The Sunshine Act

The Sunshine Act (and other musings).

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Sun-shine (suhn-shahyn)

  1. The shining of the sun, direct light of the sun
  2. Brightness or radiance, cheerfulness or happiness

The physician payment Sunshine Act purportedly provides transparency, no matter what the industry, on all payments to physicians. In our government’s opinion, this will make our behaviors open and accountable, and thus save our healthcare system money. Au contraire! This act is really a thinly veiled attempt, by publishing a “hall of shame,” to embarrass our profession, and has the ultimate aim of reducing our ability to know about and thus not prescribing potentially innovative newer therapies to our patients.

This is one of many recent government actions against physicians, now known as “providers,” that has placed our profession under direct assault. Decreased revenues, increased operating costs, along with well-intentioned, but controversial mandates on meaningful use, PQRS reporting, remuneration tied to patient satisfaction scores, and EMR adoption, to name a few, have frustrated our “gatekeepers” more than any other measures I have seen in my forty three years of practice in both the United States and Canada. The penalties for non-compliance are generally many times more than what is received.

To wit: A recent USA TODAY editorial, “Who else is paying your Doctor?” was replete with non-truths and innuendoes.[1] These included “vacations thinly disguised as educational sessions,” “payments that compromise patient care,” and “drive up costs,” “rewards for prescribing more expensive drugs,” and “when doctors are PAID (my capitals) to prescribe certain drugs…please don’t even argue that’s not a conflict.” The opposing view on the same editorial page noted that there are no credible cost estimates of such a plan and “even the government admits it has no empirical basis for determining what is improper.”

The Daily Beast’s recent article, “How being a Doctor became the most miserable profession,” a must read, has determined that many of us feel that America has declared war on physicians, and that ultimately both patients and physicians are losers. [2] Their quote: “Being a doctor is like being a janitor- but without the usual social status or union protections.”

How then does the Sunshine Act contribute to this morass?

To make ends meet physicians often increase the number of patients they see in primary care with visits lasting twelve minutes or less. There are high patient loads, stress to increase “productivity,” trying to please patients, and giving in to their demands meaning more tests and notes. In addition, there are a number of other impediments which show up daily on our desks.

When is this physician throughout the day able to get a quick update on new and potentially meaningful therapies that can be researched later? Some of these new medications, while not having clinical superiority over generic alternatives, may have superior reduction in side effects or an improved safety profile. Our patients may be able to concur, adhere and persist with a treatment regimen.

It used to be the business lunch, the mainstay of the American business model, taught in every major business school in the country. But wait!! Now, physicians are shamed by nationally publishing that they accepted a bagel and cream cheese, a salad, or a chicken sandwich, while getting information that may be helpful. Currently, more than the 50% of us already don’t talk to PhRMA. Will the Sunshine Act increase the percentage to 60% or 70%? Are we so easily manipulated?

The real truth is this. The average primary care physician in this country writes between 83-87% generics. Of the 14-17% branded, more expensive drugs written, about 40% of those HAVE NO GENERIC. Granted, they are expensive, but it is almost impossible to treat most diabetics, asthmatics or moderate to severe patients with COPD, to name a few, with the former.

My academic compatriots will insist that we can take it on ourselves to learn such things at bona fide CME events or by studying online at the end of a long day. Nope. I don’t buy it. I don’t have the time. The amount of new data to incorporate into a busy practice is staggering.

Another thought!  Our medical schools could help. Professional. Without bias. They have already ensured that their students and residents know everything that is bad about PhRMA.  No free lunches there. They can educate the masses as well. But wait again! They have no problem in accepting big research grants (now with full disclosure?) and they remain untouched by such payment tactics.

Wrong, wrong, wrong!

A research letter published in the April 2, 2014, Journal of the American Medical Association, entitled “Academic leadership on pharmaceutical company board of directors” reported that every major PhRMA company in the nation had “academic medical leadership,” representing EVERY major medical school, for example Yale, University of Michigan, University of Texas on these boards. [3]  The annual compensation for these august physicians ranged from $106,000 to a stunning $557,000. Does this require special action from Congress? Are those directors more susceptible to increasing healthcare costs by teaching decisions at their schools than I am with a taco and diet coke?

