Treatment compliance under physician industry relationship: a framework of health-care coordination in the USA

Transcription

1 International Journal for Quality in Health Care 2013; Volume 25, Number 3: pp Advance Access Publication: 13 February 2013 Treatment compliance under physician industry relationship: a framework of health-care coordination in the USA JIE CHEN 1 AND ARTURO VARGAS-BUSTAMANTE 2 1 Department of Health Services Administration, School of Public Health, University of Maryland, College Park, MD, USA, and 2 Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA Address reprint requests to: Jie Chen, Department of Health Services Administration, School of Public Health, University of Maryland, College Park, 3310A SPH Building, College Park, MD, USA. Tel: ; Fax: ; jichen@umd.edu Accepted for publication 7 January 2013 Abstract /intqhc/mzt017 Objective. Factors associated with treatment compliance have been well studied. However, no study has examined treatment compliance under the context of physician industry relationship. This study developed a conceptual framework of physician industry relationship and treatment compliance, and empirically tested patients treatment compliance and affordability under the physician industry relationship in the USA. Design. We first proposed a conceptual framework to analyze different scenarios, where the physician industry relationship could impact patients treatment compliance and affordability, taking into consideration the role of health insurers. We then employed a nationally representative data set to investigate these relationships. Multivariable logistic regressions were employed to examine the physician industry relationship and the physicians perception of patients treatment compliance. Setting and Participants Health Tracking Physician Survey. Results. Our results showed that physicians with closer industry relationships were more likely to report rejection of care by insurers [odds ratios (ORs): , P < 0.001], patients non-compliance with treatment (OR: 1.34, P < 0.01) and patients inability to pay (OR: 1.42, P < 0.01) as the major problems affecting their ability to provide high quality care, when compared with physicians without industry relationships. Conclusions. Our results shed light on the lack of articulation among industry, physicians and health insurers in the USA. It is important to make sure that different agents in the health-care marketplace, such as physicians, industry, and health insurers, coordinate more efficiently to provide quality and consistent care to patients. Keywords: patient provider communication/information, statistical methods, patient-centered care, quality improvement, quality management, statistical methods, general methodology, health policy, health-care system Introduction The relationship between physicians and industry is ubiquitous [1 6] in the USA. The 2001 National Survey of Physicians showed that 92% of physicians received drug samples, 61% received meals, tickets to events, or free travel, 13% received financial or other kinds of benefits, and 12% received incentives for participation in clinical trials [1, 7]. The pervasiveness of physician industry interactions is also reflected by the considerable marketing investments by the pharmaceutical companies. The pharmaceutical industry allocates 33% of its revenue on selling and administration [8] and spends $19 billion each year establishing and maintaining relationships with physicians. The physician industry interaction can have positive and negative effects on patient s care. The physician industry interaction could be beneficial to reduce under-prescription of essential medications. Many prescription drugs in the market would not exist without physicians involvement in clinical trials. Physicians with closer industry relationships, however, are more likely to request the addition of specific drugs from particular pharmaceutical companies on hospital formularies, are more likely to prescribe these companies drugs and are less likely to prescribe generic medications International Journal for Quality in Health Care vol. 25 no. 3 The Author Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved 340

2 Treatment compliance under physician industry relationship Policy [1, 3, 9]. Such changes in the use of medications can potentially be expensive and nonrational [3, 9] because the industry could promote some drugs with lower therapeutic advantage when compared with more cost-effective alternatives. Moreover, in the USA, health insurers are the major payers of health services and medical products. Health insurers interests and guidelines complicate the physician industry relationship. This is the first paper that to our knowledge examined patients treatment compliance and affordability under the physician industry relationship. The health benefits of treatment compliance have been well documented [10, 11]. Patients characteristics [12], health-care access and health insurance coverage could all affect patients treatment compliance and affordability [13, 14]. However, no study has examined treatment compliance under the context of physician industry relationships. It is critical that different agents in the health-care marketplace, such as doctors, industry and health insurers, work together more efficiently and better coordinated to provide quality and continued care to patients. In this study, we first set up a conceptual framework to analyze different scenarios where physician industry