What's up doc? Bribery drives prescriptions

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Big pharma illegally kicks down cash to doctors for extra prescriptions


A patient examines her receipt at the Ho Chi Minh City University Medical Center, where two doctors were suspended for allegedly of receiving kickbacks from pharmaceutical firms to prescribe their products.. (Photo by NGHIA PHAM)

Vietnam's prime minister last week asked concerned agencies to investigate allegations that Ho Chi Minh City doctors have been receiving kickbacks from foreign pharmaceutical companies to prescribe their medicines.

The bribes have allegedly pushed drug prices sky-high.

The Drug Administration of Vietnam set up a team to inspect prices at drug producers and distributors in HCMC on March 25. The agency said the findings of the inspection, which was prompted by media coverage of the bribery allegations, would be submitted to the Ministry of Health by April 15.

In a recent case, a hospital pharmacy in HCMC was found selling Cadimezol 20mg a peptic ulcer medicine at VND3,450 (US$0.18) per tablet, nearly ten times higher than its buying price.

In Vietnam, pharmaceutical companies have to register retail prices in line with state regulations on medicine prices. Doctors are not allowed to sell drugs at their private practices in order to prevent them from prescribing medicines for which pharmaceutical companies might pay them under-the-table commissions.

But pharmaceutical sales representatives have found ways to circumvent the measures.

Padding pockets

The US Schering Plough (SP) Pharmaceuticals office in Vietnam has offered doctors between 10-30 percent kickbacks on medicine prices, according to a recent Tien Phong newspaper article based on the agency's July 2009 sales report.

A doctor at the HCMC University Medical Center received kickbacks of VND528 million ($27,687) for selling SP products to treat hepatitis, according to the report. He also received another VND459 million for just one SP medicine sale in August last year, said the newspaper.

Another doctor at the center received VND226 million also for prescribing SP Pharmaceuticals' hepatitis medicines at his private practice in August last year.

A doctor at Medic Medical Center and another at Cho Ray Hospital received similar illegal commissions from SP, the paper reported.

Vietnam's annual per capita income is about $1,000.

Vince Docherty, an official at Merck Sharp and Dohme (MSD) Pharmaceuticals, which owns SP Pharmaceuticals, told Tien Phong on March 22 that the bribery problem was a serious problem and that it was a pity it had not been reported on earlier.

Asked whether or not the commissions were company policy, Docherty only repeated that the issue was serious before stating that MSD had formulated a plan to solve the problem. But he said it would take time.

Passing the burden

A pharmacist speaking on condition of anonymity in HCMC said that many medicines were selling at highly inflated prices as a result of the illegal kickbacks to doctors and increased marketing and advertising costs.

He said pharmaceutical companies were still reaping steep profits despite the big payments to doctors.

"Pharmaceutical firms don't hurt from the high kickbacks to doctors because the patients paid those expenses in the end," he said.

SP Pharmaceuticals allows its staff to give 30 percent of medicine prices to all doctors that prescribe its products, but company officials have reduced the amount to between 10-20 percent in order to keep the rest of the commission for themselves, Tien Phong said.

SP's HCMC branch sells about VND6 billion ($315,700) worth of hepatitis medicines in HCMC per month, of which VND1 billion a month is taken in by SP's Vietnam country head, the paper said.

Inside accounts

Nguyen Ha Anh, a five-year veteran pharmaceutical sales representative in HCMC, told Tien Phong that drug companies routinely give doctors gifts alongside free drug samples they are told to sell. In return for the sales and prescriptions the doctors fill, they are given a portion of the price tags, Anh said.

"Very few of them ask about the functions of the medicine, but most ask about the commission," she said, adding that she would lose business to her competitors if she didn't offer high kickbacks.

Lan Anh, a pharmaceutical sales representative for an Indian pharmaceutical firm, said hospitals had banned doctors from meeting drug salespeople. But big pharma has not been deterred.

"We meet at cafés and their private practices or at the hospital disguised as patients to give them samples and commission rates," she said.

Many of Anh's colleagues said they also bought doctors and their families gifts such as travel expenses and pre-paid tours abroad on special occasions.

She said many pharmaceutical firms avoided offering kickbacks by giving doctors samples of new and expensive medicines that they could sell to pharmacies later.

Another pharmaceutical sales representative said doctors only write half their prescriptions before pointing patients in the direction of specific pharmacies. Only when the patients return with proof of visiting the said pharmacy do the doctors complete the prescription and explain how to use the medicine.

Moping up

MSD has dismissed the head of its SP Representative Office in Vietnam after reports in the local media about the bribery.

Nguyen Duc Tuan, who was in charge of marketing at SP Pharmaceuticals in Vietnam, also confirmed on March 22 that he had stopped working at the agency. He had filed for retirement after the media's coverage of the issue.

On March 22, SP hepatitis drug sales leaders also asked for retirement from the company.

Nguyen Hoang Bac, vice director of HCMC University Medical Center, said two doctors from the center's Liver Department had been suspended and were being investigated for allegations of receiving kickbacks and bribes. He said the two included the department's head.

He also said the HCMC Medicine and Pharmacy University would also deal with lecturer Nguyen Duc Tuan, who was also allegedly in charge of marketing of SP's hepatitis products for several years.

Le Quan Nghiem, vice rector of HCMC Medicine and Pharmacy University, said the school and HCMC University Medical Center's directorate had decided to suspend the lecturer, who is also a doctor, for 15 days to investigate and clarify the allegation.

COST OF LIVING

Bribes paid out by drug companies to doctors in return for prescribing their products have increased the cost of healthcare in Vietnam, the head pharmacist at a major hospital in Hanoi said on condition of anonymity.

He said a doctor could receive a kickback of VND500,000 ($26.3) for selling a poison decontamination ampoule for VND1.1 million ($57.8).

Some salespeople employed in pharmaceutical business opened such ampoules upon delivery to ensure that doctors use them, he said.

The pharmacist also said that, according to hospital records, all patients who visited the cardiovascular department were diagnosed with liver disease whether or not they had it recently.

The pharmacist estimated that patients at his hospital could have saved about VND3 billion ($157,800) a month if doctors hadn't prescribed liver medicine inappropriately.

Tran Quang Trung, chief inspector at the Health Ministry, said it would be difficult to prove that doctors had received kickbacks from pharmaceutical companies.

He said ministry inspectors had obtained a list of doctors receiving such kickbacks in 2005 but failed to solve the cases after they weren't able to come up with sufficient documentary evidence.

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