Understanding Emerging Trends in
Industry-Academic Relationships

A presentation on the benefits of academic-industry relationships, the potential for conflicts of interest, and how such relationships may affect research at universities and future medical practice problems

Featured Speaker: Eric G. Campbell, PhD

Associate Professor of Medicine, Harvard Medical School
Director of Research at the Mongan Institute for Health Policy

Thursday, May 31 from 12:00pm to 1:00pm (Eastern)
at the  University of Connecticut, School of Medicine

Sponsored by the National Physicians Alliance, the University of Connecticut School of Medicine, Community & Continuing Medical Education and Academic Affairs & Education

Learning Objectives: Participants will (be able to):
1. Gain knowledge about general body of research regarding industry relationships and COI
2. Understand benefits of industry-academic relations
3. Identify the potential for conflicts of interest and understand how such conflicts may or may not influence research outcomes or practice patterns
4. Gain knowledge of tools and other policy initiatives aimed at reducing conflicts of interest, which may affect research or practice patterns

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On Monday March 19th, 2012, NPA President Dr. Valerie Arkoosh sat down with Martha Stewart to share information about the Affordable Care Act with a broad television audience.
Watch the segment here.

“Americans are concerned about the quality and cost of health care,” says project leader Dr. Stephen R. Smith. “Consistent with the Affordable Care Act’s achievements toward building a smarter and safer health care system that rewards quality care over quantity care, we in the medical community seek to develop meaningful, evidence-based practice reforms that will help patients receive the best care while eliminating wasteful and even harmful care.  Practicing responsible medicine means always doing what is right for the patient while being mindful that resources are finite—knowing that doing more does not always mean doing right.”

The NPA’s Good Stewardship Project created panels of practicing physicians in the primary care specialties of family medicine, internal medicine, and pediatrics who identified common clinical activities that lacked scientific evidence supporting their routine use—habits that if changed could lead to higher quality care and better use of finite clinical resources. The research appeared in the Archives of Internal medicine in May 2011: “The Top 5 Lists in Primary Care: Meeting the Responsibility of Professionalism.”[3] The project is being expanded to develop educational videos for physicians[4] and patients[5] that promote better understanding of evidence-based decision making and clearer communication for situations where less intervention is actually better care.

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Uniting physicians across medical specialties, the National Physicians Alliance creates research and education programs that promote health and foster active engagement of physicians with their communities to achieve high quality, affordable health care for all.  The NPA offers a professional home to physicians who share a commitment to professional integrity and health justice.

While there’s still work to be done, it’s good news that more medical schools in the US are adopting strong conflict-of-interest policies governing pharmaceutical industry interactions at the schools.

The American Medical Student Association’s (AMSA) 2012 PharmFree Scorecard reveals that 102 of the 152 medical schools in the US received a grade of A or B for their Conflict-of-Interest policies, up from 79 last year.

AMSA’s PharmFree Scorecard grades medical schools according to their conflict of interest policies. Policies regarding gifts, meals, paid promotional speaking on behalf of the industry, acceptance of free samples, interactions with sales reps and other policy domains are analyzed.  See the most recent grades – 2011-2012 American Medical Student Association (AMSA) PharmFree Scorecard.

It’s great the majority of schools have strong policies and that more are adopting such policies.  As more light is shed on the industry’s strategies for influencing prescribers and prescribing patterns, questions need to be asked and steps need to be taken to reduce the potential for conflicts of interest.  AMSA’s work on this is timely and important.

While more schools are adopting good policies, it’s important moving forward to make sure the policies are enforced and strengthened over time.  For example, only two medical schools report banning pharmaceutical sales representatives from campus.  While information about new drug therapies is important, information from sales reps needs to be balanced with nonbiased, evidence-based information on what works best for most people and is safest.

