Latest / CareTalk: Healthcare. Unfiltered. / The Dangers of Financial Incentives in Healthcare w/ Aaron Mitchell MD, MPH

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The Dangers of Financial Incentives in Healthcare w/ Aaron Mitchell MD, MPH · CareTalk: Healthcare. Unfiltered.

• 0:00
  It's well known that physicians who take money from pharmaceutical companies prescribe more expensive drugs.
• 0:05
  But is there also an impact on quality of care?
• 0:08
  In other words, if your doctor takes money from industry, are you more or less likely to receive high quality treatment?
• 0:20
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• 1:00
  Welcome to Care Talk, America's home for incisive debate about healthcare business and policy.
• 1:05
  I'm David Williams, president of Health Business Group.
• 1:08
  And I'm John Driscoll, senior advisor at Walgreens.
• 1:10
  Today's guest, Dr.
• 1:11
  Aaron Mitchell, is an oncologist and health services researcher at Memorial Sloan Kettering Cancer Center.
• 1:17
  His focus is on understanding how financial incentives influence physician behavior.
• 1:22
  Join the vibrant Care Talk community on LinkedIn, where you can dig deep into healthcare business and policy topics, access Care Talk content and interact with our hosts and guests.
• 1:32
  Please be sure to leave us a rating on Apple or Spotify while you're at it.
• 1:36
  Dr.
• 1:36
  Mitchell, welcome to Care Talk.
• 1:38
  Thank you for having me.
• 1:39
  So Dr.
• 1:40
  Mitchell, let's start level set for patients and health care professionals.
• 1:46
  Why should we care about incentives and payments and treatment patterns?
• 1:52
  mean, aren't all doctors focused first on the science and next on clinical outcomes and not on things like being paid off by pharma.
• 2:03
  I think they are focused first on science and evidence.
• 2:09
  But I wish I could say they were focused only on those things.
• 2:13
  And like all other humans, doctors are human and other things can bias us and us sometimes with our knowledge, sometimes without our knowledge.
• 2:22
  And I think that these kinds of incentives and relationships that we have with the drug industry operate for us on that level and can sway us and impact the quality of care we provide.
• 2:34
  When you talk about incentives and relationships, what is the nature of the financial relationships between pharmaceutical industry and physicians?
• 2:41
  Like how big is it?
• 2:43
  And then what kind of categories of payments are we talking about?
• 2:46
  Yeah, great question.
• 2:47
  So that varies a lot across...
• 2:50
  across different spheres of medical practice and across different types of physicians.
• 2:57
  In aggregate, we're talking $2 billion per year.
• 3:01
  This is $2 billion specifically of non research related payments.
• 3:06
  So if a doctor is running a clinical trial or engaging in research, then there's a lot of separate research money that would go towards those scientific pursuits.
• 3:15
  But what I'm talking about is the $2 billion that is personal payments, meaning either cash payments or other transfers of financial value like free food that is going to be consumed directly by the physician that isn't going towards generating medical knowledge.
• 3:30
  The most common kind of payment by count is a free meal.
• 3:37
  And about 90 % of these payments are that type of meal.
• 3:42
  Often this is in the context of a drug representative, pharmaceutical representative showing up at a doctor's practice.
• 3:50
  catering lunch provided to both the physician and their office staff, while they then provide some information, know, lecture, pamphlets, slides, etc.
• 4:00
  about their products.
• 4:01
  So that's the most common kind of payment by count.
• 4:05
  The most valuable payments going by dollar value are payments to physicians for speaking fees and for consulting engagements.
• 4:14
  So cases where A drug company has hired a doctor for their expertise to comment on a drug or developmental pathway, different strategic angle, such as consulting, or then speaking where they're hiring the doctor to speak on behalf of the company to promote their products and do kind of peer education to other physicians.
• 4:36
  Taken all together, like I said, about $2 billion per year.
• 4:40
  Dr.
• 4:41
  Mitchell, the $2 billion sounds like a lot, but you know, with all of the prescribers in the U .S., that actually turns out to be not a lot of dollars per doc per incentive, if you will.
• 4:53
  I what's the average kind of the average size of the incentives that could be influencing doctors?
• 5:01
  The average size is also hugely variable and hugely variable by specialty.
• 5:07
  So you have some specialties like a family practitioner.
