Doctors and big pharma protest crackdown on freebies from drug reps

Doctors are pushing back against a set of Health Ministry rules designed to make it harder for drug companies to wine and dine and hand out benefits to physicians in the hopes of winning a greater number of lucrative prescriptions.

New directives that went into effect in November aim to make the relationship between physicians and drug companies more transparent, after an investigative TV program a year ago exposed questionable quid-pro-quo relationships between some senior physicians and representatives of drug companies.

But the Israel Medical Association union, which represents more than 25,000 medical staff, has cried foul over the restrictions and threatened a labor dispute. The ministry, meanwhile, has agreed to soften some of the new requirements.

In a letter last month to the heads of all the health maintenance organizations and medical institutions, the Health Ministry’s director general, Moshe Bar Siman Tov, emphasized that the new regulations still stood despite the threat of collective action from doctors.

Still, Bar Siman Tov has been meeting with critics of the rules in order to hear them out and consider whether anything needs to be changed.

The new rules were put in place after a Channel 10 investigative program exposed doctors being courted by pharma companies in what appeared to constitute a conflict of interest.

The show broadcast one-on-one conversations between some senior doctors and drug company sales representatives which saw the former accepting, and in some cases even demanding, all-expense-paid junkets to medical conferences overseas, meals at top restaurants in Israel, food and drink to celebrate religious holidays with staff, and gifts ranging from expensive wines to fun days out for the nurses. In some cases, companies took entire departments out for meals.

Faced with the evidence, Prof Yonatan Halevy, director of the Shaare Zedek Medical Center in Jerusalem, and Prof Ronni Gamzu, a former Health Ministry director general who is now CEO of Tel Aviv’s Sourasky Medical Center, expressed shock.

“It’s one of the most serious things I have seen,” Gamzu said.

The new rules

The ministry now insists that all external funding proposals — whether for research, clinical trials, training courses, conferences, seminars or the employment of medical staff as consultants — go through a hospital committee headed by the CEO or his or her representative before being approved, within seven days, by a Health Ministry committee.

Once a year, each medical institution’s director will have to report to the ministry on how much external funding was received and what it was used for.

“Unreasonable” travel expenses or an insufficient reason to travel will not be approved and participants will have to pay their own way for “days without scientific or professional activity.”

Conferences in Israel will only be approved if the initiative comes from a medical institution, if at least three companies under different ownership are providing the funds — to prevent favorable treatment toward any one company — and if the content is “scientific and not marketing” and there are no “non-related activities,” such as entertainment and tours.

The rules also crack down on drug companies paying for trips abroad. Proposals to fund such trips must be directed to the institution’s management, which, in turn, will choose the most appropriate people to send.

In addition, drug companies are no longer to pay for first- or business-class travel, and paying for anything beyond accommodation, registration, meals and travel to and from the airport is forbidden.

The directive also places constraints on drug companies, requiring them to submit monthly reports to each medical institution on meetings held, with dates, details, the names of the products that were discussed and the names of both the trade reps and the health service employees present. Every six months, the medical institutions’ directors will have to provide reports to the Health Ministry, which will be published.

Visits by trade representatives will have be approved in advance.

Written materials, other than recognized professional literature or peer reviewed articles, will have to be approved and signed by or on behalf of the hospital director before they can be circulated around the institution or at one of its conferences.

The most controversial rule, though, forbids doctors from holding one-on-one meetings with pharma reps. Instead, at least three hospital employees must be present at any meeting with a company rep, at least two of whom must be medically knowledgeable.

In a nod to opposition from the Israel Medical Association, the ministry agreed to delay implementation of the clause for a year and allow exceptions.

The revised circular says that in circumstances where having at least three people present is not possible — and then, only with the advance permission of the institution’s director – one-on-one meetings can still be temporarily held, with the issue to be reviewed later this year.

The change, a senior Health Ministry official explained to The Times of Israel, was mainly to ease the situation of such places as neighborhood clinics, where just one doctor may be present.

In November, Shelly Yachimovich (Labor), chair of the Knesset State Control Committee, said she was “shocked” by the decision of the doctors’ union to stand on the side of the drug companies.

As a supporter of organized labor, she said this was “perhaps the strangest labor dispute in the history of the State of Israel” because it dealt not with wages and conditions but with the protection of relationships with wealth. The union’s action “stained” the whole community of doctors, the vast majority of whom were good and moral people, she charged.

