December 14, 2015

When I was a member of the Massachusetts Public Health Council, a policy-setting division of the Department of Public Health, I had to recuse myself every time we voted on a proposal in which I had a personal financial stake. In fact, I often couldn’t participate in the discussion or make a decision whenever there was an appearance of a conflict of interest, even when there really wasn’t a conflict at all. Massachusetts took this matter very seriously and had a number of lawyers scrutinize every council member and every vote to make sure we were scrupulously following the roles. So it came as quite a shock when I learned that roughly 30% of US senators and 20% of House members hold assets in biomedical and health care companies but are perfectly free to introduce, discuss, and vote on legislation that significantly impacts those companies.

According to a report by STATa new non-profit organization devoted to investigative journalism in the health care industry, our Congressional representatives are substantial investors in Pfizer, Johnson &Johnson, and Merck, along with assorted other companies. Their investments exceeded $68 million in 2014. The people who have the biggest stake often use their influence in Congress to promote legislation that just happens to coincide with their personal interest. Republican representative Chris Collins, for example, has co-sponsored a bill that would repeal the recently instituted tax on medical devices (which is one of the ways the Affordable Care Act pays for health insurance for the previously uninsured) and he just happens to be invested in the medical device industry, which vociferously opposes the tax. He also has supported abandoning FDA surveillance of products after they are on the market and just happens to be the single largest stockholder in a biotech company. This in the face of the recommendations of an independent Institute of Medicine report that the absence of any meaningful post-market surveillance is one of the weakest links in the FDA and has been responsible for delays in discovering drug toxicity that have led to numerous deaths.

It’s not just Republicans who influence health care policy despite their clear and unequivocal personal financial stake. Democrat Scott Peters has spearheaded an effort to essentially allow drug companies to prolong their already lengthy patent protection of drugs, the principal bulwark against price competition in the pharmaceutical industry. His wife is a major investor in the industry, buying over half a million dollars worth of stock in 2015 alone.

Even when they have what appears to be a conflict of interest, our congressional representatives sometimes vote against their own interests. STAT cites the case of Senator David Ritter who introduced a bill that would allow US consumers to buy medications from Canada, something that the pharmaceutical industry opposes. He has a modest personal investment (in the neighborhood of $100,000) in health care stocks. But by and large, those with the greatest influence in Congress also have the largest stakes. Collins, for instance, is a member of the House Energy and Commerce Committee—which is charged with overseeing the FDA.

Why is this a geriatric issue? Older  people are disproportionately large users of medications and devices. By way of example, more than 60% of all total knee replacements are inserted in people over age 65. The mean for pacemaker insertion is 75.5 and the mean age for ICD (implantable cardiac defibrillator) is 66.2. In the drug arena, data from 2010 showed that seniors account for 13% of the population but consumer 34% of all prescription drugs. So while conflict of interest in Washington affects us all, it affects older people most dramatically. And older people vote—they can vote out those who support their personal interests and not those of their constituents.

We've known about the perils of conflict of interest among legislators for some time, just as we've known about potential conflict of interest among physicians who prescribe drugs and devices for their patients. The widely accepted solution to the problem is disclosure. And in fact it is the federal disclosure requirement that generated the thousands of pages of congressional disclosure forms which STAT used to generate its report. Maybe this is just the first step: maybe disclosure, when analyzed the way STAT has done, will lead to shaming and behavioral change. More likely, it won’t lead to any meaningful change. Disclosure isn’t enough. Transparency isn’t enough. We need to change the rules of the game.                                                                                              

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