Financial Relationships Between VHA Health Care Professionals and Industry

VHA Handbook 1004.07

FACT SHEET

Over the last decade, health care professional societies, academic medical centers, state legislatures, government agencies, and others have instituted policies aimed at restricting financial relationships between health care professionals and the pharmaceutical, biotechnology, and medical device companies. The goal of these restrictions has been to eliminate, minimize or manage the conflicts of interests that are inherent in such relationships, removing financial incentives that can compromise professional judgment, place patients at risk, and contribute to unjustifiable health care expenditures.

Recently, studies have demonstrated that seemingly innocuous gifts and other industry paymentsinappropriately influence physician judgment. (Chimonas et al, 2007, Steinman et al, 2006) These findings have promptedtighter restrictions on the part of some health care professional societies, public disclosure plans by major medical centers (Steinbrook, 2009) and stricter prohibitions and requirements by state governments (National Conference of State Legislatures, 2008) and in proposed federal legislation (Physician Payment Sunshine Act, 2009)

As a health care provider, you have a professional obligation to ensure thatyou take the necessary steps to eliminate, minimize or manage your financial relationships with industry, including membership on company advisory committees and speakers bureaus, compensated attendance at company-sponsored presentations, and guest authorship on publications written by company employees. In all of these ways, industry seeks to use your reputation and position to market its products.

This fact sheet provides you with information to help you recognize the strategies and resources used by industry to influence your health care decisions. It also identifies your responsibilities as outlined in VHA Handbook 1004.07

Did you know…

Many health care professionals believe that compensation from industry, free meals and small gifts do not influence their health care decisions and recommendations, but research shows that self-interest unconsciously biases well-intended people and that health care professionals are not able to reliably manage their own conflicts of interest. (AAMC, 2007) Companies know that professionals can be influenced and plan marketing strategies around that knowledge. (Brennan et al., 2006)

  • The U.S. pharmaceutical industry spends almost twice as much on promotion as it does on research and development. (Gagnon & Lexchin, 2008)
  • Industry uses advanced technology to identify health care professionals who are most susceptible to marketing efforts. (Fugh-Bernam & Ahari, 2007)
  • Industry knows that trainees are particularly susceptible to industry promotions because the trainees are forming early preferences and practice patterns. (Zipkin & Steinman, 2005)
  • Industry hires “ghostwriters” at medical education companies to draft prepublication scientific papers and then pays academic experts to attach their names as “authors” of the paper to which they have made little or no contribution. (Singer, 2009)
  • “There are systematic and predictable ways in which people act unethically that are beyond their own awareness.” (AAMC, 2007)
  • “Increasing awareness of moral standards, or mindfulness, at the time of decision making diminishes the tendency to behave unethically.” (AAMC, 2007)

As a VHA Health Care ProfessionalYou Are Responsible For:

a. Avoiding and/or seeking guidance in managing potentially conflict-creating financial relationships. For example, if you are a clinician or trainee who is offered any type of monetary or in-kind payment or gift by a pharmaceutical company or medical device company,you should consider whether such a payment or gift has the potential to or could be perceived to exert inappropriate influence on your professional decision-making or judgment. If it does have such potential, you should decline the payment or gift and/or seek guidance from your supervisor, Service Chief, VA Designated Education Officer, Designated Agency Ethics Officer, and/or other appropriate official.

b. If you serve as a member of a VA decision making or advisory group, making real-time verbal disclosures of your financial relationships with industry that may have a bearing on the work of the group.

c. If your are required to complete the VHA credentialing and appraisal process, signing the following statement as part of the process: I understand that my professional obligations can be compromised by financial conflicts of interest; therefore, I will avoid conflicts or seek guidance in their management.

d. Bringing concerns about the potentially conflict-creating financial relationships of other VA health care professionals, including but not limited to the chairperson of a decision making or advisory group, to the attention of the person’s supervisor, appointing official, or facility leadership.

