New directions in preventive and long-term health care are long overdue - part 1
CONTENTS
1. Introduction
2. Risk/benefit perspective
3. Some background on multi-level marketing companies
4. Some background on Big Pharma
5. Are MLMs a legitimate form of business?
6. Of scams and fraud
7. The “problem” with targeting healthcare professionals
8. Bad companies and brainwashed nurses
9. Extra perks for HCPs and shady characters
10. Final thoughts and considerations for now
1. Introduction
This is the first part of a two-part series exploring the non-drug-based options that doctors and other health care practitioners (HCPs) are using to treat their patients.
Today, many doctors and other health care practitioners (HCPs) are offering their patients nutritional supplements and other “wellness products,” providing them with preventive and holistic long-term health care solutions that pharmaceutical drugs don’t provide. The current mainstream medical/pharmaceutical model of “a pill for every ill” has, until recently, tied doctors’ hands and kept patients trapped in a cycle of dependence on drugs and/or polypharmacy. Polypharmacy, which is most common in the elderly, is the concurrent use of five or more medications and “… is associated with increased mortality, adverse drug events and drug interactions, falls and other GSs [geriatric syndromes], low medication adherence, and greater health care costs.”[fn]"Polypharmacy - an overview | ScienceDirect Topics." https://www.sciencedirect.com/topics/medicine-and-dentistry/polypharmacy [/fn]
A survey of 600 HCPs (MDs included), published in the March 2010 edition of Nutrition Business Journal and reported on by Consumer Reports, showed that 76% (456) sold supplements in their office. Industry analysts, the report stated, expected to see this trend continue so that HCPs might become one of the “fastest-growing sales channels for supplements over the next decade.”[fn] Your Doctor As Salesman. 2021, https://www.consumerreports.org/cro/2012/05/your-doctor-as-salesman/index.htm [/fn] Some of the supplements and products HCPs provide their patients are produced by multi-level-marketing companies (MLMs) for which the doctor may be a distributor.
Detractors of the MLM business model reference the AMA’s (American Medical Association) Journal of Ethics which states that it is unethical for doctors to have an economic stake in the products they recommend to their patients claiming that it is a serious conflict of interest and puts undue pressure on the patient. Furthermore, it states that “physicians who distribute nonprescription health products provide them free or at their own cost” so that providers can remain objective and not tempted by personal profit. It claims that this will prevent providers from exploiting patients for financial gain, using products of unproven scientific validity, and having an inappropriate bias in recommending a particular product, even if it’s not necessary for that patient’s health condition.[fn] "American Medical Association Journal Of Ethics” Docobook.Com, 2015, https://docobook.com/american-medical-association-journal-of-ethics99e02bc28e52422ff6ebbab6a6d7758a87852.html [/fn]
While it is obvious to patients when doctors provide them with dietary supplements, independently or through MLMs, that they may gain financially, doctors' economic stakes in the drugs and treatments they prescribe, which we will relate below, are usually unrecognized by their patients.
MedPage Today Enterprise & Investigative Writer Sophie Putka recently wrote two articles attempting to discredit the MLM business model, their products, and the healthcare professionals who distribute them. Since this presents a new opportunity for medical professionals to provide their patients with a more comprehensive approach to health and healing, as well as provide the practitioners themselves with an additional source of income, it is important to examine the claims made and see if they are justified.
2. Risk/benefit perspective
The first and foremost issue that should be discussed in any conversation about drugs and supplements is risk/benefit. Implying that it's a non-issue since one is regulated and one is not and instead forming the argument about ethics and business models conveniently side-steps the fact that pharmaceutical drugs, by and large, are a bad risk. In 2014, Peter C Gøtzsche, co-founder of the Cochrane Collaboration, an organization established to review the medical literature in order to provide unbiased information,[fn]"Peter C. Gøtzsche: Death Of A Whistleblower And Cochrane’s Moral Collapse". Crossfit.Com, 2022, https://www.crossfit.com/health/dr-peter-gotzsche [/fn] identified pharmaceutical drugs as the third leading cause of death in the US and Europe.[fn]"Our Prescription Drugs Kill Us In Large Numbers - Polish Archives Of Internal Medicine". Mp.Pl, 2022, https://www.mp.pl/paim/issue/article/2503/ [/fn]
The FDA, based on data from 2000, acknowledges pharmaceutical drugs to be the 4th leading cause of death in the US. The FDA website today includes the same information about ADRs in text format[fn]"Preventable Adverse Drug Reactions: A Focus On Drug Interactions". U.S. Food And Drug Administration, 2021, https://www.fda.gov/drugs/drug-interactions-labeling/preventable-adverse-drug-reactions-focus-drug-interactions#ADRs:%20Prevalence%20and%20Incidence [/fn] as it did in previous renditions of its webpage when it was captured in the text box below.[fn]"Preventable Adverse Drug Reactions: A Focus On Drug Interactions". Wayback.Archive-It.Org, 2022, https://wayback.archive-it.org/7993/20161022054752/http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ucm110632.htm#ADRs:%20Prevalence%20and%20Incidence [/fn]
As Frontline News has written about here and here, Big Pharma has undue influence over the FDA in order to get its drugs approved and over doctors in order to have their drugs prescribed. (Readers who would like to learn about others' experience with a particular drug can go to the website AskAPatient here.)
