interest?

For the dialysis companies, CMS could authorize an independent company to educate the dialysis patients about kidney transplants. There’s no shortage of organizations that are qualified to provide these services.

For the transplant hospitals, CMS and/or UNOS could also authorize an independent company to educate patients about registering at other transplant hospitals and include the options patients have when a potential donor is incompatible.

A kidney transplant, whether from a deceased or living donor is a life changing and complicated process. Patients who are in need of a kidney transplant need much more help in understanding the options available to them.

Harvey Mysel is a two-­-time kidney transplant recipient and Founder of LKDN (Living Kidney Donors Network) a nonprofit organization that offers workshops and webinars to educate people in need of a kidney transplant about living kidney donation. LKDN also helps prepare those in need to effectively communicate their situation to family members and friends. LKDN’s website is www.lkdn.org and Harvey can be reached atharvey@lkdn.org

For a printable copy, click here.

Paywalls create conflict of interest between newspapers and journalists

Journalists, like academics, want their writing to be read. Newspapers, like academic publishers, like to be paid for what they sell. Journalists, like academics like to make their papers available on the web. A recent email from the editor of the Boston Globe Ideas Section makes this clear:

"As you may know, this fall the Globe launched a spiffy new web site devoted exclusively to the newspaper. You may also have noticed it means Ideas is now behind a paywall. However, we have a "one click free" policy from any outside links -- and to provide you those links, and an easy way to keep up with Ideas, we've started a Boston Globe Ideas Facebook page. We also have a Twitter feed, @globeideas. Of course we'd love it if you subscribed to Bostonglobe.com -- but we're also making it easy for you to read and share Ideas stories for free by following one of our accounts."

Commerce and self interest in medicine

A Guided Tour of Modern Medicine’s Underbelly is a NY Times  book review by Dr. Abigail Zuger of  the book WHITE COAT, BLACK HAT: Adventures on the Dark Side of Medicine. By Dr. Carl Elliott.

"A physician who specializes in philosophy and ethics, Dr. Elliott hails from that quiet zone of medicine where much of the job involves thinking about, talking about and doling out medications. Hence his primary focus is on the ever-evolving relationship between the high art of medicine and the big business of drugs.

...
"Doctors get pens and trinkets, football tickets, junkets to beach resorts. Less visible are the large sums handed over in “I’m going to make you a star” projects to groom them as trusted faces and voices in the service of some drug. Education and advertisement merge in these elaborate ventures, as the paid professor travels the country, lecturing about disease and, incidentally, the treatment thereof.


"These “key opinion leaders” are bad enough, but who would ever imagine that the curricula vitae of many academic physicians (those on a medical school faculty) are packed with journal articles actually written by ghostwriters sponsored by pharmaceutical companies?

"“Nobody expects American politicians to write their own speeches anymore,” Dr. Elliott reminds us, “and nobody expects celebrities to write their own memoirs.” Apparently doctors have now joined the ranks of the charismatic talking heads, mouthing the words of others.

"And just as “professor” generally describes someone who writes his or her own sentences, “ethicist” generally describes someone who dwells (or at least works) on an unusually high moral plane. But Dr. Elliott also takes a brief and very informative excursion into the world of the medical ethicists. Once they were highly principled, underpaid gadflies, trying to sort out medical decision making. Now they are part of a booming industry, and, speaking of industry, their ties to the pharmaceutical industry are many and complex. Many companies now hire their own ethicists. But who guards those guards?
...
"What a world, what a world, as the melting witch said in “The Wizard of Oz.” But there is one small consolation: at least Dr. Elliott didn’t have to call his book “White Coat, Black Heart.” Now that would have been depressing. The bottom line is that much of what he describes is simply the big business of medicine as we have allowed it to take shape. His bad actors are mostly just that: actors caught up in a script not of their own devising. They all come home in the evening, take off their black hats and hang up their white coats, just regular working stiffs out to make a buck. "

College admissions in Illinois, conclusion?

U. of Illinois at Urbana-Champaign Chancellor Resigns in Wake of Admissions Scandal
Richard Herman, chancellor of the University of Illinois at Urbana-Champaign, has resigned in the wake of an admissions scandal in which well-connected applicants were put on a "clout list" and given preferential treatment, the Chicago Tribune reported on Tuesday. Mr. Herman, who made a remorseful apology to the faculty after a state panel found he was the "ultimate decision maker" for clout-listed applicants, will join the university's faculty. His resignation follows those of the university president last month and several trustees.

Auctioneers and sellers: Sotheby's mixed role

The WSJ reports Sotheby's Faces Suit Over Disclosure
"Mr. Minor's attorneys say he purchased the work on advice from a Sotheby's specialist and didn't realize the auction house was selling the work to recoup money owed it by another collector. ...
Mr. Minor's suit highlights the increasingly blurred lines that can develop at auction houses between their traditional role as disinterested auctioneers and their emerging business as direct stakeholders or financiers of the work they auction. In their competition for market share and their battle to secure top art work, Sotheby's and Christie's are increasingly acquiring, trading and preselling stakes in works they auction."
...
"For buyers, deciphering the financial dealings behind a work of art has become increasingly difficult. In some cases, like Mr. Minor's, auction houses sell the work as collateral for loans. More commonly, they issue so-called "guarantees" -- promises to pay the seller a minimum price for the work sold through the auction house. The auction house has to pay the guarantee even if the work doesn't sell, so it becomes an effective stakeholder.
Guarantees have surged in recent years. Last year, Sotheby's issued $902 million in guarantees, double the amount in 2006, according to securities filings."