relationship could impact treatment compliance and affordability, considering the role of health insurers. Then, we employed a nationally representative data set of physicians to empirically investigate this relationship. It is worth noting that although we studied the health-care market in the USA, our results may provide references and policy implications of the physician industry relationships to other countries too. Physician industry relationship is common in the UK, Australia and other countries [15 19]. Although most of these countries have guidelines prohibiting companies from giving physician incentives to prescribe their products in the form of gifts or payments [15], these guidelines were either developed recently or are still being developed. Researchers from different countries [18] have consistently called for more transparency of physician industry communications. Conceptual framework Fig. 1 delineates the relationships among health-care providers, patients, health insurers and industry in the USA. In this simplified health-care market, doctors choose medical supplies, such as drugs and medical devices, on behalf of patients. On the other hand, health insurers are the main payers of these products. Under most circumstances, insurers provide formularies for doctors to select medications and sometimes require pre-approval for certain medical services. The industry negotiates with health insurers the inclusion of their products in insurers formularies, as well as prices. Health insurers also set copayment (or coinsurance) and guidelines for these products to be used, which can influence provider and patient decisions. The interactions of industry, doctors and health insurers are complex and multidimensional. A typology of three possible scenarios is the following. Figure 1 Relationships among doctors, industry, health insurers and patients in the USA. (i) The interactions of industry, doctors and health insurers are complex and multidimensional. Fig. 1 provides a simplified framework of these three agents. (Sponsor refers to patient s employer, the government or other third party payers who will share the drug cost. Industry refers to the health- care industry, such as pharmaceutical companies, or sometimes pharmaceutical benefit managers who negotiate the drug prices with health insurers on behalf of the industry.) (2) Our model is mainly focused on the interaction of industry, doctors and health insurers. It is also possible that industry can reach patients directly by promotions or advertising, so that patients will require certain medical products from the doctors. The industry promotion strategies may vary by drug quality as well. Insurance companies may also have different strategies of cost sharing to motivate patients to use the products. However, these are out of reach of this study. Coordinated case Industry balances the promotion effort between doctors and insurers. Doctors are well informed and have full knowledge of the products advantages as well as their side effects. Health insurers put these products on their formulary and charge reasonable copayments after fair negotiations with the industry. In this case, doctors would appropriately prescribe medical products to patients, and patients would pay reasonable copayment and use these products regularly. Under this coordinated scenario, three agents work coordinately to ensure patients receive the best quality care possible. Physician-dominant case Industry put more emphasis on doctors detailing and promotion. Doctors have strong incentives to prescribe the products; however, health insurers, as the main payer, refuse to pay or shift the financial burden to patients by charging high copayment or coinsurance. In this case, patients may hesitate to purchase the product or have problems to continually use the product given cost concerns. Physicians, thus, may report more problems related to health-care delivery due to insurance rejections or patients non-compliance. Insurer-dominant case Insurance companies are the main decision makers who rank different drugs and medical devices in favorable lists and set copayments after negotiations with industry. Physicians, as the main decision makers on product selection, do not have the incentives to prescribe the newly added medical product. 341

3 Chen and Vargas-Bustamante In this case, it is possible that industry-promoted product has low chance to reach patients. By definition, this scenario implies zero or a weak physician industry relationship. These scenarios imply three different associations between industry interactions and the health-care quality. In the Coordinated cases, the physician industry relationship is positively associated with patients treatment compliance, if other factors are controlled. On the other hand, in the Physician-dominant case, the physician industry relationship is negatively associated with patients treatment compliance, if other factors are controlled. In the Insurer-dominant case, we may observe weak physician industry relationship, i. e. its insignificant association with treatment compliance. Thus, the association of physician industry relationship and treatment compliance is an empirical issue. Using a nationally representative physician sample, we empirically tested this relationship in the US health-care market. Method Data and variables This study used the 2008 Health Tracking Physician Survey, cross-sectional nationally representative sample of physicians in the USA [20]. Physicians were selected from the American Medical Association and consisted of active, non-federal, office- and hospital-based physicians who provided direct patient care at least 20 h per week. The response rate was 62%. The survey was administered by mail, and the participating physicians received $50 or $75 honorarium. The survey provided detailed information on physicians demographic information, practice and patient characteristics. The Health Tracking Physician Survey also provided sampling weights to adjust for the probability of selection and survey non-responses. More detailed information about this survey method is available in its Methodology Report [20]. Dependent variable: measures of treatment compliance. The Health Tracking Physician Survey asked physicians to identify the barriers to provide quality care. The survey question was: Please indicate whether you think it is a major problem, minor problem or not a problem affecting your ability to provide quality care to: (i) rejections of care decisions by insurance companies, (ii) patient non-compliance with treatment and (iii) patients inability to pay for needed care. The possible answers to each of these questions were one if the response was no problem, two if it was a minor problem and three if it was a major problem. We constructed dichotomous variables for each of these questions that equaled one if physicians identified it as a major problem and zero otherwise. Key independent variables: physician industry relationship. The specific survey question was Excluding any food, beverages, and drug samples you may have received in your workplace, please estimate the total value of all goods and services you received in 2006 from drug, device, or other medically-related companies. Include honoraria or payments from surveys on prescribing practices conducted by marketing or research firms for medically-related companies. Physicians answers were placed in one of the following categories: 0 = none; 1 = $1 $500; 2 = $501 $1000; 3 = more than $1000. Other independent variables. We used Reschovsky s [21] conceptual model of physicians perception of health-care quality for our model specification. This health-care quality model has been adopted in many recent studies [22, 23]. According to this framework, physician demographic characteristics, patients components and practice characteristics can all affect physicians perceived quality care. In our empirical model, we controlled the following physician characteristics: gender, race/ethnicity, specialties, years of practice, board certification status, foreign medical school graduate status, practice ownership and physicians perception of market competition. Patient components included in our study were patients race/ethnicity ratios and share of patients with chronic diseases. Practice characteristics included practice types, share of practice revenues from Medicare, Medicaid, and managed care and practice location. We also included state dummies to account for differences on aggregate market effects on health-care quality. The sample size of 2008 Health Tracking Physician Survey was Excluding an additional 150 respondents with missing information on physician demographic information, 29 with unknown or missing industry relationship and 85 with missing treatment compliance variables, our final sample size was 4456 physicians. Analysis We first presented sample descriptive statistics and summarized the compliance measures by different levels of industry income. We used multivariate logistic regression models to examine the association between the physician industry relationship and three measures of treatment compliance/affordability individually. All regression models used sampling weights to account for the differential selection probability and to generate nationally representative results. We used Stata 10 to perform the statistical analyses. Results Table 1 shows the summary statistics of our sample. Approximately, 50% of physicians reported that rejection of care by insurers was a major problem that affected their ability to provide quality care. Likewise, 39 and 40% of physicians reported that patients non-compliance with treatment and inability to pay were major problems, respectively. As to the physician industry relationships, 51% of physicians in our sample received $0, 32% received $1 $500, 7% received $501 $1000 and 10% received a total value of more than $1000 from industry excluding free drug samples and food. Most physicians were males, Whites, graduated from US medical schools, reported a medical specialty, had solo or group practice and were board certified. The average number of years in practice was 18. Among the patients, on average, 64% were White, 15% were Latino, 16% were African-American and 5% were Asian 342