• 5:10
  a general pediatrician or a general internist who get next to nothing from pharma.
• 5:16
  And very few of the doctors in those specialties would be getting any kind of financial payment.
• 5:23
  And then there are other specialties like oncology, like cardiology, like rheumatology, where the average is much, much higher.
• 5:30
  So if you're going by the mean amount for an oncologist, the average oncologist by mean is about $7 ,000 to $8 ,000 per year.
• 5:39
  So again, that's a decent amount then, is not certainly in comparison to a physician salary is not huge.
• 5:47
  And that's why, as we'll talk about later, it's kind of somewhat about the dollars, but also more about the contact with industry that these dollars are a surrogate marker for in those cases.
• 5:57
  But then you'll see, it's skewed.
• 6:00
  It kind of looks like the US income distribution, right?
• 6:04
  You've got this kind of long, very low slope when you go from doctors who get nothing at all, to those who get a few hundred, a few thousand.
• 6:11
  And then you get this like top 5 % where they're making an amount comparable to their overall salary or a substantial portion of their overall salary from the drug industry in consulting and speaking fees.
• 6:24
  So when you go up to this top 5 % of oncologists, yes, it is people making close to or in excess of $100 ,000 per year.
• 6:32
  So it is very skewed.
• 6:33
  And you've got some people there where the influence is more.
• 6:35
  through contact at drug meals and the individual interactions.
• 6:38
  And you've got some people where it is the true dollar amount itself, which is, I think, is enough to be biasing.
• 6:44
  So let's talk about what's already been known before jumping into some newer research that you've done.
• 6:49
  What do we see in terms of the impact of these industry payments on prescribing patterns?
• 6:55
  The impact on prescribing patterns is very consistent and very simply described, which is that it increases prescribing.
• 7:04
  Right, so if you've gotten money from a given manufacturer for the promotion of a given drug, we know that you are more likely as a doctor to prescribe more of that drug going forward than you were in the past prior to receiving that payment.
• 7:17
  We've got a huge number of studies now, dozens.
• 7:21
  When we did a systematic review a few years ago, there was 30 some studies.
• 7:25
  There's probably twice that many now.
• 7:26
  They've all shown exactly the same thing.
• 7:29
  So that's very well known and consistent.
• 7:30
  You get money from a drug company, you prescribe more of that.
• 7:33
  that company's Now, to be fair to the drug companies, are, you know, it is reasonable to brief, educate and monitor the drugs that they're manufacturing.
• 7:47
  And you'd want the doctors to know where the bright lines are of to prescribe or not.
• 7:53
  There's a lot of drugs being developed and they know the pharmacy companies probably need, I would imagine.
• 8:01
  the doctors to help them figure out whether what's actually happening in humans is what they plan for in trials and the small studies that often, you know, precede drugs being approved and distributed.
• 8:14
  What's the industry rationale for investing in this beyond just, or is it just, you know, growing the number of prescribers and driving up the number of units prescribed?
• 8:29
  is there a...
• 8:31
  a defensive argument that makes sense to you as a doctor for why the pharmacy companies are investing in all of these fees, incentives, and it sounds like they're all pretty well fed as well, meals.
• 8:45
  So a lot there to unpack.
• 8:49
  So I think that there are many rationales for our current system and the current status quo.
• 8:56
  If you wanted to ask me my true unfiltered, opinion, you know, the I think the internal rationale and the company's memos is like, yeah, it's all about increasing sales volume.
• 9:08
  And I think that is the the primary underlying and true rationale from the industry perspective.
• 9:16
  And the public rationale, of course, is increasing physician knowledge of these drugs and And in line with that, increasing the quality and the outcomes of physician prescribing.
• 9:31
  This is a rationale which is often repeated and given by my peers, by physicians themselves.
• 9:43
  And I would say with kind of a variable, a varying degree of credulity, I think there are some people who truly believe that is.
• 9:50
  doesn't sound like you believe them though at all.
• 9:53
  forget whether they believe what they're saying.
• 9:55
  It sounds like what you're saying is, nah, it's pretty much all about sales.
• 9:59
  I think it's pretty much all about sales.
• 10:02
  That's what I think.
• 10:04
  at the same time, there are physicians.
• 10:08
  I'll give you like the, so you asked for the defensive argument.