NPA’s Unbranded Doctor Network is a national network of physicians committed to reducing the influence of pharmaceutical marketing on the medical profession.  NPA has joined forces with AMSA, Community Catalyst and the Pew Charitable Trust through the Partnership to Advance Conflict-free Medical Education (PACME) to create both external and internal pressure for medical schools and academic medical centers to adopt strong new conflict of interest policies.  The Partnership is made possible through a grant from the State Attorney General Consumer and Prescriber Education Grant Program funded by the multi-state settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin.

PACME aims to result in having 75% of medical schools in the US adopt strong COI standards and to develop physician leadership to sustain and promote this change. NPA will host a series of National Grand Rounds and Bimonthly Conflict-free leadership Calls on this issue over the course of the next three years as part of this Partnership.  See for more information on the Partnership to Advance Conflict-free Medical Education.

With 67% of medical schools in the US now receiving a grade of A or B for their COI policies, we are surely headed in the right direction… but still have more work to do to in our effort to restore trust and integrity in the medical profession.

Simply put, people who have a voice–whether in the exam room, in the voting booth, or in civic and community life–tend to be healthier.   And the more voices there are, the healthier our democracy becomes.  This is Rx: Democracy.

The NPA is committed to advancing the civic engagement of physicians and patients through leadership development, coalition building, and voter education.

>>Click Here to Promote Civic Engagement with Rx: Democracy<<

>>Download a Free Poster!<<

The NPA is a founding member of Rx Democracy, a national nonpartisan network of more than 18 national and regional groups representing America’s best clinicians, health professionals and students. Together with concerned citizens’ groups, this network helps patients and those who care for them to have a voice in their health care and their community.  We partner with civic organizations to provide opportunities for nonpartisan voter and civic engagement in health care settings and beyond.

If you believe that voting and civic participation are healthy activities, join our Rx: Democracy network to make sure everyone has the tools and information they need for a healthy democracy.

Learn more about NPA Civic Engagement and RxDemocracy

There are many physicians who will claim that these talks are educational–whether at CME, or at industry-sponsored events.  They will also claim that they only speak on behalf of medications and/or companies they believe in.  However, ProPublica’s excellent Dollars for Docs investigative series has detailed ways in which PhRMA and other industry actively seek to control physician’s presentations and often target the speaking physician as much as their audience.  However, there are rising concerns that these relationships might not only raise costs, but could lead to harm or promote care that might not be in patients’ best interests.

If physicians and industry are proud of these relationships, then they should be wiling to open their books for patients’ review.  If we are receiving medical advice and care from professionals, we should be able to know if their interests might be skewed based on their relationships with industry.  The Sunshine Act will help accomplish this: patients will be able to review who pays their physicians, and can make their own decisions as to whether this has any impact on care.  In return, putting this information out in the open will encourage physicians to be transparent and encourage us to provide evidence-based care that is patient-centered.

Until the Sunshine Act’s database is available online, I recommend using ProPublica’s searchable database to see if your physicians are getting paid by PhRMA and medical device manufacturers.  What you find might be revealing…and your physician’s response if you ask them about payments might be surprising.  I readily admit that not all these connections are necessarily bad…but in that case there should be even less need to hide them.

NPA has a strong position about conflicts of interest in medicine, which led to our Unbranded Doctor campaign.  Patients deserve unbiased medical care, and physicians should be held to that standard.  We are willing to do our part.

Join us.

Update – February 2012

NPA’s Public Comments regarding Implementation of the Sunshine Act Provisions of the Affordable Care Act, submitted to CMS 2/17/2012

Please click below to view a recording of the NPA 1-hour webianr on the newly released final rule for Accountable Care Organizations (ACO) with Kavita Patel, MD, MSHS, Managing Director for Clinical Transformation and Delivery, Engelberg Center for Health Care Reform at the Brookings Institution. (Recorded 11/11/2011)

Dr. Patel is a fellow in the Economic Studies program and managing director for clinical transformation and delivery at the Engelberg Center for Health Care Reform at the Brookings Institution. Previously, Dr. Patel directed the health policy program at the New America Foundation, and served in the Obama administration as Director of Policy for the Office of Intergovernmental Affairs and Public Engagement in the White House

If you have a question or comment about Accountable Care Organizations, please post a comment below.