The legislators obviously think so. They are convinced I will sell my first-born for a pen. What will I do for a creamy latte? As we all know even if these lunches and the sandwich/bagel largess, did as they suggested, powerful market forces prevent us from often writing what we think is best. Prior authorizations, failure on two or three generics, are a fact of life in primary care. Where is the oversight on the sweet deals major pharmacy benefit managers (PBM’s) make with PhRMA to get their drugs on formularies?

No, we need to continue to be our patients’ advocates, practicing medicine in a scientific way and of course being acutely aware of the costs involved. We need to continue to be more proactive than reactive. When we prescribe a medication that will improve a patient’s condition as indicated by scientific studies, then so be it. If I choose to get preliminary information at a quick business lunch, then leave me alone!

The irony is that this ‘brightness’ comes from the ‘darkness’ of Washington. As one Senator who has railed against lobbyists recently said when confronted at a resort where lobbyists paid serious money for access, “that’s what we do as Senators… we raise money.” We all know how they respond to these high priced tactics….look at the earmarks and contract winners that occur as a result of such actions. Why then single us out? Our approval ratings are in the top three most admired professions in the country (along with pharmacists and nurses at about 60%). Yes… all involved in healthcare. We are among the most trusted in the nation! And Congress? The last time I looked, about 8%.

The answer is that physicians are an easy target.  They have to do something! Since when could ten of us around a table agree on anything? As a friendly administrator once told me,”like herding cats!”

There’s no doubt that marketing will result in the use of some of these higher priced drugs, but, for the overall health of our nation the question should be, “Is that always a bad thing?” For me, and the majority of physicians in this country, the answer is a resounding NO!  It seems to be a lost fact that many of our best generics were once expensive branded agents.

The Sunshine Act is one of many government initiatives that will ultimately reduce innovation and the availability of exciting new treatments, unlike the explosion of life altering and saving medications that have become available over the past fifteen years.

Let’s call it what it is, another knee-jerk law from our legislators, paraded before a biased media that will have more bad outcomes than good. In a country where a boxer pockets $24 million a match, where retired or defeated politicians peddle influence from K Street, surely singling out this modest lunch is discrimination at its worst. Is there someone brave enough out there to challenge it in a court of law?

Feeling crucified? Or, as a gifted professor told our class on the first day of medical school in 1967, “God and the doctor we like adore, but…only when in danger not before. The danger over both are like requited, God is forgotten, the Doctor slighted.”
“God is forgotten…the Doctor slighted.”

 


David Wayne Bell, MD

Bowling Green, Ohio


Published May 20 2014


Biosketch:

Dr. D. Wayne Bell is a family practitioner with 41 years’ experience providing care both in Canada and the United States. He has been a clinical assistant with the department of family medicine, University of Toledo Medical School since 1996 and as well is the senior member of the institutional review board (IRB) of Bowling Green State University. Dr. Bell is the founding and current CME chairman of Wood County Hospital’s accredited CME department, and has spoken numerous times at local, regional and national CME and non CME events. Dr. Bell also testified before the legislative subcommittee of the Ohio Legislature for the Asthma Bill, which he introduced, and allowed students to carry relief inhalers in schools (1999). He currently is in Family Practice at Wood County Hospital in Bowling Green, Ohio.


References: 

  1. Opinion editorial. Who else is paying your doctor? USA Today News. February 27, 2012. http://usatoday30.usatoday.com/news/opinion/editorials/story/2012-02-27/doctors-drug-industry-payments/53276626/1.  Accessed May 8, 2014.
  2. Drake D. How being a doctor became the most miserable profession. The Daily Beast. April 14, 2014. http://www.thedailybeast.com/articles/2014/04/14/how-being-a-doctor-became-the-most-miserable-profession.html. Accessed May 8, 2014.
  3. Anderson TS, Dave S, Good CB, Gellad WF. Academic medical center leadership on pharmaceutical company boards of directors. JAMA. 2014 Apr 2;311(13):1353-1355.