By Martha Rosenberg
Professional medical associations (PMAs) are foundational to the U.S. medical system, developing practice guidelines, providing medical education, and publishing journals. While there are scores of PMAs, probably the most well-known and largest are the American Heart Association (AHA), with over 33,000 members, the American Academy of Pediatrics with over 64,000 members, and the American Medical Association (AMA), with more than 200,000 members.
Yet, according to doctor-authored opinion pieces in medical journals, conflicts of interest (COIs) such as a lack of transparency about industry money received, can present ethical challenges. For example, does funding from a drug or device maker influence an association’s recommendation in its official guidelines? There are reasons to be concerned that it might.
Such conflicts of interest “require PMAs to maintain a high degree of academic independence and scientific integrity by avoiding inappropriate influence from commercial interests,” wrote Dr. Steven Nissen in the Journal of the American Medical Association (JAMA). Dr. Nissen, named one of the most influential people in 2007 by TIME magazine, told the Cleveland Jewish News, “Some physicians focus only on their medical practices, but along with actively maintaining mine, I have chosen to speak out on matters of public policy” and “to be free of conflict of interest, I never receive an honorarium from any drug company I work with.”
Financial Conflicts of Interest Identified in the British Medical Journal
Researchers writing in the BMJ in 2020 followed the “money trail” of several prominent PMAs and found their leaders received significant drug maker largesse between 2017 to 2019.
“Leaders of the North American Spine Society received more than $9.5 million for general payments,” wrote the researchers. Orthopaedic Trauma Association leaders received more than $4.7 million during the time period. Michael McKee, MD, president, Orthopaedic Trauma Association, responded to the research article by saying most of that funding was for research. Other PMA leaders took money for similar reasons.
“Research payments linked to leaders of the American Society of Clinical Oncology were over $54 million and for those of the American College of Cardiology, almost $21 million,” noted the BMJ study.
The researchers obtained the financial information from the U.S. Centers for Medicare & Medicaid Services (CMS) Open Payments system, which maintains transparent databases mandated by the 2010 Sunshine Act to disclose financial relationships between industry and medical practitioners and teaching hospitals.
“Despite their influence over key aspects of medicine, the leaders of professional medical associations have received limited scrutiny about their relationships with industry,” wrote the researchers. “Industries interested in maximizing markets,” can easily drive “overdiagnosis, overuse, and overmedicalization,” resulting in at least 20 percent of healthcare spending that is estimated to be wasted.
Is the American Heart Association’s Food Certification Program a Conflict?
Almost everyone is familiar with the 108-year-old American Heart Association (AHA) and its public health messaging. Yet fewer people know the organization is paid by food manufacturers to put a “heart-check” emblem on hundreds of foods which reads “American Heart Association Certified Meets Criteria for Heart Healthy Food.”
According to the AHA, food manufacturers can pay up to $6,000 for yearly licenses for five food products. The program not only raises conflicts of interest questions but also questions about medical veracity.
In an interview with the Huffington Post, cardiologist Barbara H. Roberts, author of The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs, said, “The AHA rakes in millions from food corporations for the use of its ‘heart-check mark.’ Some of the so-called heart-healthy foods it has endorsed include Boar’s Head All Natural Ham, which contains 340 milligrams of sodium in a two-ounce serving, and Boar’s Head EverRoast Oven Roasted Chicken Breast, which contains 440 milligrams of sodium in a two-ounce serving. High sodium intake raises blood pressure, which increases the risk of cardiovascular disease. In addition, studies have shown that eating processed meat increases the risk of diabetes and atherosclerosis.”
The AHA did not respond to questions from The Epoch Times when contacted for this story.
Questions About Diabetes Associations
According to its website, the Juvenile Diabetes Research Foundation (JDRF) is funded by many corporations including the drug makers Abbott, Lilly Diabetes, and Novo Nordisk who are “Platinum Partners” contributing between $1,000,000 and $2,499,999 annually. The Access to Medicine Foundation calls Lilly Diabetes and Novo Nordisk two of the world’s top three insulin makers. (The third is Sanofi.) Since insulin is basic to diabetes care and prohibitively costly, some have asked why JDFR and the American Diabetes Association (ADA) have not been more aggressive in protesting the high price of insulin on behalf of patients.
The authors of a 2022 story in the U.S. political magazine Jacobin say they have suffered from high insulin prices. “Living with this illness is a precarious existence. As people with T1D [type 1 diabetes], we have traveled to other countries to get cheaper versions of the drug and have been forced by insurance companies to use lower-quality insulin,” they wrote. “Many people with diabetes meet in parking lots to exchange supplies or starve themselves to lower the amount of insulin they need.” Twenty-five percent of insulin-dependent diabetics “ration insulin, which can lead to complications including life-threatening diabetic ketoacidosis, blindness, amputation, and death,” wrote Annalisa Van Den Bergh and Robin Cressman.