The Israel Medical Association failed to respond to repeated requests from the Times of Israel for comment.

But its own code of ethics (published in Hebrew) on “reducing conflict of interest with the drugs market” provides clues to the reason for its opposition.

The union paper attacks as “dauntingly low” the amount of state investment in medical research and the advancement of doctors’ professional knowledge and charges that as “the pharmaceutical industry is the only body that exists today for research and development…. harming this relationship will impair our ability as an advanced society to research, invent and create.”

The paper adds that while relationships between medical professionals and drug and medical equipment companies need guidelines, these must be set internally, and not by government.

Drug and medical equipment companies have also tried hard to have the health ministry regulations overturned. Last year, the High Court rejected two petitions — one from the pharmaceutical companies, the other from the drug company reps. The companies had issued dire warnings to the press about widespread layoffs among the reps because of the new rules. They have also intimated that they may take their business running lucrative drug trials elsewhere.

Shaare Zedek’s Halevy told a State Control Committee meeting on the issue in November that he proposed banning drug company reps from hospitals altogether.

The claim that doctors were dependent on drug reps for knowledge was “embarrassing nonsense,” he said.

No gifts, no drugs

The depth of the symbiotic relationship between doctors and pharma companies, and the kickbacks and conflicts of interest that dominated the relationship, was revealed in the Channel 10 program, which featured a former drug rep going undercover and recording conversations.

In one conversation, a hospital pharmacist could be heard saying, “If there’s no gift, I’m not ordering [drugs from your company].”

In another, a doctor used one company to leverage a better deal from another which would allow him to take his wife with him overseas for free as well.

Taken together, the conversations revealed that drug companies not only finance most medical research, they are also the main underwriters of doctors’ ongoing education. Not only do they pay to fly doctors overseas, they fund medical conferences in Israel and pay physicians thousands of shekels to lecture – often with company input on the content of the presentation beforehand.

One doctor was heard admitting on the program that because of his lecture, prescriptions of the company’s drug seemed to be rising.

Hospitals and health funds have budgetary shortfalls, the program charged — and the drug companies have stepped into the vacuum “like a sugar daddy.”

Drug company reps who agreed to be interviewed incognito — from behind and, in one case, with a distorted voice — testified that head nurses and pharmacists regularly opened their records to reveal which and how many prescriptions of the company’s drugs for particular conditions doctors were writing.

The reps, whose low salaries are supplemented by bonuses subject to sales, saw around 15 doctors a day and had unfettered access to hospital wards and doctors’ offices, the TV program was told.

One company had a computer graphic showing which doctors were prescribing which drugs, along with tongue in cheek descriptions, such as “likes gimmicks” or “talks too much,” and recommendations as to which incentives should be offered to each physician to maintain or increase sales.

Ron Tomer, deputy CEO and co-owner of a drug company called Unipharm, told the program that the alleged behavior of certain doctors seemed to explain why several months after his company had issued cheaper generic versions of a particular drug, doctors would move over, or back, to prescribing much more expensive alternatives.

Marketing intensified in the run-up to the Health Ministry’s annual discussions over which drugs to subsidize, the program heard.

According to Halevy, there were occasions where two or three doctors would provide the same recommendation, using the exact same wording, whereupon it would be clear that the drug company had written the text.

Ministry also getting a piece of the action

It’s not just doctors who were on the take.

Last month, the Marker, a business daily, revealed that for more than 20 years the Health Ministry itself has run an NGO which, over the past three years, has accepted hundreds of thousands of shekels from 10 pharmaceutical companies including Teva, Novartis, Reckitt Benckiser, Janssen, Abbvie, and MSD.

The cash — which comes in addition to the proceeds of some NIS 33 million ($8.9 million) held by the NGO in assets — is used, according to the Health Ministry, to fund conferences and overseas trips for staff at government psychiatric hospitals which do not have associated research funds through which the money can be channeled.

Each year, the Health Ministry publishes figures and breakdowns (in Hebrew) about donors, donations and the projects for which the gifts were earmarked.

These show, for example, that drug and medical equipment companies were responsible for more than NIS 70 million ($18.8 million) of the NIS 142 million ($38.3 million) donated to the entire health service in 2017, the last year for which figures are available.

The top recipients of the NIS 142 million ($38.4 million) were Barzilai Medical Center in coastal Ashkelon (the bulk for a rehabilitation wing) and the Maccabi health fund (most of it earmarked for the Assuta Hospital in nearby Ashdod).