Primacea Blog

Primacea's founders describe the problems and pathways for physicians to manage their industry relationships under the bright lights of the Sunshine Act in a March 2013 Endovascular Today cover story.

"From inventing a new device to providing expertise on how it might be improved or best used, physicians interact with industry in a variety of ways, often receiving paid compensation for their time and work or being provided with meals or travel expenses. While ordinarily understood to be of value by many within the field, public and political scrutiny has increased in recent years, and legislation now dictates that all financial ties be disclosed publicly, online."

The interview describes the background of the Sunshine Act, how it grew to 76,000 words of regulations, and the reporting responsibilities around financial exchanges between industry and physicians.

It emphasizes the need for physicians to take responsibility for their own compliance. Every payment that physicians receive, directly or indirectly, will be reported on a publicly searchable website. Unless a physician has the tools to accurately record and track these relationships, he or she could find that they are ill-prepared in the event that questions arise about the work they do. Industry and hospitals will spend hundreds of millions of dollars annually to comply with the Act. Unfortunately, none of these expenditures will necessarily protect a physician.

Need to develop appropriate infrastructure for industry collaborations

Should physicians have relationships with industry? Those who say yes believe that it is vital to advancing medicine. They point to the polio vaccine, HIV/AIDS medications, kidney dialysis, angioplasty/stents, artificial joints and numerous other historic breakthroughs. All of these advancements required the collaboration of innovative physicians and industry to improve the quality and duration of patients' lives.

Those that say no claim that such relationships inherently interfere with physicians' obligations to patients (when practicing medicine), students (whether trainees or peers) and the public (when conducting research). They cite news reports of physicians earning millions of dollars in unreported income for their industry work and social science research concluding that a gift as small as a notepad or cup of coffee may influence behavior. The end result, they believe, is the erosion of public trust.

Medical societies, academia, industry, consumer advocates and legislators universally understand and believe that physician-industry relationships are fundamental to improving medical science and patient care. They are also forming a consensus that the best way to maintain public trust is to ensure that these relationships operate under increasing transparency. I wholeheartedly support both conclusions.

The Physician Payment Sunshine provision of the new healthcare law and similar state statutes address the transparency issue in physician-industry relationships by requiring the public disclosure of all physician payments. Many recent state laws, medical society rules and hospital policies go further by banning gifts, limiting industry contact during regular business hours and influence on continuing medical education (CME) events, and by requiring detailed relationship reports. While well meaning, the end result has been a new and complicated regulatory environment.

Hospitals and industry have been able to direct their substantial legal and compliance infrastructures to help manage their obligations in today's environment. Unfortunately, these resources are often not available to us as individual physicians, and we remain ill equipped to navigate these complexities on our own. As a result, feeling that our motives are being questioned and not having a clear understanding of proper compliance procedures, many of us have reduced or even abandoned these otherwise productive and constructive relationships.

In my work, I have seen firsthand the significant impact that innovative physicians have on the advancement of medicine. I firmly believe that losing the contributions of these talented physicians will reduce our ability to improve patient care, and I worry as to the ultimate impact on the U.S. to provide appropriate care for our aging population.

For these reasons, I believe it is time for us to take action to ensure that these crucial contributions can continue. First, we must recognize that the changing environment requires a change in the way we conduct our relationships. We no longer can simply operate as "sole proprietors," but must build our own adequate regulatory compliance infrastructures to support the universal goal of transparency. We must also work together as a group to design and implement training and practical processes that will enable physicians to understand and comply with the many different requirements. With these new regulations, the ultimate goals (and our priorities) have been set. We now must step up our efforts to get there.

Physicians familiar with financial conflict of interest reporting are often uncomfortable with the time tracking and reporting requirements of "conflict of commitment" rules set by hospitals and other institutions that limit time spent on industry collaboration and other outside professional activities.

Primacea has analyzed the outside professional activity policies of twelve leading academic medical centers. Eleven allow faculty physicians to spend up to 20% of their time on outside professional activities. At the twelfth, Johns Hopkins, the allowance is "determined by the department director after discussion with the faculty member."