The research letter, published October 1 to coincide with the NPA’s annual meeting in Washington, D.C., used data from the 2009 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine how often the recommendations included in the Top 5 lists were being followed in practice. The authors then estimated the cost savings that would have occurred if the recommendations had always been followed.

The Top 5 lists—generated for family practice, internal medicine, and pediatrics—reflect common clinical activities in primary care where the quality of care could be improved. The recommendations made by panels of NPA doctors are strongly supported by the scientific evidence and would lead to significant health benefits and reduce risks, harms, and costs.

The largest annual dollar savings ($5.8 billion) would be achieved by adherence to the recommendation to prescribe low-cost generic statins when initiating cholesterol-lowering treatment rather than high-cost, brand name drugs.

The total cost saving estimate of $6.76 billion is conservative, as the methodology used by the authors could not capture the cost savings for all items on the Top 5 lists in primary care. The items related to treatment of mild-to-moderate sinusitis; avoidance of early referral of serous otitis media to ENT; using corticosteroids to control asthma in children; not doing Pap smears on women who have had a hysterectomy for benign reasons; and DEXA scans on men less than 70 years old were not included in the cost saving figures. Thus, the total cost savings would be larger than the $7 billion estimate.

The authors note that except for the large savings that would accrue from using generic statins, the amount saved from the Top 5 lists in primary care represent only a small fraction of total health care costs.  The hope of the NPA Good Stewardship project and the American Board of Internal Medicine (ABIM) Foundation, which funded the project, is to have all specialties generate their own Top 5 lists. The widespread adoption of similar lists could go a long way towards changing the culture of medicine by encouraging physicians to make wise clinical decisions and be good stewards of finite clinical resources.

The NPA has received a second round of funding from the ABIM Foundation that will enable the Top 5 lists to be put into practice. Demonstration practices are being recruited to showcase implementation. Training videos are being produced to help physicians communicate with their patients about treatment plans consistent with the Top 5 list recommendations. A version of the videos is also being produced to be shown to patients in waiting rooms. These videos will be shared with other specialty societies embarking on their own efforts to generate Top 5 lists in their respective fields.

Six weeks ago, I bought 300 pencils and brought them with me on the bus ride to my clinic in southeast Washington DC.  The other doctors and nurses bought similar back-to-school supplies, as they have done every year, and together we have been distributing them to our patients as they come in for their check-ups before returning to school.  At first glance, this is a simple, kind act of charity and goodwill.  After all, school supplies are relatively cheap, and it is heartwarming to think of neighborhood pediatricians giving their patients tokens of good luck for the upcoming school year.

However, we have many mothers asking if we can spare an extra set of school supplies for their other child waiting for them at home.  They have stretched their last dollar as far as it will go, and between taking care of that month’s rent, groceries, electric bills, prescriptions, bus fare, and co-payments for medical services, there simply wasn’t enough to get each child their own new set of pencils, notebooks, rulers, markers, and so on.  To look in these mothers’ eyes is to see the exhausted extent of resourcefulness and sacrifice.

Whether the rest of the country is experiencing a good economy or a miserable one, the families I care for are constantly facing financial hardships.  They may not use elaborate spreadsheets to organize their budgets, but they are faced with heartbreaking choices about spending, costs, and investments every day.  They ask themselves questions no parent should have to ask:  do we forego eyeglasses for one child so that all the children can go to the dentist?  Can we afford the co-pays for speech therapy and the co-pays for asthma medications?  Each of these decisions cost money, time, health and dignity.