As a Chairperson of a VHA Decision Making or Advisory Group You Are Responsible For:

a. Communicating to nominees to a decision making or advisory group those conflict-creating financial relationship that would disqualify them from service on that group and the procedures for real-time verbal disclosure that will be part of the group’s conflict-of-interest process.

b. Clarifying for all members of the decision making or advisory group what a financial relationship is and reminding members on a routine basis about their obligations regarding disclosure and recusal.

c. Soliciting during meetings a verbal disclosure of members’ financial relationships with industry that may have a bearing on the work of the decision making or advisory group.

d. Ensuring that meeting minutes reflect sufficient information about those disclosures to provide a basis for quality review and conflict-of-interest management.

e. Managing conflicts of interest stemming from financial relationships disclosed by members of the decision making or advisory group.

f. Consulting with the Designated Ethics Official, when needed, to review the Confidential Financial Disclosure Form 450 of decision making or advisory group members and to address any member conflicts of interest that need further management.

g. Bringing your own potentially conflict-creating financial relationships to the attention of the supervisor or appointing official and informing the decision making or advisory group of decisions and actions taken in response.

As a VHA Service Chief, You Are Responsible For

a. Ensuring that VHA health care professional staff within your area of responsibility are oriented to the types of financial relationships with industry that pose a potential for conflicts of interest.

b. Conveying to the best of your knowledge to chairpersons of decision making and advisory groups any potential or actual conflicts of interest concerning VHA health care professionals who serve on such groups that may have a bearing on their committee service.

c. Reinforcing expectations regarding professional norms and conflicts of interest. Actions to accomplish this may include:

(1) Reviewing individual prescribing data received from local Pharmacy and Therapeutics (P&T) Committees and using this information as a basis for counseling practitioners on outlier status, including querying practitioners about financial relationships with industry.

(2) Scrutinizing staff requests to use annual leave, administrative absence or leave-without-pay to participate in industry-sponsored events.

(3) Assessing potential conflicts of interest in staff topic selection for presentations at VA facilities, for example, if the topic could be seen to promote the interests of a company that provides financial support to the staff member.

References

Association of American Medical Colleges (AAMC) (2007). The scientific basis of influence and reciprocity: A symposium. Available at

Brennan RA, Rothman DJ, Blank L, Blumenthal, D, Chimonas, SC, Cohen, JJ, et al. (2006) Health industry practice that create conflicts of interest: A policy proposal for academic medical centers. JAMA, 2006;295:429-433.

Chimonas A, Brennan T, Rothman DJ. Physician and drug representatives: Exploring the dynamics of the relationship. Journal of General Internal Medicine 2007;22:184-190.

Fugh-Berman A, Ahari S (2007) Following the script: How drug reps make friends and influence doctors. PLoS Med2008;4(4): e150 doi:10.1371/journal.pmed.0040150. Accessed December 30, 2008.

Gagnon MA, Lexchin. J (2008). The cost of pushing pills: A new estimate of pharmaceutical promotion expenditures in the United States. PLoS Medicine, 5(1). Available at PLoS Med2008;5(1): e1 doi:10.1371/journal.pmed.0050001. Accessed December 30, 2008.

National Conference of State Legislatures(2008).PrescriptionDrugState Legislation. Available at

Pharmaceutical Research and Manufacturer’s Assn. Code on Interactions with Health Care Professionals (January 1, 2009). Available at

Physician Payment Sunshine Act of 2009. S 301. Available at

Singer N. Senator Moves to Block Medical Ghostwriting. August 19, 2009.

Steinbrook, Robert (2009). Online Disclosure of Physician-Industry Relationships. N Engl J Med 2009;360: 325-327.

Steinman MA, et al. “The Promotion of Gabapentin: An Analysis of Internal Industry Documents." Annals of Internal Medicine 2006; 145(4):284-93.

Zipkin, DA, Steinman, MA (2005). Interactions between pharmaceutical representative and doctors in training: A thematic review. JGIM, 20:777-786.

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