Conflicts of interest: the role of norms

There has lately been much discussion of norms in the realm of politics and governance.  But norms are also important in the business world, particularly  those established within a profession.

In Regulating Conflicts of Interest Through Public Disclosure: Evidence From a Physician Payments Sunshine Law, Matthew Chan of William College and  Ian Larkin of  UCLA  Anderson  review the literature and report on the results of their recent study in the area of pharma companies providing things of value to prescribing physicians and legal mandates to make disclosure in Massachusetts, which has such a requirement, and several  other states which don’t. They also conclude with an interesting thought about the role of norms in COI mitigation.

In particular, they show a significant post-disclosure reduction in brand name drug prescriptions by Massachusetts physicians, relative to control doctors in other states. These effects are driven by heavy prescribers of brand name drugs in the pre-policy period, particularly for drugs with large pre-policy sales forces. Effects are also detected before the first data were released, implying that the effects are not because patients or administrators responded to the disclosed payments. Instead, some physicians may have reduced payments after disclosure is mandated, leading to changes in their prescriptions. Taken in tandem with the many studies showing that industry payments influence prescribing, this study suggests a strong role for mandatory public disclosure in reducing conflicts of interest in medicine and costly prescribing of brand name drugs.

They further note:

These results carry important managerial implications in healthcare. For health care managers and officials concerned with the effects of pharmaceutical marketing on prescription drug costs, increasing the coverage of disclosure or making disclosed payments more salient (e.g. by implementing hospital-wide communications or campaigns) may be an effective method for changing physician behavior. Other physician conflicts of interest may also benefit from disclosure. For instance, the “Total Transparency Manifesto” and the “Who’s My Doctor?” campaign advocates for physicians to disclose all sources of potentially conflicting incentives, including incentives for ordering additional tests or procedures (Wen 2013; Sifferlin 2014). Approximately 70% of surveyed physicians believed that clinicians are more likely to perform unnecessary procedures when they profit from them (Lyu et al. 2017); disclosure of these payments may be worth exploring, especially as alternative pay structures continue to be introduced into the field, thus making fee-for-procedure structures more optional.”

.They conclude with the following:

These results may also carry important implications for how managers and officials manage conflicts of interest even in non-healthcare settings. The principal-agent problems inherent in drug prescribing, where an informed expert makes important decisions for an uninformed principal, are found in many other industry settings such as retirement planning, consumer insurance, mortgage origination, and legal advice, to name a few. However, within medicine, there are norms (such as the Hippocratic Oath) that place great importance on earning a patient’s trust (Sah 2019); since our results suggest agents must care about appearing unbiased in order for disclosure to work, it remains for future research to test whether disclosure is effective in settings where such norms are not as heavily emphasized. Nevertheless, the results in this paper suggest that disclosure is at least worth exploring further in these contexts, despite the literature on the pitfalls of disclosure,

As a COI generalist, I am particularly interested in the notion that unlike the other professions they mention, “within medicine, there are norms…”  Of course, in light of the striking statistic that “70% of surveyed physicians believed that clinicians are more likely to perform unnecessary procedures when they profit from them” one might wonders what the real norms are.

But still, the point is an important one, and I do hope that there will be future research conducted along the lines they propose.

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