So what constitutes 20% of a physician's time? The medical center policies specify one day per week (Columbia, Pennsylvania and Yale), four days per month (Duke and Michigan State), 13 days per quarter (Stanford and Washington University) or 48-52 days per year (Baylor, Harvard, UC San Francisco and Washington University in St. Louis).

To help ensure accurate tracking, time spent on outside professional activities should be recorded in your accounting system. Track your "Outside Days" as inventory items. At the beginning of each period, set the Outside Days inventory to the number of allowed days (for example, 52 days at the beginning of each year). Each time you invoice a client, subtract the number of Outside Days spent.

Charitable and non-medical outside activities should not be deemed to consume Outside Days. The same is arguably true for consulting done after hours, on weekends and during vacations (unless your institution specifically limits total consulting days).

For a truly accurate accounting, Outside Days should be calculated as hours spent divided by hours in your actual day. How many hours are in your normal day? Of the twelve institutions we analyzed, only UC San Francisco defines a workday (eight hours); the rest leave it to their physicians. If it's up to you, be conservative. A physician who works from about 7:15 am to 8:30 pm could comfortably define a 12-hour workday. Why is this definition needed? Because spending 4 hours consulting and 8 hours at the hospital should be recorded as one-third of an Outside Day.

Physicians are responsible not only for reporting their time spent on outside professional activities but also for keeping future time commitments within their institutions' allowances. The same accounting system should be used for both of these functions. Whenever you enter into a consulting contract, you should consider entering the time commitment as a sales order for Outside Days into your accounting system. For example, say you agree to participate in a three-day scientific advisory board meeting plus another 12 hours of consulting throughout the year. Record a sales order for four Outside Days.

Whenever you are asked for a "conflict of commitment" report, run an inventory analysis that shows how many Outside Days you have spent, have committed and have remaining.

Following these steps will allow you to both provide required periodic reports and show that you are proactively meeting your institution's time disclosure requirements. In this age of increasing transparency, such disclosures of time spent on outside professional activities will be required of more and more physicians.

According to a study published in the Archives of Internal Medicine, only 14% of physicians provided consulting services to industry in 2009, down from 28% in 2004. The study speculates as to potential causes of the decline: press coverage of physician-industry relationships, changing medical school and hospital policies, increased public reporting of consulting relationships, and/or reduced spending by pharmaceutical and medical device companies.

Two years ago, The New York Times told the stories of leading academic scientists, including a cardiologist, a psychologist and an oncologist, who decided to no longer accept paid engagements with industry. One physician explained his decision as "responding to societal pressure." He noted that he is less willing to collaborate on treatments now that receives no pay for spending weekends on advisory boards, and he concluded "I resent the fact that I had to make this decision."

Several physicians told Primacea of similar feelings: all missed contributing their ideas and experiences to the process of advancing medicine. So why did they reduce or stop consulting? Overwhelmed by changing laws and rules, many concluded that continuing industry engagement wasn't worth the risk to their careers and reputations. Others feared being the next subject of an investigation or newspaper article. One even declined to accept royalties legitimately earned on a breakthrough invention.

Concerned physicians acknowledge that a number of physicians were improperly retained and compensated at times in the past. To the extent that the reduction in physician consulting is due to industry eliminating such inappropriate hiring, these recent changes are positive. However, to the extent that these changes primarily reduce productive physician-industry interactions, more appropriate regulations need to be developed.

Conversations with leading physicians lead me to conclude that the vast majority of the decline in physician-industry interaction can be traced to two concerns: public suspicion about physician motives in working with industry and personal fear about conforming to complex and changing legal, regulatory and institutional requirements. More research is required to better understand this issue from the perspective of physicians.

We must reverse the decline in collaborations between physicians and medical companies. Three things must happen so that physicians may continue their critical role in advancing patient care (as has been acknowledged by physician and industry leaders and is nearly universally accepted). First, the value of such collaborations must be more broadly appreciated. Second, a consensus must be formed as to what constitutes appropriate interactions. Third, processes for certifying ethical collaborations must be instituted.

A landmark study of medical journal disclosures found that authors failed to report half of their financial relationships with industry. Conducted at Columbia University's Center on Medicine as a Profession and published in the Archives of Internal Medicine, the study compared disclosures in journal articles with physician payment data from five orthopedic device companies:

Our findings indicate that current journal disclosure policies do not yield complete or consistent information regarding industry payments. More than half of the articles in our sample failed to acknowledge an authors' relationship to a company. In no article could readers know how substantial the company payment to an author was. More stringent journal policies were not associated with greater transparency. Although prominent authorship position and article-payment relatedness were associated with increased disclosure, nondisclosure rates remained high: even when the recipient of company funds was the first, sole, or senior author, only 54% of the articles mentioned the company tie. Similarly, even among articles directly or indirectly related to payments, the disclosure rate was only 50%.

Omissions, misinterpretations and errors in compliance reporting by a number of physicians have led to protracted investigations and a negative impact on public trust. Now that an increasing number of drug and device companies are disclosing payments to physicians—and with the Physician Payment Sunshine reporting provisions of the new healthcare law taking effect March 31, 2013—comparing physician disclosures and industry disclosures will be much easier.

It is easy to predict many more such comparisons.

The availability of industry disclosures of physician payments leads the study authors to conclude that there is "an unprecedented opportunity for the medical profession to move to a system of full, verifiable transparency."

It occurred to us that other medical organizations might also take advantage of company disclosure data. Academic medical centers might use company-supplied data to supplement faculty's conflict of interest statements. Pharmacy and therapeutics committees, as well as other purchasing bodies, might use these data in reviewing members' disclosures. So too, professional medical associations might also refer to company data to examine disclosures by officers, directors, and members who help develop educational activities or formulate clinical guidelines. Finally, governmental bodies might compare these data with the disclosure statements of advisory committee members, study group members, and intramural and extramural researchers.

Physicians are required to provide conflict of interest disclosures to universities, hospitals, journals and medical associations; many of these disclosures have unique formats and requirements.

Get ready for audits to accompany physician disclosures. Physicians now have two choices: (i) Proactively work to develop a disclosure system that more accurately describes their relationships with industry or (ii) do nothing and live with the very negative consequences that arise from flunking.

Discussions with legislators, regulators and thought leaders often brings up the question, "When physicians consult for industry, do they actually help make better products or are they just being paid for marketing?" Medtronic Chairman and CEO Bill Hawkins answers from deep experience, explaining to the press, academia, the public and shareholders that the medical device field depends on physician-industry collaboration.

"I'm hard-pressed to think of any innovation we've had that didn't come from Medtronic working with physicians," he tells The Wall Street Journal. Medtronic innovates at a rapid pace, renewing product lines in its $15 billion business about every three years.

In a Darden Health Care Conference keynote speech, Hawkins noted that the medical technology industry is unique because ideas originate at a patient’s bedside, move to the development bench, then return to the bedside. These ideas have generated more than 14,000 patents for Medtronic.

In an editorial this summer, Hawkins wrote:

Collaboration between physicians and industry remains absolutely critical to the delivery of state-of-the-art health care in this country. The medical-device industry simply cannot develop life-changing products without collaborating closely with some of the world's most highly skilled and innovative doctors and surgeons.

Physicians are the best source of ideas about how to make medical devices like artificial joints, neurostimulators, stents and pacemakers work in the human body after implant. In turn, a skilled medical-device company is the best at building the new designs. Both sides of this innovation team are indispensable in bringing new products and therapies to market to benefit patients.

Hawkins reports to shareholders that "collaboration with physicians and surgeons is vital for innovation and for the health of our industry." He adds that innovation "both starts and ends with the physician, in an ongoing and iterative cycle that fuels rapid and essential product and procedure innovation."

Do physicians actually help make medical products better? According to the head a 60-year-old global healthcare leader that helps more than seven million patients manage their chronic diseases, yes.