By Peter Young

 

Financial conflicts of interest exist between companies and physicians, and these relationships have the power to influence physicians’ medical practice (1,2,3). Transparency in these clinical relationships can yield a higher standard of ethics and improved informed consent. A recent controversy between leading medical journals, however, showed profound disagreement about whether conflicts of interest should be disclosed at all (4,5,6,7), even though in 2009 it was found that 70% of physicians hold a relationship with industry. Are conflicts of interest no longer a problem?

 

In the 2000s, prominent Baltimore cardiologist Dr. Mark Midei, held a financial relationship with Abbott Laboratories, a cardiac stent manufacturer. It was reported in 2010 in a senate report that Dr. Midei inserted 30 cardiac stents in a single day in August 2008. In reaction to the number of stents inserted, Abbott Executive Vice President, John Capek, wrote in an e-mail, “it is the biggest day I remember hearing about.” Two days later, in celebration of the stent record, Abbott held a barbecue at Dr. Midei’s home and later disclosed a $1,235 reimbursement paid to an Abbott employee for attending that barbecue. This dinner is a small gift when compared to the millions Dr. Midei received from Abbott over several years of collaboration. It should not be surprising, then, that of the 1,878 stents inserted into patients by Dr. Midei, it was later determined that 585 of them were not medically necessary. If the financial relationship between Abbott and Dr. Midei were more transparent, it is possible that many of his patients may have sought second opinions prior to receiving cardiac stents from him.

 

The need for transparency has been recognized with a federally administered online database, known as the Open Payments Program (OPP), which collects and discloses data on the types of benefits that physicians receive from pharmaceutical companies, but the database can be hard to navigate, data may be difficult to understand, and there is low awareness about the program.

 

In a nationally representative survey, Harald Schmidt, Dawei Xie, and I found that a mere 8.4% of American residents have heard of the Open Payments Program, and of those, only 1.5% have ever used the website. This is surprising since we found that two-thirds of the same sample thought knowing about these types of relationships are either important or very important. The OPP is a step in the right direction, but without greater awareness, the database is failing short of its intended goals.

 

There are other issues with the OPP, namely that data are hard to understand if the website does not present doctors’ received payments in context. It is difficult to understand whether one thousand dollars is on the higher or lower end of the spectrum of benefits received by physicians. For example, the Open Payments database shows that, as a group, Philadelphia interventional cardiologists received $3,132 on average during the last 5 months of 2013. However, one of these cardiologists received $47,662 during the same period.* Before seeing these data, a patient may have considered a three thousand-dollar payment to be on the higher range of benefits received by doctors. Seeing the data here in context quickly changes that notion.

 

While the OPP added new national comparison and medical specialty comparison features just this past summer, this work needs to go further. The OPP should include physician comparisons between state, city, and zip code limits, providing even more meaningful comparisons for patients who are searching for a physician. Furthermore, seeing comparisons between different benefits categories, can help orient patients who may be concerned with a particular type of benefit (such as food, lodging, speakers fees, etc.). This data is already collected by CMS, and has been shown to be important to patients. High payments need not lead patients to rule out physicians, but rather, it can prompt open discussions about COIs, which have been shown to lead to more trusting relationships and higher patient compliance.

 

In our piece, published in the International Journal of Health Policy and Management, we make two policy suggestions to remedy the two above-mentioned problems. The first is to provide data for individual physicians not merely in absolute terms, but in meaningful context, that is, in relation to the zip code, city, and state averages. The second, increase access to the OPP dataset by adding hyperlinks from physicians’ professional websites directly to their Open Payments disclosure pages. We believe that both suggestions are easy to implement, and that both can do a long way to ensure a higher level of patient-centered care.

 

*This search into Philadelphia interventional cardiologists was completed in June 2015.

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