1 Boring Old Man

Beware the fine print of Glaxo’s big drug-marketing announcement

The Week

by Peter Weber

December 17, 2013

On Tuesday, British drugmaker GlaxoSmithKline vowed to unilaterally disarm in the controversial marketing war that has helped fuel the pharmaceutical industry’s robust growth in the past 30 years. This is potentially a big step toward curbing conflicts of interest and doctor payola, especially if other drugmakers follow suit. But right now the fine print leaves plenty of wiggle room. Here’s what GSK is doing: First, it says it will stop paying doctors to promote its products at medical conferences, dinners, training classes, or other events for "audiences who can prescribe or influence prescribing." The company won’t directly pay for doctors to attend such conferences, either. The other big change is to how GSK pays its sales force, dropping the practice of tying compensation directly to the number of prescriptions written by doctors each sales rep visits. Instead they’ll be paid based on their technical knowledge, client feedback, and GSK’s overall performance...

Here’s where the fine print comes in:

• First, the new rules won’t change much of anything in the large U.S. market: Under its deal with the Justice Department, GSK has already adopted the proposed global sales rules in the States, and a provision of ObamaCare mandates that pharmaceutical firms publicly disclose how much they pay doctors, with the amounts available in a searchable government database starting next fall. That has led the entire industry to ease up on the doctor junkets and speaking fees already.
• Second, industry shifts make the education part of the sales mission less important: Well-informed specialists are prescribing more and more medications, replacing prescriptions from generalists and primary care physicians. Drugmakers have already laid off tens of thousands of sales reps since 2006, when the sector peaked at 105,000 sales jobs.
• And third, it’s not clear GSK’s changes are as far-ranging as they sound. The company maintains that it still needs to educate doctors about its products, and says it will still "support fair, balanced, and objective medical education for health care professionals" through "unsolicited, independent educational grant routes." These grants have often been given out through for-profit companies that rely on drug company largess, says Harvard Medical School’s Dr. Jerry Avorn, a critic of Big Pharma’s marketing practices.

Caveats aside, kudos to Glaxo for getting ahead of the curve on cleaning up marketing practices that notoriously push up medical costs while boosting already bulging pharmaceutical coffers. Here’s hoping the changes are real — and contagious to the whole industry.

The one on the left is from Dr. Nemeroff’s CV. It’s the number of Pharmaceutical companies he was associated with [advisory boards or speaker’s bureaus]. And the one on the right is from one of Senator Grassley’s printouts back in 2008 when he was investigating the KOLs who weren’t reporting their income to universities accurately. On the ordinate [y axis] is the number of presentations of the type GSK says they are stopping PER MONTH Dr. Nemeroff was giving. They were all over the country. At this time, he was chairman of Emory’s psychiatry department, editor of the Neuropsychopharmacology Journal, on boards and committees. And this is the count of publications PER YEAR with him on the author by-line:

In this case, there was a GSK/NIMH grant worth a mint headed Emory’s way among other things – I guess a well-earned perk. While this wasa worst case, it was an example of the rampant use of physicians as stealth sales reps throughout American [and World?] medicine. Dr. Nemeroff may be the worst, but the collective impact was staggering, larger than we’re likely to ever know. Whether GSK’s pledge to stop this kind of thing comes from a religious conversion or from more terrestrial concerns, it’s the biggest of deals.

All of my medical life, pharmaceutical advertising has been part of things, part of being a doctor. I never gave it much thought, What was different about the last twenty-five years was that they found ways to advertise without it showing. It never used to occur to me that an article in a medical journal like the American Journal of Psychiatry was constructed under the tutelage of a drug company. I never thought of famous physicians as Key Opinion Leaders – people whose notoriety was a commodity to be bartered for its impact on my prescribing habits. If that was going on in my distant past, I didn’t know it and I would have considered it fraud. Now, it’s so ubiquitous that it’s the rule rather than the exception, and it has produced an enormous amount of confusion – too much to fathom. And a lot of that confusion is because the famous doctors became KOLs. Maybe Nemeroff, my chairman, was the absolute worst, but there were plenty of others at places like Harvard and Stanford, the venerated halls of learning in medicine and psychiatry. That I was on a clinical faculty at a place where those things were happening and didn’t really know it is a testimony to the very stealth that is on trial here.

The woods are lovely, dark and deep.
But  I  we have promises to keep,
And miles to go before  I  we sleep,
And miles to go before  I  we sleep.