4 Treatment compliance under physician industry relationship Policy Table 1 Summary statistics of physician characteristics using the 2008 Health Tracking Physician Survey (total sample size = 4456) Outcome variables n %... Quality-index measure Rejection of care by insurers Patients non-compliance with treatment Patients inability to pay Independent variables Physician industry relationship Total value received from industry (except drug sample and free food) $ $1 $ $501 $ More than $ Female Years of practices years Physicians race/ethnicity White, non-hispanic Hispanic African-American, non-hispanic other Medical school USA International Board certificated Specialty Internal medicine Family/general practice Pediatrics Medical specialties Surgical specialties Psychiatry ObGyn Type of practices Solo/2 physicians Group 3 physicians Health Maintenance Organization (HMO) Medical school Hospital based Other Full/part owner Income from practice of medicine Less than $ $ $ $ $ $ $ $ $ More than $ Proportion of Hispanic patients (%) Proportion of African-American patients (%) (continued ) Table 1 Continued Outcome variables n %... Proportion of Asian patients (%) Proportion of native patients (%) Proportion of patients with chronic diseases (%) Number of contracts from managed care None Average revenue from Medicaid (%) Average revenue from Medicare (%) Average revenue paid on capitated basis (%) Urban/rural Large metro, 1M+ residents Small metro, < 1M residents Other Perceived competition Not at all Somewhat Very competitive Americans. Physicians also had 53% of patients with chronic conditions. Most physicians practices were located in large or small metropolitan areas and had more than five managed care contracts. Table 2 reports the summary statistics of three outcome measures by different levels of industry income. The percentages of reporting major problems increased with physicians industry income. For example, when compared with those with $0 industry income, physicians with more than $1000 industry income had 18 and 7% higher likelihoods of reporting rejection of care by insurers and patients noncompliance with treatment as major problems, respectively (P < and P < 0.01, respectively). Table 3 presents the results of multivariate logistic regressions. In the regression of rejections of care by insurer, the odds ratios associated with industry income were 1.24 (95% CI: ), 1.64 (95% CI: ) and 1.85 (95% CI: ), increasing with the amount of industry income. The odd ratio of more than $1000 industry income was 1.34 (95% CI: ) in the regression of patient s noncompliance with treatment. The odd ratio of $500 $1000 industry income was 1.42 (95% CI: ) in the regression of patient s inability to pay. Results showed that physicians specialty and practice types were significantly associated with the likelihoods of reporting major problems. Results also showed that minority physicians or physicians with more minority patients were more likely to have major problems with these three outcome measures. Physicians with more patients with chronic diseases, with more managed care contracts or who received higher 343

5 Chen and Vargas-Bustamante Table 2 Treatment compliance/affordability measures by industry income Total value received from industry (except drug sample and free food) $0 $1 $500 $501 $1000 more than $1000 n (%) n (%) n (%) n (%)... Rejection of care by insurers 1019 (45) 747 (52)*** 191 (58)*** 272 (63)*** Patients non-compliance with treatment 853 (38) 569 (40) 131 (40) 197 (45)** Patients inability to pay 939 (41) 632 (44) 170 (52)*** 209 (48)** Data source: 2008 Health Tracking Physician Survey. Sample size: ***P < **P < *P < (The reference group is $0 industry income.). revenues from Medicaid, or who reported more competition, were also more likely to report treatment compliance as a major problem. Sensitivity analysis To test the robustness of our results, we applied different multivariate models. We first used ordered-probit models, treating assessments of treatment compliance as multicategory variables. Subsequently, we used ordinary least square models, treating treatment compliance as continuous variables. All these models produced similar results. Discussion Our results shed light on the lack of coordination among industry, physicians and health insurers in the USA. If a specific drug (or medical device) is not on health insurance formularies, patients may not be able to afford it or regularly take it. In these cases, physicians may perceive a reduced ability to provide quality of care that reflects an inherent conflict between insurers who emphasize cost-effectiveness criteria and the marketing goals from pharmaceutical companies. Patient s quality care and the perceived ability of physicians to provide it may be compromised under this conflict of interest. According to our conceptual framework, our findings showed that the current health-care market could be closer to the physician-dominant case described in our conceptual framework, where physicians perceived barriers to provide high quality care due to the restrictions established by insurers. In addition, our results showed some evidences that a greater relationship with the industry would somehow influence physicians decisions of the prescriptions. The multivariate results indicated that having greater industry involvement increases the likelihood of insurance company denials of treatment. Previous studies also showed that when compared with physicians with no relationship with the industry, physicians with this relationship would be more likely to request the inclusion of promoted drugs in formularies and more likely to prescribe drugs that were promoted by the industry [9]. Thus, if the industry influence induces physicians to prescribe less standard treatment, the proposed treatment may face higher likelihood of denial. Nevertheless, insurer s involvement in the physician industry relationship might reduce physicians opportunist behavior. If prescribed drugs had a limited therapeutic value or a lower cost-effectiveness ratio when compared with existing drugs or generic alternatives, patient s quality care and financial security might be compromised. The inclusion