Like with policy-making in Washington, DC, a lot goes on behind-the-scenes in healthcare. However much we hope decisions are made from a place of pure altruism, the reality is, that’s rarely the case.
Healthcare is political, and whenever we’re talking about something political, it’s all about power and influence. As outlined in the seminal volume The Bottom Line or Public Health, edited by William Wiist, pharmaceutical and medical device companies occupy a central role in the entire healthcare system, shaping research questions/priorities, influencing medical education, hiring doctors as consultants or spokespersons, marketing directly to consumers about products, and even shaping the very conception of health and disease that we as a society ascribe to.
This commanding hold doesn’t happen over night, or even through a single action. As Carol Tavris and Elliot Aronson describe in the fantastic book Mistakes were Made (but not by me), physician decisions are influenced more by small gifts than large gifts, all the while they remain steadfast in their belief that their integrity cannot be compromised. Bioethicist Carl Elliot has written extensively on this topic, and has further highlighted how industry’s reach now extends beyond clinical decision-making into the moral realms of bioethics, the very place we (sometimes mistakenly) turn to for impartial guidance.
Here’s a bit of good news, though.
Thanks to a provision in the Affordable Care Act, we now have the “Open Payments” program, which requires public reporting of payments to doctors by industry. The hope is to bring some of that behind-the-scenes wheeling and dealing into the public domain.
A new study in the journal Pediatrics assessed the extent of ties between industry and physicians, including pediatricians, using Open Payments data from January 1 – December 31, 2014.
Overall, researchers identified 9,638,825 payments to 463,470 physicians, totaling $1,186,217,157.
Below is a breakdown of these payments by physician specialty. For cardiology, more than 97% of doctors received payment from industry amounting to more than $127 million, by far the largest among medical specialties.
Looking at the primary care specialties, 71% of family medicine providers, 58% of internal medicine providers, and 35% of pediatricians received industry payments.
The study focused in on pediatricians, and assessed the most common “types of payment” from industry to providers, shown in the chart below.
Now to one of the most interesting findings of the study.
Here’s a listing of the top 10 most common drugs associated with payments to pediatricians.
Three of the top 10 drugs are for ADHD, accounting for about 25% of payments. Vaccines were the second most common product associated with payments.
What’s most striking here is the coincidence of industry payments to pediatricians happening around the same time as a huge reported uptick in ADHD diagnoses over the past decade. And some are questioning whether this uptick is genuine or simply a result from medicalizing common child development behaviors related to immaturity.
Now, I’m not saying one caused the other. There isn’t sufficient evidence to make that claim. But I do think it’s clear that industry is involved in healthcare. Industry does compensate physicians in different ways. And many of these compensations pertain to drugs that treat conditions which are being diagnosed more frequently than in the past.
Doctors and other healthcare providers remain some of our most trusted sources for health information and advice. Yet, as some of healthcare’s inner workings become more public, I wonder if this confidence might waver, similar to what we’ve seen in politics more broadly in the US.