In an attempt to curtail the endless stream of freebies from drug companies and medical device manufacturers, the Permanente Medical Group has adopted strict conflict of interest rules for their 5,500 participating Northern California physicians.

The change affects the largest medical group in the nation, who treat nearly 3.2 million Kaiser Permanente Northern California members. Other medical groups contracting with Kaiser around the country are expected to use the new rules to draft their own.

The Permanente doctors have had policies regarding drug companies for about 20 years, but the new rules address the increasingly complex relationship between doctors and vendors.

"One important reason to update the policy is that (drug and medical device) companies have gotten very clever in their strategies," said Dr. Sharon Levine, a pediatrician and associate executive director of the Permanente Medical Group in Northern California.

The new policy bans gifts, such as tickets to entertainment events, and meals for physicians and their families from vendors and manufacturers.

Physicians can no longer accept honoraria from vendors for teaching or giving presentations, including payment for time, travel expenses, meals or social activities. All education funding on behalf of companies is directed to the group's continuing medical education programs.


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The rules were devised over six months and adopted last fall by the medical group's 39-member board of directors. They went into effect in December. Kaiser Permanente health plan was not involved in the decision to adopt the new guidelines.

The rules address the triad of "food, friendship and flattery" between doctors and pharmaceutical companies — a phrase coined by Dr. David Blumenthal of Massachusetts General Hospital in a New England Journal of Medicine article published last October.

Blumenthal urged physicians to examine the nature and extent of these relationships, noting that social scientists have found that "humans are vulnerable to a powerful, unconscious 'self-serving bias'; that is, they have trouble seeing themselves as biased when the bias serves their needs or advances their own perceived interests."

A 2001 survey of physicians nationwide by the Kaiser Family Foundation found that 92 percent received free drug samples from companies; 61 percent received free meals and tickets for entertainment or travel; and 13 percent received financial or in-kind benefits.

Levine said the idea of "food, friendship and flattery" struck a chord.

"The primary duty of the physician is for the physician's interest to not be more important than the patient's — that goes back to Hippocrates," she said.

Even accepting something as small as a Starbucks gift card from a pharmaceutical representative is prohibited. "There's no way that contributes to the patient's benefit," Levine said.

But physicians can still accept honoraria from educational institutions, nonprofits or government agencies — with prior approval from the medical group's board of directors.

They can also participate in research, clinical trials and development of medical devices — many of which are underwritten by pharmaceutical or medical device companies — but those agreements are negotiated by the medical group on behalf of the doctor, not by the doctor personally.

Levine said the rules are important as technology advances. Today, doctors have ample opportunities to get financial rewards for helping companies develop orthopedic devices, for instance, or design monitoring equipment.

Doctors can play a legitimate role in this process of creating durable equipment provided that the work "happens in a transparent way," she said. The Office of the Inspector General of the U.S. Department of Health and Human Services in April 2003 cautioned drug companies about making excessive payments to physicians for consulting and offering inappropriate gifts. The report implied that these excessive costs would drive up prices of Medicare and Medicaid services. 

Since the Kaiser physician rules were implemented four months ago, Levine said doctors have forwarded her e-mails they received from drug and medical device companies with enticing offers.

One vascular surgeon from Kaiser Oakland received an e-mail from a durable equipment manufacturer in advance of a major medical conference in San Francisco that included a list of expensive San Francisco restaurants. The manufacturer asked the doctor to pick out his preferred restaurants for lunch and dinner each day of the conference — making it clear that the manufacturer would pay the check.

"The people who end up picking up the tab are the people having vascular surgery," Levine said. "That's where we have to ask the hard questions."