Medical students’ first contact with pharmaceutical companies, often now referred to as “Big Pharma,” was early in their training when companies gave gifts to students, often in the form of leather “doctor” bags.  As pharmaceuticals became bigger and bigger business and as medicines contributed a larger and larger percentage to the cost of healthcare, the ethics of the relationship between healthcare providers and pharmaceutical companies was brought into question. 

When I started medical school in September 1969, our class voted overwhelming not to accept
gifts from pharmaceutical companies.  For many physicians this ethical conundrum carried over into our professional careers such that many of us refused to accept personal gifts from pharmaceutical companies.  Others demanded increasingly expensive gifts in order to give access to pharmaceutical representatives. Finally, legislation regulated what pharmaceutical companies could or could not give to a physician and this was measured in a dollar amount for personal gifts including meals.

In the past 45 years, pharmaceutical companies have increased their costs, profits and have increasingly developed a social consciousness and have looked for ways to collaborate with physicians and other healthcare providers for the benefit of patients and the communities they serve.  Without doubt the most conspicuous means by which this has been done is through the providing of sample medications.  This has enabled healthcare providers to provide medications to those who could not afford to buy them.  Pharmaceutical companies have also developed corporate means of supplying expensive and essential medications to patients.  

As healthcare has matured, different segments of the industry have begun to see how the healthcare team extends beyond traditional doctor, nurse, staff positions and includes many therapists, pharmacists, administrators and others who contribute significant value to the care patients receive.  Now, rather than seeing each other as simply commercial partners using each other for entrepreneurial purposes, healthcare providers and “big Pharma” are increasingly seeing professional opportunities for collaborating to improve the care which patients receive.

Over the past few years, SETMA has met independently with several of the nation’s largest pharmaceutical companies to discuss the “new” methods and structures of healthcare delivery such as medical home, data analytics, and value-based rather than volume-based care.  These discussions did not intend economic benefit to SETMA but focused on healthcare quality, safety, and value to the residents of Southeast Texas, both those who receive care from SETMA and those who do not.  Because of SETMA’s initiatives which have been in development for the past 19 years, there were some difficulties in finding potential points of collaboration with SETMA.   

The following is a summary of some of the discussion with one of the companies.  This summary includes a contrast of SETMA with other healthcare organizations with which this company has met.  A “big pharma” representative said:

“It was a great conversation and we continue to learn every day as we move forward in this new healthcare environment. A little background, you can see my title below. Yes, I lead a pharmaceutical team of about 100 people. In the past, we have followed a ‘traditional’ approach to working with providers would have been offering economic benefit to the provider or offering gifts like trips, vacations, etc. Now, in this new world we are seeking to partner and earn a seat at the table to provide solutions that are ‘patient centric,’ which while meeting the needs of providers, also provide solutions that support disease management and assistance with helping providers meet quality metrics.  In order to do so, we have sought out to learn all we can about ‘meaningful use,’ and how it impacts the provider from health information technology, protocols, etc. We have learned about quality metric incentive programs as it relates to commercial insurance and Part D Medicare reimbursements and frankly how offices are now required to interact and ‘prove’ their impact. This presents all kinds of opportunities with other organizations. SETMA is so far advanced with this approach and leading by example that it is challenging on my end to find alignment points.

“As I prepared to meet with SETMA, I sought to learn about your practice and understand what your needs might be. My first insight:  SETMA is light years ahead with technology. Many offices have just recently converted and those that had earlier, are now faced with challenges of HIT companies closing doors, not following up on ‘issues.’ or not enhancing the systems to provide needed capabilities.  SETMA’s system is AMAZING.  Its capabilities allow for quick learning and thus quick adjustments on your end.  

“Second, I don’t know of another practice that has the accreditations that you hold.  This represents more than just marketability; it represents a team of healthcare providers working closely together to ensure many details are met to reach these goals. It speaks volumes to your team, how you lead them, and the culture you have built over time, i.e., a true team. 

“Lastly, how your organization involves so many for the benefit of the patient is somewhat overwhelming: your Patient-Centered Medical Homes, your Community Council and the SETMA Foundation, are just a few. 

“Please know that you are setting an excellent example of how it should be done. Your organization is truly changing the approach to healthcare and showing others what ‘good’ looks like.” 

The focus of this summary is dramatically different than what it might have been in 1969.  The benefit to patients is central to the pharmaceutical company’s goals and to what SETMA would expect and/or would accept from a pharmaceutical company.   The focus is on how two different participants in the same industry can collaborate for the benefit of the people we both serve.

SETMA is proud that such things can be said about our development and SETMA is proud to be part of the transformation of healthcare which results in a transformation of the relationships between other participants in the healthcare industry.  We are proud to participate in the fulfillment of the Triple Aim of healthcare change which was first enunciated by the Institute of Healthcare Improvement.   The Triple Aim includes:  improving the patient’s experience of care, improving the outcome of care and decreasing the cost of care in the process.  No doubt the pharmaceutical industry, like healthcare providers such as SETMA, has a great deal to learn about how we can contribute to the Triple Aim and to healthcare transformation.  No doubt, either, that we are both committed to the process and to the  outcome of excellent care, and to doing both in such a way that makes care accessible and affordable to everyone.

When our technology creates possibilities with which our medical ethics cannot deal

Healthcare providers’ relationship with big pharma has gotten more complex because the cost of healthcare goes up in direct proportion to the complexity of the care received. New therapies are almost always expensive. Television solicitation of patients with Hepatitis C for curative therapy at $96,000 per patient are seen daily. There are an estimated 4.1 million people in the USA who have Hepatitis C. If all of them were treated it would cost approximately $400,000,000,000 (400 billion dollars). Transplant centers are expanding their standards for approval of liver transplants, with many now willing to transplant alcoholics who have not stopped drinking alcohol.

The Wall Street Journal, April 26, 2018, reported on how we are now confronted with drugs for cancer which can cost $1,000,000 for the treatment of one patient. This expands our ethical dilemma to a a discussion which we do not want to have but which we must face. Who is going to get these treatments and who is not going to get them? Who is going to pay for these treatments and at what point will society determine that these treatments cannot be afforded: The Million-Dollar Cancer Treatment: Who Will Pay?

There is no moral, ethical, or equitable way to answer some of these questions but answer them we must. This Wall Street Journal article puts this conundrum front and center on our healthcare policy radar.

The ethical challenges we face today makes the questions with which we struggled in 1969 seem inconsequential. If we believe that healthcare should be available to everyone on an equal basis and we do; if we believe that there should be no economic barriers to the receiving of that care and we do, what do we do when society can no longer provide care due to its enormous cost? That’s what we face today. How we answer these questions will define who and what we are as a nation.