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Paul D. Thacker is a journalist and former U.S. Senate staffer who first drafted the Physician Payments Sunshine Act. Trudo Lemmens is professor and Scholl Chair in Health Law and Policy at the University of Toronto's Faculty of Law and the Dalla Lana School of Public Health. The authors provided unpaid expertise to the Ministry of Health on the transparency bill

Ontario's Health Minister Eric Hoskins should be lauded for his proposed transparency law that will require medical companies to disclose payments to health-care providers. Physicians, such as Dr. Hoskins, are often shunned by colleagues for putting a spotlight on problematic practices in health care. We count on Dr. Hoskins' colleagues and other health-care providers to work with him to strengthen the integrity of the health professions, to shine a light on practices that damage health care, and to restore patients' trust. To be clear, this legislation is only an important first step.

Commentators continue pointing to North America's opioid crisis as a reason transparency laws are needed, and rightly so. An award-winning investigation last year by the Associated Press found that drug companies spent years funding doctors, medical societies, think tanks and experts to manufacture a narrative that pain was under-treated and that new patented opioids were safer than others. This orchestrated advertising disguised as medical advice helped fuel the current opioid epidemic. But as the opioid death toll mounted, and experts began warning that prescribing was out of control, the pharmaceutical industry employed another tactic: A new group called Advocates for Opioid Recovery began publishing op-eds and providing interviews to push for opioid addiction treatment. Their solution? More medications. But when a reporter began questioning its funding and ties to drug makers, the group went quiet.

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Evidence shows that complex and overlapping tactics to promote health-care products are not new. Some years back, the U.S. Congress released a confidential copy of Forest Laboratories' 2004 marketing plan for a new antidepressant. The company's tactics included spending $34.7-million (U.S.) to pay 2,000 doctors to make 15,000 marketing lectures. The company also projected spending $36-million (U.S.) on lunches dropped off by sales people at doctors' offices. "Providing lunch for a physician creates an extended amount of selling time for representatives," the company's marketers wrote. This was only the money spent by one company, for one drug, and for only one year. Many similar marketing tactics have been documented in the media and in the medical literature.

Transparency of gifts, payments or other benefits to doctors will not be enough. Even health-care providers who choose to keep the industry at arm's length cannot escape influence, which is why the health-care professions should support a broad regulatory framework. For example, there is overwhelming evidence that many articles on new drugs and medical devices in leading medical journals are ghostwritten by product manufacturers. These articles influence prescription behaviour and professional guidelines. Industry payments further influence doctors' continuing education, finance think tanks and professional societies, and help select speakers at medical conferences. Health-care providers do not have the time in their day to unravel these complex ways that companies seek to influence them. That's why the money funding these practices needs to be brought to light, so that they can be studied and analyzed by media, civil society and policy analysts.

We hope that Ontario will also impose transparency on payments to marketing companies, professional societies, companies that provide education, and patient advocacy groups. Health-care providers should know if a company paid to write a medical article, funds a group they might join, or helps pay for a speaker at a conference or meeting. And we all need to know if a patient advocate extolling the benefits of a drug or medical device and pushing for getting a drug approved or funded is secretly receiving money from a company.

Mere transparency will not be enough, and along with the website reporting these payments, Ontario should consider programs to educate both patients and physicians. In one study, researchers reported that 74 per cent of patients believe receiving money influences how doctors treat patients and that 57 per cent would look up their doctor's payments if they were public; 51 per cent of patients would be less likely to choose a doctor taking money. However, in another study, researchers sent patients information about their doctor's financial ties with industry, and very few said it changed their opinion about their doctor. None chose to find a new physician. Doctors show similar erratic opinions. One study revealed that many physicians believed industry gifts would influence their colleagues, while denying such gifts could influence them.

Yet, there is ample evidence that payments do influence physicians. A recent analysis found that the more money doctors receive from drug companies, the more brand-name drugs they prescribe. Even something as small as a lunch has been shown to make a difference.

Broad transparency will enable further study, help educate physicians and patients and provide a basis for new legislative and regulatory intervention. Indeed, the more we learn from the countries that have introduced transparency rules, the clearer it becomes that we will also need prohibitions and restrictions.

For all these reasons, Ontario's initiative is to be lauded. It should, however, be bold and comprehensive, and be seen as a first step. And others should follow suit. The federal government has no reason to take a wait-and-see approach when it comes to strengthening the integrity of health care.

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