In wining and dining of doctors, are ethical lines being crossed?
They say they best way to a man’s heart is through his stomach. That could explain why so many salesmen pitch products to clients over dinner and drinks. But what happens when that client is the person you trust with you and your family’s health? One Buffalo resident is shining some light on how pharmaceutical representatives feed your doctor and how it impacts drug sales.
Pharmaceutical representatives often pitch their drugs by taking healthcare providers out to dinner. So is your doctor being wined and dined?
Sales tactics that are acceptable in the private sector sometimes cross ethical boundaries in the medical field. Pharmaceutical reps have to abide by certain guidelines so these informational dinners aren’t seen as kickbacks.
But cheating those rules can be as easy as asking your waiter. That’s what former restaurant worker and Buffalo resident David Essi found out while working in the industry a few years ago. He also has a masters degree in bioethics.
“I was asked on a few different occasions to alter receipts to verify compliance,” said Essi.
Essi laid out these problems last summer in the American Medical Association Journal of Ethics. He says providing meals to physicians has been shown to increase drug sales. He concedes these dinners are small potatoes compared to the exorbitant speaker fees sometimes given to doctors to pitch drugs, but still worth examining.
Some of the rules to be followed when pitching your drug to a doctor over dinner: No cocktail service. Wine and beer are to be served only during dinner service, not after. No “to go” orders. Bottles of wine must not exceed a price tag of $36, and spending per clinician may not exceed $125.
To provide more oversight, third-party compliance companies are hired to help plan and document the dinners. But Essi says there’s little incentive to play by the rules.
The compliance companies use the restaurant bill to document proper conduct. Essi says these bills can be easily changed to show compliance.
“Changing receipts, changing beverages, changing the number of meals, lowering the number of meals, really, to account for people that didn’t sign in but still were eating there,” said Essi. “Those charges sort of get tucked behind.”
He says one of the most common reasons receipts are altered is to hide the attendance of extra guests -- usually spouses.
Essi says it’s easy to change other things on the receipts. Mislabeling drink orders, for example, can get around the no cocktail service rule. One compliance representative told him flat out that if evidence of a violation did appear, he should remove it from the bill.
Brian Dahl heads a compliance consulting company in Kansas. He understands Essi’s reasoning that these dinners don’t look good on the surface.
“Speaker programs definitely pose a risk that they can be seen as mechanisms to provide payments or inducements to physicians to write prescriptions for a company’s product,” said Dahl.
But he says most pharmaceutical reps do play by the rules.
“I think there still are some rogue companies out there, but I think most of the mainstream companies are realizing that the cost of noncompliance can be pretty steep and it’s just good business anymore to do their business in a compliant manner,” said Dahl.
Essi says the profit-driven structure of pharmaceutical companies make them willing to assume the risks of cheating if it winds up benefiting long-term sales.
He says notorious noncompliance cases often stemmed from whistleblowers, not government oversight. If a compliance company implemented more scrupulous oversight measures like video recording, Essi says, it would snag itself in the marketplace.
Virginia Evans served as chief compliance officer for Centra Health until last fall. She agrees the current structure is unacceptable.
“Managers running the restaurants then kind of shift the risk off to the people who are actually managing the event, or in some cases the server, who is the person with, you know, the least amount of power, if you will, in the whole relationship, and is the least able to say, 'No, Dr. Smith, you can't have a scotch and soda because this is supposed to be an educational event,'” said Evans.
Dahl raised questions about the use of alcohol at these educational sessions altogether.
“I can see the point about, you know, if it’s not appropriate for students to be drinking in class, why should it be appropriate for a physician to be drinking in a situation where they’re supposed to be learning about a product? I can definitely understand that point,” said Dahl.
“At the same time, you have to take into a little bit of consideration of, the physicians are generally at these programs after a long day of seeing patients and doing their day job. So, there needs to be a little bit of incentive to actually be able to get them into the room.
While doing research, Essi pretended he was a restaurant manager and called a compliance company. He asked if breaking compliance rules would bring more risk for the restaurant.
“Without any sort of hesitation, the compliance rep just said, ‘As long as the receipts don’t show that those rules weren’t followed, that’s really all we care about,’” said Essi.
With no liability on the restaurant’s behalf and a gratuity based culture for servers, Essi says it’s laughable that a restaurant should be expected to enforce this kind of policy. He acknowledges that speaker meals are a lightly shaded ethical gray area.
Dahl says there are bigger fish to fry.
“The bigger component, and this is kind of validated through the enforcement actions that have been brought over the last few years, is not the meal, but the payment that’s being provided to the speaker,” said Dahl. “Generally you’re talking about a lot more money there, a much larger transfer, when you’re paying a speaker whatever it is, whether it be $2,500, $3,000, to be in the room providing the presentation to their peers.”
The American Medical Association declined numerous requests to comment.
Essi says any solution must involve rethinking the current system’s incentives and disincentives. Vermont is the only state that currently prohibits industry-provided meals at speaker programs. Essi says one solution is to do that on a national level. Another solution, he says, would be to leave the educating to pharmacists.