• 10:11
  I'll give it.
• 10:11
  So there's some physicians who would like say like, totally, no, it's 100 % like this is the drug companies are aligned, our interests are like, everyone's interests are 100 % aligned, right?
• 10:20
  The drug company wants us to do a good job prescribing because if we prescribe wrong or have side effects, that's bad for them.
• 10:27
  So they want to educate us and educate us well.
• 10:29
  And then when we're educated well, this is also perfectly aligned with patient interest.
• 10:33
  So I think that's like the strongest form of this argument.
• 10:35
  And there are certainly our physicians I've heard make that and I'm convinced 100 % believe it.
• 10:40
  And then there's some other physicians who would say have a slightly more nuanced take on it, but one that would still be pretty okay with the status quo.
• 10:50
  which is like, yeah, I know that they're always gonna try and sell me on the drug.
• 10:54
  I know they're gonna try and make it sound better.
• 10:57
  They're gonna emphasize the novelty and emphasize the new aspects of a drug.
• 11:00
  But I'm good enough to be able to filter that part out.
• 11:03
  And if that is 10 or 20 % of what I'm getting, they're also gonna prescribe me just the dosing levels, the interactions, the things that are really practical considerations, and I'm busy.
• 11:15
  So getting it straight from them in a really condensed form is the most time efficient way for me to learn about a product.
• 11:22
  I'm aware enough as a physician of their incentives to be able to filter out any junk or any spin and hey, why not also get a lunch along with it while I'm busy in clinic.
• 11:34
  So think that would be a rationale.
• 11:36
  Well, it's a little bit more skeptical of the underlying incentives.
• 11:40
  of industry, then is also very willing to participate in these engagements at the same time.
• 11:46
  John, you gotta eat.
• 11:47
  So that's how it is.
• 11:47
  All right.
• 11:49
  So this is a good summary of what we know about how pharma works and how physicians respond and so on.
• 11:57
  But you broke some new ground in a recent study that was published toward the end of last year about pharmaceutical industry payments of non -recommended and low value cancer drugs.
• 12:06
  And I want to know about what was the new area that you were focused on?
• 12:10
  How'd you go about doing that study?
• 12:11
  So there's been a lot of research that I alluded to before that has just shown that receiving money from drug companies affects prescribing and it increases prescribing.
• 12:22
  All of this work, including a few studies that were done by myself and some colleagues, were all looking at areas where like all of the differences that we were looking at, say the different drugs.
• 12:34
  they were all kind of on a level playing field.
• 12:35
  Like you could say any of these drugs would be appropriate for a given set of patients.
• 12:40
  And so we're looking by design to cases where these drugs are interchangeable and substitutable, are industry relationships, industry money able to sway in those settings?
• 12:50
  Clearly the answer is yes.
• 12:52
  So now I want to take the next step in research and saying, okay, is industry money enough to sway doctors even when...
• 12:58
  Now these treatment options are not on the level playing field.
• 13:02
  Now we've got something that a doctor should not be doing or should be choosing something else.
• 13:06
  Is it enough to influence physicians even in these scenarios?
• 13:09
  So that was our kind of motivating interest in doing the study.
• 13:13
  And the way we did it was really four studies in one.
• 13:16
  We looked at clinical guidelines to establish a set of four different practices, four different, call them practices or drugs or services.
• 13:26
  in oncology where we have recommendations from guideline committee saying this is not something you should be doing.
• 13:32
  And then looking at four different groups of patients, each of whom was the applicable group of patients for this service, like a patient who, you know, their doctor would be saying, am I going to do this?
• 13:42
  Am I not going to do this?
• 13:43
  And then we follow their care going forward using Medicare claims.
• 13:47
  This is like a large national data set of all patients who are covered by Medicare.
• 13:52
  And we ask, we can then link these patients to their physician.
• 13:59
  And then we ask, OK, does a cancer patient with prostate cancer, are they more or less likely to get this non -recommended service when their doctor had recently received payments from that company's manufacturer?
• 14:13
  So that was the core of our question and the core of how we answered it.
• 14:16
  And we found that across these four different scenarios, the answer looked like yes in three out of the four.
• 14:23
  Just to be clear, Dr.