These tragic choices are just part of the surface of devastation poverty is wreaking upon American children throughout their formative years.  At birth, an infant born in poverty in America is more likely to have a lower birthweight and a higher risk of dying than an infant born to a family with a more stable income.  During infancy and toddlerhood, poverty has been found to negatively impact critical neuro-cognitive processes in brain development.  Skills such as acquiring language, organizing information, and maintaining attention are all undermined when children are raised in poverty.  During this back-to-school season, I have been disappointed but not surprised by the disparity in learning disabilities between poor and non-poor children (14.1% vs. 8.5%).  The critical brain functions established in early childhood determine not just an individual’s academic performance, but also one’s future potential to contribute to society.

Additionally, poverty is associated with what public health experts call food deserts, which are areas where affordable, nutritious food is difficult to obtain.  Families and children living in a food desert, such as southeast DC, face paradoxical perils of food insecurity and hunger on one extreme, or obesity on the other.  For the children living with hunger, one third of the children eligible for food stamps are still not receiving them.  Living with food insecurity worsens the underdevelopment of the neuro-cognitive processes described above.  At the other extreme of malnutrition, one in three children in low-income families is overweight or obese, resulting in the first generation of Americans who will have a shorter life expectancy than their parents.

These injustices of poverty fall particularly hard on minority children.  As of 2009, over one third of black children and one third of Latino children lived in poverty, as compared to a little over a tenth of white children.  Today, 1 in 3 Latino infants and 2 out of 5 black infants are born into poverty.  Over the course of childhood, minority children are far more likely to face barriers to obtaining needed medical care. Black children without health insurance are 75% more likely than uninsured white children to have gone without needed medical care because of cost.  Latino children are 50% more likely to have an unmet medical need than white children.

The dire statistics may seem endless, but the good news is that we have the tools to strengthen our children’s lives. Between the CHIP Reauthorization Act of 2009 and the Patient Protection and Affordable Care Act of 2010, poor children’s access to health care can improve.  Currently, Medicaid and CHIP cover 30 million children across the country.  The Supplemental Nutrition Program for Women, Infants, and Children (WIC) provide for just over 9 million mothers and their children.  Three quarters of the Americans currently receiving SNAP benefits (Food Stamps) are in families with children.

The American Recovery and Reinvestment Act in 2009 made improvements to the Child Tax Credit, providing up to $1,433 more for families earning wages at or just above the minimum wage.  Similarly, the Earned Income Tax Credit (EITC) was expanded for married couples and families with three or more children.  These provisions, combined with others in ARRA, kept 2.4 million children out of poverty.

The accomplishments of these policies and programs should be seen as just the beginning of the hard work ahead for all of us.  Right now there are many who question whether we can afford to build upon these efforts and to develop new innovations in reducing poverty.  My argument is that we cannot afford not to act.  Every year, child poverty costs our economy $500 billion dollars in health care expenses, lost productivity, and criminal justice.

Clearly, we have tools at hand to reduce and eliminate child poverty in America.  What we lack is not skill, but will.  The greatest obstacles in this struggle are apathy and cynicism, for it is those forces that tell us that poverty is inevitable, and therefore acceptable.  But in making poverty acceptable, we make it inevitable, and so a vicious cycle perpetuates itself.  Like many Americans, I want to trust in the institutions of medicine, public health, government, business, and others to break this cycle and eliminate poverty through shared determination and effective collaboration.  Poverty is only a death sentence if we allow it to be.

The second phase of the project will provide proof of concept by actually implementing the “Top 5” recommendations in actual practice.

The NPA is looking to recruit primary care practices as demonstration sites for the second phase of the “Good Stewardship” project.

Primary care practices selected to be demonstration sites will put the “Top 5” lists into practice and become showcases for other practices to emulate.  Practices must agree to participate in training sessions to acquire the appropriate set of communication skills. Practices must have in place clinical record-keeping systems, such as electronic health records, that would enable the project staff to evaluate pre- and post-intervention clinical decision-making in those clinical encounters.  Selected practices will receive $1,000 to defray the costs of on-site data collection and reporting.

Contact Dr. Steve Smith at Stephen_R_Smith@brown.edu if you are interested in having your practice established as a demonstration site.