Thursday, January 21, 2010

Harvard Medical School limits outside income: a good start

Partners Health Care, the physicians group comprising the clinical faculty of the Harvard Medical School at Massachusetts General Hospital and Brigham and Women’s Hospital, has recently set “strict” limits on the compensation that about “two dozen senior officials” (including department chairs, vice presidents and others) can receive from serving on the corporate boards of biotechnology and pharmaceutical companies, according to Duff Wilson in the New York Times, January 3, 2010 , Harvard Teaching Hospitals Cap Outside Pay. These physicians will also be prohibited from receiving any speaking fees from drug companies. The article indicates that many medical schools have put limits on such outside income, but that Harvard’s are the strictest yet. And consequential, because Harvard has so many leaders who sit on such boards. Apparently, the ban on speaking fees was decided first by the policy committee, and then the board income was limited so as not to limit outside income for junior faculty (who may speak for drug companies) but not senior leaders (who are more likely to be on the boards). There is no indication of limits on the participation of anyone on boards of other types of corporations, although biotechnology and pharmaceutical, along with medical device companies, are the most likely to create a conflict of interest.

Many do not see these restrictions as enough. The chair of the Partners’ policy committee, that wrote the rules, distinguished cardiologist Eugene Braunwald, is quoted as saying “We’re the first to go in this deep, and we’re still into it only up to our knees.” Former New England Journal of Medicine editor and Harvard professor emeritus Arnold Relman definitely thinks that they are too weak: “I think that’s a gross conflict for an official of an academic medical center to be on the board of a pharmaceutical company...It’s happening more and more around the country…If it isn’t stopped, I think the academic institutions are going to lose the confidence of the country and the government and they will no longer deserve the tax exemption or anything else. They will be part of industry itself.” Regular people may not see the restrictions, to $5,000 a day (based on $500 an hour for a 10-hour day of actual work on the board) as too severe, but they are not moving in the world of corporate boards. Dennis Ausiello MD, chair of medicine at Mass General, has received over $200,000 since 2006 from sitting on the board of the pharmaceutical giant Pfizer. “I certainly think I should be compensated fairly and symmetrically with my fellow board members,” he says. However, he will abide by the rules. “I’m not there to make money… if my institutions rule otherwise [i.e., against being compensated as are his fellow board members], as they have, I will continue to serve on the board.”

Clearly, Ausiello has a different perspective than Relman, because he believes that he makes a positive contribution being on the board: “I’m very proud of my board work,” while Relman thinks the very presence of medical school faculty on boards is corrupting its mission. Interestingly, both the committees seeking to restrict the participation and corporate pay experts agree that paying board members based on corporate performance and profit ties them to the profitability of the corporation. The Times notes that “Thomas Donaldson, a professor of business ethics at the Wharton School of the University of Pennsylvania…who advises large companies on corporate governance, said dual roles in a hospital and at a drug maker were ‘dicey at best’ because a director’s duty is to look out for the corporation’s financial interests.” He said: “It strikes me as a breath of fresh air in a room that’s getting progressively more stale. I hope this will set a standard for others — hospitals, medical schools.” The Harvard rules specifically prohibit this, believing that pay for work (@ $500/hr) at least has the chance of allowing its faculty to maintain some scientific integrity.

The issue can be complicated for insiders. Deborah Powell MD, former dean of the medical school at the University of Minnesota and an advocate for policies that encourage restraint, herself accepted a paid position on the board of Pepsico. Many believe that her subsequent firing was due, in part, to negative publicity from this action. (U of M medical school reorganizes; dean out by summer, Tim Post, Minnesota Public Radio, January 29, 2009). The American Academy of Family Physicians (AAFP) has recently developed a “corporate partnership” with Coca-Cola that has received a great deal of criticism both within and outside the family medicine community – criticism that has not resulted in the AAFP ending the relationship. Which is a greater conflict of interest for physicians and medical school faculty members – alliances with companies, such as Coke and Pepsi, whose products are clearly detrimental to health, or sitting on the boards of corporations that make medical and pharmaceutical products? I leave the call to you; to me they are both rotten. Corporations want them to get the imprimatur of science and health that these relationships provide. Organizations like AAFP want them for the money. Presumably the individuals on the faculty of Harvard and other medical schools also like the money, but also may, like Drs. Ausiello and Powell, think that they can make significant positive contributions to health through their roles on the boards. And, if these people are full-time employees at their main job, who should get the money that it engenders? Harvard is, as noted, limiting the income, but is allowing corporations to use the rest of the money that the board member would have gotten paid as a charitable donation to any charity not linked to Harvard, Partners, or the hospitals. That deals with the money issue, but still leaves the questions about the ethics of participation, even for free, that are raised by Dr. Relman and others.

Interestingly, the Times article cites the Partners’ decision as, in part, due to the fact that “Harvard, in particular, has come under scrutiny from Senator Charles E. Grassley of Iowa, a leader of Congressional inquiries into the influence of money in medicine.” I say “interestingly” because Grassley, the Finance Committee's ranking Republican, received more than $2 million from the health and insurance sectors since 2003 (Industry Cash Flowed To Drafters of Reform, Washington Post, July 21, 2009). Of course, like the medical school faculty who believe that they are doing important work and are not influenced by the pay (which Sen. Grassley doubts), Grassley himself says the campaign contributions have no effect on his positions (Grassley: Campaign Contributions Hold No Sway, Press Center from the Des Moines Register, August 31, 2009). Double standard? Of course. Ironically, Grassley uses his investigations into the policies of places like Harvard as evidence that he is not “bought” by those interests!

Harvard is taking the right first steps and those principles should guide other medical schools in the future to take even stronger action. And the same should be done for contributions to members of Congress.

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