• 14:24
  Mitchell, your background is as a clinical oncologist, a medical oncologist who's actually got doing clinical work in these categories that you research.
• 14:36
  So you're an expert on the healthcare side and you've also got a background in public health and epidemiology.
• 14:42
  So you're really in an ideal position.
• 14:44
  It's not just you're looking from the outside.
• 14:46
  You've really got an insider's view of what and can judge.
• 14:52
  based on your own work, what are the better or the more guideline oriented, better outcome drugs for these very sick patients?
• 15:05
  I I think that was the interesting thing for me is the level of qualification you bring.
• 15:10
  Now, David, what's your thought on that?
• 15:13
  Yeah, my level of qualification is that at least for one of the categories, I would have been able to do it because there's something called choosing wisely.
• 15:19
  And there's something that's basically, know, somebody you'd have to choose unwisely in order to do it.
• 15:24
  So there was, was interesting in these categories.
• 15:26
  There was one that was like very clear cut.
• 15:27
  Like this is on the, the, literally the poster child of what not to do.
• 15:31
  And it's like, what would it take to get a doctor to actually do that?
• 15:34
  So I won't comment further.
• 15:35
  We'll let Dr.
• 15:36
  Mitchell explain.
• 15:38
  So I mean, to some extent, yes, like the insider perspective did help a little bit.
• 15:46
  Like there are a lot of, I think we started with a larger list of candidate practices.
• 15:55
  And then where my expertise as an oncologist really came in is being able to say, which of these cases and in which of these low value services can we really make the claim confidently that the care we are observing in this Medicare data set is the non-recommended care?
• 16:14
  Because almost everything, like almost all drugs, things, scans, what have you across cancer, there's some group of patients where it's entirely appropriate.
• 16:23
  So it's always a question of risk stratification and patient selection.
• 16:27
  So even if there's a drug which may be in 90 % of the real world cases where it's used, we think it's probably overuse, it's probably not needed.
• 16:36
  I want to be 100 % confident when I'm making that claim in the data.
• 16:41
  And if there's 10 % of patients where it's the right choice for a doctor to make.
• 16:45
  And I can't tell when I look in this really messy, high level Medicare data set, then we throw that one out, right?
• 16:50
  We're throwing out cases where we can't be confident that it's the wrong choice and not the right choice.
• 16:55
  exactly.
• 16:55
  And that is something that that really takes the oncology background to be able to judge.
• 17:01
  But that that that takes a lot of the noise out of the data.
• 17:04
  mean, that that to me is why the work is is really compelling.
• 17:09
  And is there is there anything that would explain?
• 17:13
  this branded drugs versus not branded drugs.
• 17:15
  I wasn't quite under tracking necessarily some of the findings you had there and what was driving them.
• 17:21
  So you're zeroing in on the one group out of the four where we did not see the expected association between a doctor receiving money from industry and then using more of that of the company's product.
• 17:36
  So the one where that was not the case was when we looked to see if we looked at a set of cancer drugs that had recently gone generic.
• 17:47
  And what we were asking was, was a doctor who'd recently received money from the brand name manufacturer, did they continue to use the brand name drug more often, even when there was a generic or a biosimilar alternative?
• 18:01
  We found the answer was no.
• 18:03
  And our rationale for that, or our best explanation for that admittedly unexpected finding is that what we think we are, The reason we think we see that is that we've not accounted for a physician's practice setting.
• 18:19
  And what I mean by that is the biggest single determinant other than specialty.
• 18:24
  So we're looking at oncologists, the biggest determinant of whether an oncologist is getting a lot of money from industry or a little bit of money from industry is whether they are in academics or community practice.
• 18:34
  And we see the people at academic centers.
• 18:36
  like myself, get on average far more money from industry.
• 18:40
  For us, the average is tens of thousands of dollars per year.
• 18:42
  So you just more industry payments.
• 18:44
  And then also, because we're parts of a larger institution, we're going to be more often subject to a formulary restriction.
• 18:51
  So if I'm a doctor where I'm at a center where they've already someone top down in our pharmacy department or in the supply chain, basically all these things I don't really know the details of, if they've already made the switch over to the generic, top down very quickly, then we've got this group of doctors who are both more likely to get industry payments in epidemiology terms.
• 19:13
  That's our exposure, right?
