Will the Sun Shine All Over Canada? Making Transparent the Financial Relationships of the Medical Industry (Part 2: Towards Effective Transparency)

By Jean-Christophe Bélisle-Pipon

As detailed in Part 1, Ontario government just enacted the Health Sector Payment Transparency Act, a Canadian first in terms of transparency. The act requires that “transfers of value” (or payments), related to medical products (drugs and medical devices), between a payor and a recipient be reported to the Health Ministry. The Act gives the Ministry unprecedented powers to require, analyze, and publish such data online.

A Transformational Act?

Will this act radically transform the practices and the public knowledge that we have about the financial relations of the medical industry? The effective implementation of the regulations will tell us. However, the fact that Innovative Medicines Canada (formerly known as Rx&D, IMC is the organization representing the interests of the pharmaceutical industry in Canada, like PhRMA in the US) has concerns about the Act is a rather positive sign that this legislation might result into pro-social changes. IMC is invoking both ideological concerns (industry’s interactions with HCPs imply cooperation rather than influence) and logistical concerns (“if the threshold for payments is low, a sales representative could easily lose a receipt and forget to report it”), as well as its  own commitment to limiting undue influences.

It is true that the pharmaceutical industry in Canada has tried to self-regulate its practices with its code of ethics by preventing its members from:

“offer[ing] to any Stakeholder […] any gift […] as an incentive or reward for prescribing, administering, recommending, purchasing, paying for, reimbursing, authorizing, approving or supplying any product or service sold or provided by the Member, or to obtain any other improper advantage for the Member.”

This type of self-regulation is laudable. However, until today, there were very few ways to monitor such practices, and to ensure an objective assessment of wrongdoings. Even though some practices are prohibited by ICM, the fact remains that the industry maintains strong financial relations with HCPs and that this may translate into changes in HCPs practices. If it was not benefiting the industry, the top 10 Canadian companies would not have paid close to $50 million to HCPs and organizations in 2016. More transparency may help educate the public about the fact that it is not only doctors who are targeted, but increasingly nurses, dietitians, and pharmacists.

To be cynical, discontented companies still have a window of opportunity to ensure that the upcoming regulations follow the Canadian tradition of inoperative transparency, such as by lobbying for a threshold so high that the act will end up having very little effect, thus emasculating the positive outcomes of a transparency regime.

Conclusion

This act is an important first step towards greater transparency of the industry’s practices, and all provinces should adopt such provisions. Regulations, disclosure procedures, and thresholds should be harmonized across Canada (such a recommendation is even supported by ICM), through a concerted effort by all the provinces and the federal government. This is crucial since Canada has a poor record in terms of interoperability of platforms (e.g. Canada.ca and Phoenix, the federal payroll platform, the slow implementation of electronic medical records, and the list goes on).

In addition to designing efficient regulations, some questions remain. Why are natural products not included? It may have been desirable to have a comprehensive picture of HCPs’ and organizations’ financial relationships. Also, considering that the law includes education and research activities related to medical products, why not includeresearchers and experts advising the government on medical and pharmaceutical policies? These two populations enjoy epistemic authorities and may be important vectors of influence, all the more so with the growing reliance on science-based decision-making.

Lessons must be drawn from the American experience, in particular by ensuring that the launch of the platform and the beginning of mandatory disclosures coincide with supporting and educating HCPs about the benefits of such disclosure, while making sure to avoid giving the impression of policing diligent and dutiful practices. As a highly public tool that should contribute to public confidence, it is important for the government to take steps to ensure that patients (and journalists, who are likely to be the first to make headlines with the physicians receiving the highest payments) understand the scope of the data disclosed. Guidance must be provided on how transfer of value should affect their assessment of their HCPs’ moral character and nuances on what constitutes valid concerns and what is rather valueless in terms of influence and ties to the industry. Transparency should not lead to distrust-mongering, but to fostering positive pro-social changes.

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