The authors were not entirely pleased with diabetes nonprofits and recent U.S. national legislation.
“Major diabetes nonprofits have supported incremental measures but have remained silent on more meaningful reform,” they wrote. While JDRF and ADA both supported the insulin pricing cap in the Build Back Better bill and the House-passed Affordable Insulin Now Act that caps insulin out-of-pocket expenses, the measure only pertains to co-pays, the Jacobin authors wrote. “Copay caps tie our survival to the health care status quo because anyone is at risk of losing their insurance, allow the big three to continue to profit from $300 a vial insulin, and in our view give the false impression that the problem is being solved.”
The ADA did not respond to The Epoch Times’ request for a comment about its insulin pricing efforts but the JDRF did. The JDRF told The Epoch Times it has long advocated to lower out-of-pocket insulin costs for people with diabetes. “This includes our recent multi-million-dollar investment in the Civica insulin project that will provide three of the most frequently prescribed insulins for $30 per vial and $55 for a box of five pens, regardless of insurance status. We have also spent years lobbying Congress and calling on insulin manufacturers, health plans, employers, and the government to take action to lower the cost of insulin. These efforts have led to the recent $35 monthly cap on insulin costs for Medicare enrollees.”
The PMA says less than one percent of its funding comes from companies that manufacture insulin and they disclose those monies on their website.
“These companies have no role in decisions about advocacy and research priorities. Most of our funding comes from those affected by Type 1 diabetes, who raise funds from their friends, families, and professional contacts through our Walk, Gala, Ride, and other fundraising programs,” the JDRF responded.
While the JDRF may provide a reasonable argument for the judicious use of corporate funders with vested interests, other examples raise more concerning issues.
Concerns About Association Conflicts of Interest Are Not New
More than ten years ago, concerns about pharmaceutical funding influencing policy guidelines and clinicians were already surfacing. Researchers wrote in the journal Annals of Family Medicine that, “there has been dramatic increase in the diagnosis and pharmaceutical management of common chronic illnesses.” After conducting a study of Type 2 diabetes and hypertension treatment in 44 primary care clinics in Michigan, they recommended “limiting the influence of the pharmaceutical industry on clinical practice, toward improving the well-being of patients with chronic illness.”
One example of such apparent influence was reported by the Milwaukee Journal Sentinel. “In 2009, the American Geriatrics Society joined others in advocating for greater opioid use to treat chronic pain in seniors, especially those 75 and older,” it reported. “The new guidelines recommended that over-the-counter pain relievers, such as ibuprofen and naproxen, be used rarely and that doctors instead consider prescribing opioids for all patients with moderate to severe pain,” read the article. “The group’s guidelines are a key reference for thousands of doctors on the front line of medicine.”
On the basis of Geriatrics Society disclosures, it was found that of a panel of 10 experts who made the pain recommendations, at least “five had financial ties to opioid companies, as paid speakers, consultants or advisers at the time the guidelines were issued.”
The Epoch Times Reaches Out To Other Medical Associations
The Epoch Times asked the North American Spine Society to comment on the BMJ’s characterization of its industry funding and Jeff Karzen, senior manager of publications at Society, said he had no comment.
Dr. James Kirkpatrick, chair of the American College of Cardiology [ACC] Ethics and Compliance Committee told The Epoch Times of the figures named in the BMJ article, “The ACC itself collaborates with industry, including in the administration of unrestricted, multi-company financial support. In doing so, we follow the highest standards of oversight, transparent structure, and unbiased management.”
“It is worth noting that, in the BMJ study, more than 90 percent of payments made to ACC leaders was in the form of research support, which is categorically different than direct payments to physicians and other transfers of value, as it is usually administered through a third party, such as a medical school, research institute, or granting agency,” he wrote.
The American Society of Clinical Oncology also emphasized research support when responding to The Epoch Times’ request for a comment. “As referenced by the BMJ article, the majority of financial relationships with healthcare companies were related to research and paid directly to academic institutions,” said the Society. “This research serves an important role in clinical oncology and is critical to making progress against cancer through improved treatments that advance cancer care for patients.”
On its website, the Society states, “ASCO regards the management of potential conflicts of interest as paramount to the integrity of ASCO’s programs, products, and services. Its COI policy primarily relies on “disclosure of all financial relationships that might result in actual, potential, or perceived conflicts of interest” but also “recognizes that some relationships cannot be managed with disclosure alone and identifies additional management steps in this case.”
Certainly, PMAs are invaluable in researching and raising awareness of respective diseases, providing medical education and publishing journals, but some medical voices would like to see greater transparency and firewalls with industry especially when it comes to practice guidelines. As both writers in the Annals of Family Medicine and Jacobin have noted, the sales of pharmaceutical products should never come before patients’ interests.
To find out possible industry funding of medical practitioners, hospitals, and medical centers that you may visit, you can search the CMS Open Payments database. Another useful database where such information can be searched is ProPublica’s Dollars for Docs site.