• 19:14
  They're more likely to have the exposure and they're more likely to already be funneled in towards the generic drugs because they're practicing at an academic center where the generic drug is already the standard.
• 19:25
  So we've kind of, that's our explanation for why we think we actually saw more prescribing of generic drugs.
• 19:33
  among the doctors who had received more payments because they were the academic ones.
• 19:37
  lived on both sides of that as a PBM guy where formulas really do drive a lot of the behavior and a lot of the focus for both institutions as well as pharmacy managers really change the structure of incentives once the generics are available because of the complex compensation that happens before that gets to you.
• 20:00
  That makes a great deal of sense.
• 20:02
  But let's talk about the one.
• 20:04
  So it's I think it's interesting that there was one is counterintuitive.
• 20:06
  It's always good to have something like to study next so you can see what they went the impact there is.
• 20:11
  But what I thought was interesting is going back to the earlier argument and talking about how the oncologists say, well, you I can filter through that.
• 20:18
  I understand what's going on and so on to put that up against something that's the most clear cut that I saw, which is when literally about the sort of choosing wisely is basically a statement from the association, you know, from the physicians that says don't do this.
• 20:33
  And so you're sort of saying, you know, when people are doing it anyway, is it out of ignorance or is it, are they somehow influenced?
• 20:39
  That to me was also the most interesting case in a sense.
• 20:43
  And I wonder how, if you go back and discuss with some of those oncologists who, you know, give you that rationalization before what their reaction would be to a finding like this.
• 20:52
  So is your question, how, how do you, how do oncologists react to these?
• 20:58
  to these findings?
• 21:00
  think I know how they react, is the unwise choosers.
• 21:03
  what what what do you think you take this?
• 21:05
  Well, again, practically thinking, you you put on your white coat, your stethoscope, you walk down the hall and say, here's the research.
• 21:12
  What is what is the response of your peers likely to be?
• 21:15
  Are they going to buy you lunch?
• 21:17
  When I've presented this in in peer settings, I've I've encountered.
• 21:24
  Resistance to the idea that we.
• 21:28
  could be swayed to provide substandard care.
• 21:34
  And I've received the criticism that in some form or fashion, my results must be driven by confounding or by making the often reported error of mistaking correlation for causation.
• 21:53
  And when I hear these arguments, I point towards some of the statistical methods that we've employed in the study that really directly address these concerns, right?
• 22:02
  We've set it up in a way that we were looking at a change in a physician's own practice.
• 22:08
  So you're not, it's not that you've received this money because you're already a high prescriber of these low value services, know, reverse causality.
• 22:17
  We are able to see a given patients, I'm sorry, a given physicians own patients prior to and subsequent to receiving money.
• 22:26
  And we see that their own personal practice increases or the utilization of these low value services increases after they've received a payment.
• 22:35
  So in my view, it's pretty well controlled or well adjusted for potential confounders like that.
• 22:43
  I think that's kind of the, you know, I kind of like motivated reasoning, but I think that's the impulse of a physician when they're presented with evidence that somehow is taken, and I don't think it does impute integrity, but I think when people read it for the first time, or maybe hear me talk about it for the first time, I think that's a clear implication that people start to feel and naturally feel defensive and want to find out some reason why it's not right, or there's a hole in my analysis somehow.
• 23:11
  So what about, so physicians, okay, so just to paraphrase, they're kind of hopeless and persuading.
• 23:17
  What do you tell a patient?
• 23:18
  How should a patient think about this research?
• 23:20
  Is anything that a cancer patient or family might do differently or somebody even in another specialty, should it motivate anything that they're doing in terms of choosing physician, interacting?
• 23:33
  But David, even before that, Dr.
• 23:36
  Mitchell, should patients be afraid of getting the wrong drug?
• 23:40
  I mean, should they be afraid?
• 23:42
  And how should they kind of take care of themselves?
• 23:47
  That's so hard to answer.
• 23:48
  So no, I don't think you should be afraid of your doctor.
• 23:55
  I think that going back to maybe the first or second question, yes, the first thing that doctors are always turning to and the elephant in the room for determining a physician's practice is what the scientific evidence is and what the clinical guidelines say, and that is the 99 % of it.
• 24:20
  And I think what I'm studying is additional influences around the edges and in smaller biases.