of more expensive drugs in these formularies might hinder the objective of health-care cost reduction. Thus, health insurers should establish more regulations to limit the pervasive effect that industry advertisement among physicians could have on the quality of care delivered to patients. For instance, health insurers may enhance health-care quality by testing the costeffectiveness of drugs included in formularies, more restrictive drug utilization reviews, provide more information to consumers, among other actions. Our results also showed that physicians primarily treating racial and ethnic minority patients were more likely to report patients low treatment compliance and inability to pay. These findings are consistent with the health disparity literature that minority patients were more likely to have worse health-care quality and lower health-care access [24]. In addition, consistent with previous literature [23], our results showed that physicians with more managed care contract or those who face higher market competitions were more likely to report rejection care by the insurer and patients low treatment compliance and inability to pay. Our study had some limitations. First, the physician industry relationship was self-reported. Physicians might underreport this relationship that was known as social desirability bias [25]. Thus, the reported drug income could be considered as a lower bound for the relationship estimated in our models. Second, patients treatment compliance and affordability were physicians self-perception and might not reflect the real treatment compliance. However, physicians selfassessment of quality care may provide valuable insights into the absence of objective clinical information [16]. In addition, although we included all available covariates from the survey, our results were still subject to omitted variables that might be associated with treatment compliance. For example, patients cultural background, social economic status and other variables could influence their decisions of whether to 344

6 Treatment compliance under physician industry relationship Policy Table 3 Logistic regression: the association of industry relationship and physician self-reported compliance measures Rejection of care by insurers Patients non-compliance with treatment Patients inability to pay OR 95% CI OR 95% CI OR 95% CI Total value received from industry (except free drug and food) $0 Reference Reference Reference $1 $ *** $501 $ *** ** More than $ *** ** Female Years of practices *** *** *** Physicians race/ethnicity White, non-hispanic Reference Reference Reference Hispanic African-American, non-hispanic * other ** Medical school USA Reference Reference Reference International Board certificated Specialty Internal medicine Reference Reference Reference Family/general practice * Pediatrics *** ** Medical Specialties ** Surgical specialties *** Psychiatry *** *** ObGyn Type of practices Solo/2 physicians Reference Reference Reference Group 3 physicians * * Health Maintenance Organization *** *** (HMO) Medical school *** Hospital based *** *** Other ** Full/part owner ** Income from practice of medicine Less than $ Reference Reference Reference $ $ * $ $ $ $ $ $ * More than $ Proportion of Hispanic patients *** *** Proportion of African American patients *** * Proportion of Asian patients Proportion of native patients Proportion of patients with chronic diseases *** *** *** Number of contracts from managed care None Reference Reference Reference * (continued ) 345

7 Chen and Vargas-Bustamante Table 3 Continued Rejection of care by insurers Patients non-compliance with treatment Patients inability to pay OR 95% CI OR 95% CI OR 95% CI ** *** *** ** *** Average revenue from Medicaid (%) *** Average revenue from Medicare (%) Average revenue paid on capitated basis (%) Urban/rural Large metro, 1M+ residents Reference Reference Reference Small metro, < 1M residents * Other * * Perceived competition Not at all Reference Reference Reference Somewhat Very competitive *** * * Pseudo R Values are percentages that reflect nationally representative weighted results. Sample size: The estimated population size = All regressions include a full set of state dummies. ***P < **P < *P < take medications regularly. Finally, we investigated the association between industry interaction and perceived treatment compliance with a cross-sectional design. With such analysis, it was difficult to infer a causal relationship between industry relationship and physician perceived quality of care. Despite these limitations, our results underscored the need for policy makers to address this problem. More patients were aware of and showed concerns with physician industry interaction in the USA [4, 26, 27]. Meanwhile, consumer advocates in Australia [18], UK [15], Turkey [19] and other countries have long demanded details of the financial relationships between doctors and industry. Luckily, some medical organizations have realized this problem and implemented according policy to make the physician industry relationship more transparent to the public [5, 28, 29] such as Boston Medical Center, the University of Michigan Health System and the Yale University School of Medicine. As an important component of the ongoing health-care reform in the USA, the Obama administration has recently set new guidelines, such as the Physician Payments Sunshine Act, for drug companies to disclose the payments or gifts they make to physicians for research, consulting, etc. Similarly, the