While there is much material on the internet discussing the pros and cons of dietary supplements, they are associated with relatively few adverse events. (Consumer Labs is one organization that analyzes a variety of supplements for quality and value; readers who would like information about particular supplements can visit their website here.)
3. Some background on multi-level marketing companies
The first “official” MLM company may have been Nutralite, which began in the 1940’s, and proceeded to grow in the US as well as in other countries. In the 1960s, a few Nutralite distributors broke away to found MLMs Amway and Shaklee.[fn]Holmes, Chuck. "The Evolution And History Of MLM And Network Marketing | Online MLM Community". Online MLM Community | Resources, Tips & Training For Network Marketers, 2014, https://onlinemlmcommunity.com/the-evolution-and-history-of-mlm-and-network-marketing/ [/fn]
What makes MLM companies unique is their marketing strategy which not only compensates their distributors for each sale they make, but also for the sales that the distributors who’ve they recruited make, creating a downline of distributors and a hierarchy of multiple levels of compensation. Sales are direct to consumer, generally made by word of mouth, through personal relationships, and relationship referrals. In addition, it is easy for just about anyone to join with a minimal investment, compared to other businesses; the website, product, brand recognition, and legal have already been taken care of.
As evidenced by the charts below, MLMs are contributing billions of dollars to their country’s respective economies with wellness products being the most popular.
Source: “Leading direct selling markets worldwide 2021”. Statista, 2021. https://www.statista.com/statistics/743446/leading-direct-selling-markets-worldwide/
Source: “Global Sales by Product Category.” WFDSA, 2022. https://wfdsa.org/wp-content/uploads/2022/06/Product-Report-2021.pdf
4. Some background on Big Pharma
The pharmaceutical industry, as we know it today, is the creation of John D. Rockefeller, an oil magnate who realized that many drugs could be synthesized from petroleum, providing an additional and highly lucrative source of income for himself since these medications would be patentable. It would be even more profitable, he recognized, if patentable drugs were the only legitimately recognized type of medicine allowed. In 1910 he commissioned the Flexner Report which was presented to Congress and which called for the standardization of medical practices, giving sole authority for medical accreditation to the AMA. Based on this report, Congress changed laws regarding medical practice, helping to make pharmaceutical based medicine the only legitimate form of medicine in the United States. Afterwards, Rockefeller, teaming up with Andrew Carnegie, showered medical colleges with much needed financial support only if they would follow his drug-based medical model.[fn]Eric Schmidt, LAc. "How Rockefeller Created the Business Of Western Medicine – Acupuncture & Dry Needling, Santa Monica, CA". Meridianhealthclinic.Com, 2019, https://meridianhealthclinic.com/how-rockefeller-created-the-business-of-western-medicine/ and Glass, Helena. "BIG PHARMA: THE WHO WHAT WHERE AND WHEN - Rockefeller". Helena, 2019, https://helenaglass.net/2019/09/25/big-pharma-the-who-what-where-and-when-rockefeller/ [/fn],[fn]The video “How One Man Took Down America,” is a short synopsis of how Rockefeller took over medicine can be viewed here.[/fn]
What's unique about the pharmaceutical industry is that they have a ready-made and captive clientele - patients who don’t have other medical options for which an insurance company will reimburse them. It is also the only industry that can’t sell to the end user (New Zealand and the United States are the only two countries that allow direct to consumer drug advertisements) nor is the end user the one who makes the purchasing decisions. Instead, pharma sales forces sell physicians and other healthcare professionals on their drugs, medical equipment, and medical devices, expecting, that in turn, they will prescribe them for their patients, the end users.
Their sales forces sell mostly door to door (direct selling), visiting doctors and nurses in their workplaces; sales reps are even found in operating rooms.[fn]Farmer, Blake. "NPR Cookie Consent And Choices". Npr.Org, 2022, https://www.npr.org/sections/health-shots/2018/11/23/659816082/sales-reps-may-be-wearing-out-their-welcome-in-the-operating-room [/fn]
The Pew Prescription Project by Pew Trusts demonstrates, in the chart below, the many direct marketing tactics the industry uses to market to doctors and patients.[fn]"Persuading The Prescribers: Pharmaceutical Industry Marketing And Its Influence On Physicians And Patients". Pewtrusts.Org, 2013, https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2013/11/11/persuading-the-prescribers-pharmaceutical-industry-marketing-and-its-influence-on-physicians-and-patients [/fn]
As is evidenced by the chart below, the pharmaceutical industry is extraordinarily lucrative, especially in the US, where the use of and price of prescription drugs are much higher than in other countries.
