Healthcare has become "less about well-founded, trusted relationships between healthcare professionals and patients" and more of a "profit-driven service industry," say a pair of Dartmouth Institute researchers. But they offer solutions.
A "background of obvious corruption" permeates the healthcare industry in five ways, impeding the delivery of higher integrity healthcare, with reduced waste, and lower costs, say Dartmouth Institute researchers Elliott Fisher, MD, and Glyn Elwyn, MD.
"Solutions to these problems are visible, but will be difficult to introduce unless there is a much wider recognition that healthcare has become less about well-founded, trusted relationships between healthcare professionals and patients. Rather, it looks more like a profit-driven service industry, where commercial interests have influenced the value chain."
The five problems identified by Fisher and Elwyn in the article published in Circulation are:
1. Pharmaceutical companies often know about, but fail to disclose, harmful effects of new drugs that can cause adverse events including patient deaths, or illegally promote products with unproven claims.
When prosecuted for such activities, they regard settlement payments amounting to millions of dollars "merely as the price of doing business."
2. Clinical practice guidelines that inform physician decisions have "become an industrialized, often sponsored process," with multiple and conflicting guidelines on the same topic.
Often these guidelines are produced by expert panels composed of specialty groups with links to pharmaceutical companies, with incomplete evidence.
3. Physicians often neglect to include patients in the decision-making process or are unable to share evidence that would influence patient choice of care approach.
4. Quality measurement systems now in place "fail to ensure sufficient accountability." Providers and healthcare organizations and institutions have "neglected" measures that value care delivered to patients based on their informed preference.
5. "Disease mongering," by which the healthcare industry creates the concept of an illness to increase the market for physician or pharmaceutical intervention, either through direct-to-consumer marketing or by lowering thresholds for diagnosis, "expand[s] the number of worried consumers," or the population at risk.
Such practices may also bring "potential harms to patients of more testing or additional treatment."
The authors point to two recent books, "Bad Pharma" byBen Goldacre,and "Deadly Medicines and Organised Crime" by Peter Gotzsche as adding to the "body of work" describing how pharmaceutical companies influence medical research in their favor.
Best and Current
To restore integrity in research, regulators should require clinical trials to compare new drugs against the "best current therapy" rather than placebos to measure outcomes that matter to patients, the authors suggest.
Transparency
Additionally, publications and peer reviewers should demand declarations of authorship to combat "ghostwriting," a practice in which academic researchers "accept arrangements that compromise their integrity."
Fisher and Elwyn write that research publications "should have prominent warnings where the trial design, management, and analysis were not done independently of a company who stood to profit by the outcomes.
Payment Reform
Payment reform that rewards value over volume, and a move to scoring systems that put more weight on outcome and performance measures rather than process measures, can help patients and providers better judge the value of care, they advise.
Review and Assessment
The authors call for wider acceptance of a growing practice—often done covertly by patients—to use smartphones or other devices to record clinical encounters, sometimes to re-listen to what was said or to use in litigation.
Broader acceptance of the practice could "mean that the content of medical practice would be accessible for review and assessment…. [on] how providers informed, involved, and sought the preferences of the patients."
Marketing
While it would be legally difficult to limit the ability of companies to market their products directly to consumers, "stakeholders could be better engaged to develop standards, trusted sources of health information, and shared decision-making." And, the authors continued, "a more skeptical media [could] help consumers be wary of hype that over promises."
"Without some ability to monitor the quality of information given by commercial organizations, to check veracity and assess the potential to do more harm than good, we risk manufacturing inappropriate demand for interventions that have marginal benefit at best, and at worst, high costs and harm that could be avoided."