National Health and Medical Research Council in Australia also calls for developing new guidelines to make the industrial sponsorship transparent and credible [15]. Many countries have guidelines developed by different institutions prohibiting companies from giving physician gifts or financial incentives [15], although the standard regulation of physician industry relationship is still lacking. For example, in the USA, Pharmaceutical Research and Manufacturers of America, and The American College of Physicians, have their own guidelines. These organizations may have different goals, and thus a multiplicity of guidelines may lead to lack of coordination and the adequate definition of an effective framework that both the industry and physicians can observe. It is important that future guidelines should be developed jointly [15] with the aim of reducing the likelihood of conflicts of interest between patients and physicians. Conclusions Our study underscored the need for policy makers to address the conflicting goals between the cost-effective criteria used by public and private insurers to reimburse patients and the profitability goals pursued by pharmaceutical and other medically related companies. Patients are in the middle of this conflict, facing barriers to receive and afford appropriate health care. It is important to encourage coordination among doctors, industry and health insurer, to promote patient s quality care. It is the role of public institutions to ensure that these practices do not weaken current efforts to control costs while providing quality and consistent care. Funding No funding resource is disclosed. 346

8 Treatment compliance under physician industry relationship Policy References 1. Campbell EG, Rao SR, DesRoches CM et al. Physician professionalism and changes in physician-industry relationships from 2004 to Arch Intern Med 2010;170: Campbell EG, Gruen RL, Mountford J et al. A national survey of physician industry relationships. NEJM 2007;356: Moynihan R. Who pays for pizza? Redefining the relationships between doctors and drug companies. BMJ 2003;326: Coyle SL. Physician-industry relations. 1. Individual physicians. Ann Intern Med 2002;136: Rothman DJ, McDonald WJ, Berkowitz CD et al. Professional medical associations and their relationships with industry a proposal for controlling conflict of interest. JAMA 2009;301: Blumenthal D. Doctors and drug companies. NEJM 2004;351: National Survey of Physicians. Part II: Doctors and Prescription Drugs. Washington, DC: Kaiser Family Foundation, Reinhardt UE. An information infrastructure for the pharmaceutical market. Health Aff (Millwood) 2004;23: Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000;283: Balkrishnan R. The importance of medication adherence in improving chronic-disease related outcomes: what we know and what we need to further know. Med Care 2005;43: Chen J, Rizzo J, Rodriguez H. The health effects of delaying or forgoing medical treatment. Am J Med Qual 2011;26: DiMatteo MR. Variations in patients adherence to medical recommendations. A quantitative review of 50 years of research. Med Care 2004;42: Gibson T, McLaughlin C, Smith D. Cost-sharing for prescription drugs. JAMA 2001;285: Winkelmann R. Co-payments for prescription drugs and the demand for doctor visits-evidence from a natural experiment. Health Econ 2004;13: Wager E. How to dance with porcupines: rules and guidelines on doctors relations with drug companies. BMJ 2003;326: McNeill PM, Kerridge IH, Henry DA et al. Giving and receiving of gifts between pharmaceutical companies and medical specialists in Australia. Intern Med J 2006;36: Rani F, Murray ML, Byrne PJ et al. epidemiologic features of antipsychotic prescribing to children and adolescents in primary care in the United Kingdom. Pediatrics 2008;121: Weyden M. Doctors and the pharmaceutical industry: time for a national policy? MJA 2009;190: Semin S, Güldal D, Özçakar N et al. What patients think about promotional activities of pharmaceutical companies in Turkey. Pharm World Sci 2006;28: Center for Studying Health System Change Health Tracking Physician Survey methodology Report [Internet]. Washington, DC: HSC, Reschovsky J, Reed M, Blumenthal D et al. Physicians assessments of their ability to provide high-quality care in a changing health care system. Med Care 2001;39: Reid RO, Friedberg MW, Adams JL et al.. Associations between physician characteristics and quality of care. Arch Intern Med 2010;170: Fang H, Rizzo JA. Do psychiatrists have less access to medical services for their patients?. J Mental Health Pol Econ 2007;10: Vargas Bustamante A, Chen J. Physicians cite hurdles ranging from lack of coverage to poor communication in providing high quality care to Latino patients. Health Aff (Millwood)2011;30: Edwards AL. The Social Desirability Variable in Personality Assessments and Research. New York: Dryden, Edwards D, Ballantyne A. Patient awareness and concern regarding pharmaceutical manufacturer interactions with doctors. Internal Med J 2009;39: Gibbons RV, Landry FJ, Blouch DL et al. A comparison of physicians and patients attitudes toward pharmaceutical industry Gifts. J Gen Intern Med 1998;13: Greenland P. Time for the medical profession to act new policies needed now on interactions between pharmaceutical companies and physicians. Arch Intern Med 2009;169: Chimonas S, Rozario NM, Rothman DJ. Show us the money: lessons in transparency from state pharmaceutical marketing disclosure laws. Health Serv Res 2010;45: