At ProHealth, drug company representatives aren’t welcome
Practice leaders: Policy promotes transparency, better medical ethics
For decades, drug companies have sent representatives straight to doctors’ offices with friendly smiles and free samples to encourage physicians to prescribe their products, but now one of the state’s leading medical practices will no longer let them through the door.
“The motivation was to remove any external influences from our clinics,” said Ana Ohan, communication specialist for ProHealth Physicians of Farmington.
Founded in 1997, ProHealth includes over 90 practice locations in Connecticut and cares for more than 10% of the state’s population. Now owned by OptumCare, its 350-plus providers range from primary care physicians to those who specialize in physical therapy, neurology and plastic surgery, among other areas.
The policy barring representatives
from ProHealth offices was instituted in August. It was not meant as a stand against the pharmaceutical industry, Ohan said, but rather as a measure to promote transparency and prevent any potential conflicts of interest.
“Over the years, I did find pharma reps somewhat helpful,” said Paul Dolinsky, a retired physician of 36 years who joined ProHealth in the 1990s. “Do I consider [banning them] a big loss? Not so much. … Of course they had a limited, biased perspective that you had to be aware of, but some of the information could still be useful.”
In 2018, the Wheeler Clinic, which provides medical care to residents in over 15 communities across the state, decided not to allow physicians to accept samples or interact with pharma reps. Most hospitals and medical schools also prohibit interaction with salespeople.
The practice of pharma representatives building close relationships with individual doctors is called “detailing,” said University of Michigan Professor Puneet Manchanda, who co-authored a Yale journal article on the effects of direct-to-physician drug marketing.
Physicians do not directly purchase drugs from a sales representative. Rather, the representative provides scientific information about the drug while building a relationship of trust and familiarity with the doctor in hopes that he or she will prescribe it to patients.
“Most physicians believe they’re not impacted by detailing, but on average, we found there is actually a modest amount of influence,” said Manchanda. “Physicians, after all, are humans.”
Pharmaceutical companies began targeting doctors particularly after the Durham-Humphrey Amendment created the modern prescription system in the early 1950s. Since then, they have spent billions of dollars on marketing and building relationships with doctors. Dartmouth researchers found that between 1997 and 2016 alone, companies spent $5.6 billion reaching out to physicians and another $13.5 billion on free samples.
ProHealth’s decision comes as the relationship between physicians and pharmaceutical companies is under intense scrutiny in the wake of the opioid crisis.
In a study published earlier this year in the medical journal JAMA Network Open, researchers cited the connection between marketing of opioid drugs to physicians and the number of prescriptions written. The study linked payments for meals, travel costs and consulting fees with counties that have higher overdose death rates. Stamfordbased Purdue Pharma, the maker of OxyContin, ended its marketing of opioids to doctors in 2016.
“As long as physicians are the gatekeepers of prescription drugs, the only way for drug companies to make money is to ensure doctors will prescribe their products,” said Marc A. Rodwin, a law professor at Suffolk University in Boston who has published several books on conflicts of interest in the medical field.
While prescribing practices may be under more scrutiny following the opioid crisis, Rodwin and Manchanda said this is likely not a direct driver of policies banning sales representatives. Most physicians learned about opioids and painkillers back in medical school, so pharmaceutical companies do not need to focus on heavily marketing them.
“Detailing is particularly important for new drugs,” said Rodwin. “A new product will not be prescribed until it is well-known, and detailing is very effective as opposed to holding lectures or sending around articles.”
One of the medical field’s biggest concern about the relationship between physicians and pharmaceutical companies over the past 20 to 30 years is the spread of biased information about a new drug.
“There’s real grounds for concern about doctors relying on the sales rep’s biased information,” Rodwin said. “It could lead not only to biased prescribing, but over-prescribing. … Even if a drug is not prescribed correctly, pharma still makes money off it, so it’s hard to set up a system of checks and balances.”
Policies banning sales representatives may be helpful to patients if physicians are turning away from biased information sources toward research and clinical studies that have no stake in the success of a particular drug, Rodwin explained.
If more physician offices institute sales representative bans, Manchanda said he expects drug companies to compensate through research sponsoring, advertising at medical conferences, and digital marketing “as they already have begun doing.”
“I have no doubt [pharmaceutical companies] will continue to continue to adapt,” said Dr. Joseph Ross, a professor at the Yale School of Medicine. He noted the U.S. is one of only two countries that allow direct-to-consumer marketing for prescription drugs.
“It has to do with our free speech laws,” he said. “By law, corporations are treated and given the same rights as people.”
If the government prohibited drug companies from advertising to consumers, it could count as censorship. In 2018, pharmaceutical spending on advertising topped $6.4 billion, and just like drug prices, it shows no signs of dropping.
Dolinsky, the recently retired ProHealth physician, found prescription commercials to be misleading because they neglect to state the drugs’ costs. Even with decent insurance, some medications could cost patients hundreds, if not thousands, of dollars, he said.
“‘Ask your doctor,’ that used to drive me crazy,” he said.
The FDA does not require similar drugs to be tested against one another in clinical trials before they go to market, just placebos. This makes it even more difficult for physicians to decide which drug to treat patients with, Dolinsky said.
“For example, we have 12-14 drugs in one class to treat depression alone,” he said. “How do we know which is best? It’s difficult to decide. Often, we have to look at the side effects.”
Because it is impossible to predict exactly how each patient will respond to a new drug, Dolinsky found the free samples provided by pharma representatives useful.
“I’d hate to have a patient go out and purchase a drug, just to find out that for whatever reason, it does not agree with them,” he said. “With these costs, it can be difficult to even get folks their medicine at all.”
As the practice of banning pharmaceutical representatives becomes more common, Dolinsky wondered how medical students will learn to handle dealing with drug companies if not under their school’s guidance.
“You can’t go through the world without learning to disseminate the information presented to you,” he said.