Sea Change on Financial Conflicts of Interest in Health Care?

For the last quarter century, members of the medical and scientific communities have detailed the corrosive influence of industry payments to clinicians and biomedical scientists. Groundbreaking studies have repeatedly revealed how drug company gift-giving influences prescribing practices, how corporate sponsorship biases research, and how compensation from industry leads people to suppress research results, downplay harmful side effects, and put their name on papers to which they have made little or no contribution. Since none of this influence could occur without the participation of the health care providers and scientists themselves, professional bodies—including academic institutions, journals, and professional societies—have placed certain conditions on relationships with industry. One of these is that individuals don’t get to keep these financial relationships secret.

Public policy concerning transparency about these financial relationships has reached a tipping point, reflected in recent state and federal initiatives to require disclosure of industry payments and other transfers of value to health care professionals. Disclosure used to be a strictly local phenomenon, with narrow requirements on individuals to provide information to an institutional committee that would, in turn, maintain confidentiality. It is now subject to more expansive rules—companies must provide detailed information to government agencies that then make it publicly available. Individual disclosure can be thought of as a retail approach, useful for transparency in publication or to comply with faculty by-laws. By contrast, corporate disclosure of payments is a wholesale approach that gets at the systemic problem of industry using health care professionals as a core component of its marketing strategy.

Vermont, Minnesota, California, Maine, West Virginia, Massachusetts, and the District of Columbia have all recently passed legislation requiring drug companies to disclose the payments they make to prescribers. A 2007 overview of the experiences in two of these states found that 2,689 health care professionals in Vermont received 1.1 million dollars over two years. In Minnesota, 6,583 health care professionals received 23.6 million dollars over three years. In both states, the largest percentage of specified payments was for speaking and education, with some payments in the thousands and tens of thousands of dollars¹—amounts far exceeding the $100 maximum endorsed by the Pharmaceutical Research and Manufacturers Association (PhRMA).² Information gleaned from these disclosures—and, in some cases, failures to make required disclosures—casts doubt on the industry’s claims of self-regulation and transparency.³ In 2008, nine additional states introduced similar legislation.⁴

The Physician Payments Sunshine Act of 2009 is proposed federal legislation that would require drug, device, and medical supply manufacturers that receive payments through government insurance programs to disclose to the Department of Health and Human Services “payment or other transfer of value” to “a physician, a physician medical practice or a physician group practice.”⁵ Payment or transfer of value includes but is not limited to cash, items, services, stock options, honoraria, entertainment, food, travel, charitable contributions, speaking fees, and grants of more than $100 per calendar year.

This legislation, introduced by Senators Charles Grassley, Republican of Iowa, and Herb Kohl, Democrat of Wisconsin, is one outcome of an ongoing series of investigations by Grassley’s finance committee. According to Science magazine, the committee is investigating thirty individuals at twenty universities for violating federal conflict-of-interest reporting rules. So far, the hearings have revealed that prominent psychiatrists and government-funded psychiatric researchers have significantly underreported income received from drug makers. In the case of three Harvard-based child psychiatrists, the reported payments were off by $3.4 million.⁶ In 2004, when Emory University contacted Charles Nemeroff, chair of its department of psychiatry, about violations of the university conflict-of-interest policy, Nemeroff assured the administration that he would restrict his outside earnings from GlaxoSmithKline to a figure below the $10,000 National Institutes of Health threshold for disclosure. He reported $9,999 in income from GSK that year. Grassley’s committee, however, found that he actually received $171,031.⁷

In addition to the erosion of public trust resulting from these deceptions, the promotional work done by psychiatrists on behalf of drug companies has been...