• 24:28
  especially in cases where evidence is clear cut, doctors are going to follow the thing that is most evidence -based.
• 24:37
  That said, there are biases.
• 24:41
  certainly, I have a family member where a doctor is prescribing a continuing to prescribe a brand name drug when there's a generic fully equivalent version right there.
• 24:53
  They've told my family member that they think that this brand name version is better and going to treat them better.
• 24:58
  I'm not going to get it the middle there.
• 25:02
  But there are cases.
• 25:03
  There are cases where someone's maybe views or maybe biased views are going to skew towards a higher cost or a low value option.
• 25:11
  And so to come back to the question of what an individual patient can do, I think it is not to not trust your physician because I think 99 % of the time what they're doing is they're duty bound to provide the best care to you.
• 25:28
  And I think that's always what they believe they are doing.
• 25:31
  And then you can maybe on the side just check and see in open payments what are your, what are if any major relationships with industry that your doctor has.
• 25:43
  They may not have any.
• 25:45
  Maybe it's only been a few hamburgers here and there, but if they are a major researcher or a major stockholder with a company and they've also recommended that company's drug to you, it's still probably the best thing.
• 25:57
  It's still probably coincidental or maybe yes, they have that conflict, but it's still also the best thing clinically.
• 26:02
  But then you can at least ask the question, okay, this doctor has maybe an interest here.
• 26:08
  they've recommended this company's drug to me, you can ask them, what would the alternatives be?
• 26:12
  Is this really the only drug that would be a therapeutic option?
• 26:16
  Is there another that's generic?
• 26:18
  Is there another from a different company that you're not recommending solely because there's different side effects?
• 26:23
  Like you can get into that decision when, which I think would be relatively, you know, small number of individuals on a patient level, a small number of cases where your doctor does have a substantial relationship with a company that.
• 26:35
  where it could be impacting your care.
• 26:37
  And you can just do that double check.
• 26:38
  And then if something comes up, then you can ask that question.
• 26:41
  So last question for you, because this is very interesting research that you're doing.
• 26:45
  What's your next area of inquiry?
• 26:47
  Are you going deeper on this one?
• 26:49
  So this recent study that we've been talking about was really just phase one in a much larger study.
• 26:56
  So we look at these four practices that are known to be low value.
• 27:02
  We found that there's a thumb on the scale there.
• 27:04
  It looks like industry payments can influence us.
• 27:07
  But now we're trying to expand our lens into all of oncology writ large, like really looking into the full spectrum of cancer, and treatment selection.
• 27:19
  And we're planning on asking this question now in both directions.
• 27:23
  Are there cases where receiving money from industry can lower?
• 27:29
  the quality of care can lower the quality of treatment selection on the systemic level, and are there also coincident cases where it can increase the quality?
• 27:39
  I think one of the main things that drug companies do when you look at which drugs are getting promoted, by and large, it's new drugs.
• 27:46
  And in a lot of cases, new drugs don't add a lot to what we already have, but in some cases, there are true breakthroughs, right?
• 27:55
  And if it's say like, going back 10 years to when the first immunotherapy drugs came out, the faster doctors started getting educated and started using those, the better.
• 28:05
  So are there cases where a doctor who gets the sales pitch and starts using a good drug faster, are there also cases where it can improve?
• 28:15
  And then kind of on nets, what's the balance?
• 28:17
  And can we start to better identify and better anticipate areas where...
• 28:21
  And there's a role for these payments that at least, yeah, in theory could be positive or at least is neutral and where the cases where it looks like we might be increasing the low value care that we've been studying up until this point.
• 28:32
  So that's our next study is to widen the lens and go broader.
• 28:36
  Great.
• 28:36
  Well, that's it for yet another episode of Care Talk.
• 28:39
  Our guest today has been Dr.
• 28:40
  Aaron Mitchell, oncologist and health services researcher at Memorial Sloan Kettering Cancer Center.
• 28:46
  I'm David Williams, president of Health Business Group.
• 28:49
  And I'm John Driscoll, Senior Advisor at Walgreens.
• 28:51
  If you like what you heard or you didn't, we'd love you to prescribe on your favorite service.
• 28:56
  Dr.
• 28:56
  Mitchell, thank you so much for joining today.
• 28:59
  It's been a pleasure.
• 29:00
  Thank you for your interest.