2014年10月4日讯 /生物谷BIOON/ --一直以来，在中国以药养医的模式都广受社会各界的批评，不仅仅是由此推高了药价并造成了不必要的经济和资源浪费，更重要的是这一模式会导致医生在治疗患者过程中对用药具有选择倾向性并可能造成严重的健康后果。然而，以药养医并不是我天朝的专利，事实上在美国，这也是一个棘手的问题。
自奥巴马政府上台以来，白宫一直都在努力推动医疗改革法案，而在这一命途多舛的法案中就有一条披露原则，要求生物医药公司定期披露对医生的赞助与礼金等各方面资助。如今，经过美国医保与医疗服务中心（US Centers for Medicare and Medicaid Services, CMS）统计，仅2013年最后五个月，美国医生收到来自各个生物医药公司的各类经费、资金就超过了35亿美元。这一数据的公布也引起了美国各界的轩然大波。
一方面是许多媒体都对这一措施表示赞赏，认为将有利于医疗改革的推进并降低美国人医疗的成本，但是也有一些人认为这一披露原则将可能导致患者、医生和生物医药公司之间难以预料的影响。华盛顿大学的伦理学家Sunita Sah认为，不光是患者希望能够公布这一信息，一些提供医药或法律建议的咨询者也倾向于主动提供这一信息。而一些生物医药公司和医生则诟病目前这一系统的数据不够准确，且网站功能并不完善。最重要的是他们认为患者仅从这一网站获得的这些数据可能会对患者做出错误的引导。患者可能会认为接受了来自企业礼物的医生可能无法完全站在公正的立场上对患者进行治疗；另一方面，一些接受企业资助的研究项目的公信力也可能会受到质疑。而这也是目前医院和研究机构最为担忧的事情。
由此可以看出，医疗产业问题在世界各国都是一个老大难的问题，而对于如何处理这一矛盾，世界各国也都在各出机杼。虽然目前看来，奥巴马医改的这一披露原则仍存在这样或那样的问题，但至少是向前迈进了一步，这也为中国解决医患关系提供了一定的借鉴。
详细英文报道：
US database of payments to physicians is likely to complicate ties to patients and drug companies.
Over the course of just five months in 2013, US doctors received more than US$3.5 billion in consulting fees, travel reimbursements and gifts from pharmaceutical and medical-device companies.
That revelation comes from Open Payments, a database launched on 30 September by the US Centers for Medicare and Medicaid Services (CMS). Transparency advocates praise the move, but others say that such disclosures can have unintended effects on the relationships between patients, physicians and the companies that pay them.
The CMS database was created by the Affordable Care Act, the health-care law better known as 'Obamacare', which requires biotechnology companies to disclose any payments greater than $10 made to any of the 546,000 physicians affected by the law.
Such disclosures appeal to patients, who want to know whether their doctors are compromised by industry ties, says Sunita Sah, an ethicist at Georgetown University in Washington DC. Sah has found that when given a choice, providers of medical or legal advice are more likely to disclose their conflicts - especially if they do not have any1.
But physicians and the biotechnology industry worry that the database will backfire. Thus far, the CMS site has proven difficult to use - lacking such tools as a search bar - and the agency says that one-third of its data has problems. "Publishing inaccurate data leads to misinterpretations, harms reputations and undermines the trust that patients have in their physicians," the American Medical Association warned in a 30 September statement.
Even without those problems, trade groups such as the Pharmaceutical Research and Manufacturers of America and the Biotechnology Industry Organization warn that patients have too little information about what conflict of interest actually means. "It's very difficult to distinguish real consulting and research money from gifts - putting it nicely - that are really bribes," says George Loewenstein, an economist at Carnegie Mellon University in Pittsburgh, Pennsylvania. "It's very likely to just introduce a lot of noise into individual patients' decision making."
Susannah Rose, an ethicist at the Cleveland Clinic in Ohio, says that the effects of supplying such information are not always straightforward. Some studies suggest that patients are likely to trust a physician who has the support of industry. "If they are so good that they're actually getting paid a lot of money, it must be a good indication of their quality," Rose says, adding that the disclosure also makes the physician seem more honest2.
But more research suggests that patients trust a physician less when they know that he or she has a potential conflict of interest, which is why context (such as the nature of the relationship with industry) is particularly important, Sah says. Patients are actually more likely to follow the advice of a doctor they think is biased owing to a relationship with industry. Patients "don't want to signal distrust", Sah says. "Even if they distrust the advice, they don't want to insult the doctor." But, she adds, they are less likely to return to that physician3.
Some research suggests that researchers themselves are more likely to discount academic papers that are funded by industry, regardless of how well the studies are designed. In addition, researchers are more likely to trust a paper stating that there is no conflict of interest than one that does not4.
Loewenstein is eager to see whether US doctors and industry change their behaviour in response to the disclosures. Some research suggests that experts who disclose conflicts of interest are more likely to feel "morally licensed" to give biased advice5. And Loewenstein says that there can be a "tell-tale heart effect", in which doctors reject gifts to avoid having to later disclose them. Companies may also stop offering such compensation.
Sah says that refusing money from industry could hurt research efforts, she says, which is what the industry organizations fear. Or pharmaceutical companies may start finding new, creative ways to route the money to physicians - gifting it to hospitals or educational programmes, for example.
The extent to which industry money influences a physician's decision making is hard to measure, says Loewenstein. Data on gifts received and prescriptions written over time are scarce and difficult to analyse. "It's inconceivable that pharma would be so naive as to make so many gifts if they had no effect on the bottom line," he says. He and other researchers hope that the new database will help to make a more quantitative assessment, but he says that it will probably be many years before they can find good answers.