TOV: Profit Over Patients?

As a doctor, is it possible to accept transfer of value (TOV) payments and still prioritize your patients’ wellbeing? The interplay of money and medicine is a polarizing topic (you likely had a knee-jerk reaction to the question above) but the various arguments that surround it, although not new, are back in the public eye (1). This time, the conversation was sparked as a result of a whistle-blower lawsuit, text messages (2), and an internal investigation that together paint a picture of doctors at the Dole veterans hospital being allegedly “groomed” by the world’s largest medical device company, Medtronic, to overuse its vascular products, despite knowing the damage that such overuse was causing within their patient population.

The lawsuit in question was filed by a sales representative for a competing medical device firm in 2017, and alleges that there was an illegal kickback scheme through which Veterans Affairs (VA) health care workers received steakhouse dinners, expensive electronic devices, and tickets to live sporting events; in-turn, Medtronic procured a lucrative contract with the hospital. Additionally, representatives of the company, there to train physicians at the facility, allegedly encouraged the use of their devices even when not medically necessary.

This all came to light when Rick Ament, who had just been hired to lead the facility, observed that the Dole VA, which is relatively small, had one of the most expensive cardiac programs in the US. This initial curiosity led to several discoveries, including an overuse of devices that he could described as “egregious” during his testimony (3). In one case, a surgeon used a shocking 33 devices in one procedure. The overuse of medical devices coincided with a sixfold increase in amputations at the VA, although the email chain where this was stated drew no conclusion as to whether the two circumstances were connected. I would say that it’s not hard to see the potential risk of introducing unnecessary foreign devices into patients’ bodies in procedures that were often inappropriately overperformed. Indeed, as the lawyers representing the whistleblowers wrote, “This is not medical treatment. This is abuse.”

If proven to be true (Medtronic is crying false allegations), hopefully this is only a one-off case of the greed and misconduct of a select group of physician. But the question still remains: Do TOV payments influence the average clinician’s decision-making and, should they be accepted?

Late last year, we heard from Thomas V. Johnson, who explored the question in more detail. He described what he has coined the “TOV effect” – clinicians showing bias in their prescription of glaucoma drops for which they have received TOV payments. And it’s particularly important to note that the TOV effect wasn’t limited to large TOV payments; the median TOV in his study was a modest US$65.

Does this mean that you should stay away from TOV payments all together? Not necessarily; when talking about how to combat the TOV effect, Johnson explains that genuine and continued awareness of the problem is key to avoiding it. Industry is vital to ophthalmology as a specialty – and to medicine at large. The relationships built between ophthalmologists and their industry partners play a significant role in driving innovation and increasing the quality of care for patients. But, in the words of Thomas V. Johnson, ophthalmologists “must be able to take full responsibility for our prescribing decisions” – and, for that matter, all decisions made on behalf of patients.

What is your approach to TOV payments? Do you think accepting TOV payments is a conflict of interest for clinicians? What are your thoughts on the Dole VA lawsuit? Please let us know in the comments below or drop us an email: [email protected].