* Value means value of the commercial side of the drug sector. Torreya estimates it at approximately $7.03 trillion. Of this, $6.1 trillion is associated with publicly-traded companies.
The public generally believes that the pharmaceutical companies are working for their benefit (even those who own shares in these companies), not realizing that each individual company is responsible to its shareholders, not to the general public. Since they already have a captured market, the priority is on making sure investors see a “nice” return on their investment.
Craig Garthwaite, a healthcare economist at Northwestern University’s Kellogg School of Management, when asked by Los Angeles Times columnist David Lazarus, whether drug companies are responsible for the well-being of patients or just for their shareholders, he replied:
They’re in business for their shareholders, full stop…
Whether you like it or not, that’s what publicly traded companies do,” he said.
Lazarus broached the question in relation to the astronomical cost of a life-saving diabetes drug produced by Eli Lily. Since it became available in 1996, Lily increased the price 30 times, from $21 to $300 for one vial, a month's supply. Lazarus is dependent on this medication.[fn]Lazarus, David. "Column: For Drug Companies, Making Shareholders Happy Is More Important Than Treating The Sick". Los Angeles Times, 2019, https://www.latimes.com/business/lazarus/la-fi-lazarus-lilly-loxo-drug-prices-20190108-story.html [/fn]
As Tarra Bannow, writing for Modern Healthcare, demonstrates with the following chart on profit margins, pharma investors must be pretty happy.[fn]Bannow, Tarra. "Pharma Profits Highest In Healthcare". Modern Healthcare, 2019, https://www.modernhealthcare.com/finance/pharma-profits-highest-healthcare [/fn]
5. Are MLMs a legitimate form of business?
The first of Putka’s two articles on health professionals and MLMs focuses on the industry and on nurses who are looking for a side income or who have left the field due to burnout and are now selling wellness products through MLMs.[fn]Putka, Sophie. "Healthcare Workers A 'Catch' For Multilevel Marketing Companies". Medpagetoday.Com, 2022, https://www.medpagetoday.com/special-reports/exclusives/99375 [/fn]
In the section headed “What are MLMs?”, Putka gives a disparaging view of the industry, stating, among other things, that
[a]lthough reliable data on MLMs are hard to come by, it's generally accepted that the vast majority of those who sign up to sell MLM products -- from essential oils to weight-loss supplements -- lose money. One study found that only 11% of MLM reps reported making a profit of more than $5,000. A 2018 AARP study found that 74.3% of MLM participants surveyed lost money or broke even during their time selling, but experts told MedPage Today that the actual percentage is probably much higher.
MedPage Today’s page entitled “KevinMD.com” and bylined as Social media’s leading physician voice, is written by a doctor known as PassiveIncomeMD, who is, himself, an MLM distributor. He explains why he entered the industry and the mindset needed to be successful. (Emphasis added.)
… Besides the fact that my wife and I are involved in one, and it’s made a significant impact on our income, the number of physicians getting involved these days is huge.
My goal is not for everyone to go out and join an MLM company. I absolutely do not think it’s for everyone, but some will be successful if they understand it and treat it for what it is, another job. However, the flexibility, scalability, and potential for residual income are what drew us to the business.[fn]Passive Income, MD et al. "Why Are So Many Doctors Doing Multi-Level Marketing?". Kevinmd.Com, 2018, https://www.kevinmd.com/2018/01/many-doctors-multi-level-marketing.html [/fn]
Learn more about the MLM industry here. MLM millionaires explain how to succeed in this industry here.
6. Of scams and fraud
The FTC (Federal Trade Commission) regulates companies, those selling supplements as well as pharmaceuticals for trade and commerce issues. Dietary supplements are under FDA regulation as foods, not drugs.
In her section “Feds Pursue MLMs,” Putka writes:
In 2020 and 2021, the FTC made a push to prevent misleading messaging from businesses, including MLMs. The agency sent out three rounds of letters to several MLM companies and others as part of what it describes as "ongoing efforts to protect consumers from COVID-19 scams." Many had invoked the pandemic in their appeals to potential customers, taking advantage of an air of instability.
As in any industry, there are good players and bad players. This issue was addressed in an article here.
MLMs prove no match for Big Pharma, however. Pharma companies regularly receive warning letters from the FDA[fn]"Warning & Notice Of Violation Letters To Pharmaceutical Companies". U.S. Food and Drug Administration, 2021, https://www.fda.gov/drugs/enforcement-activities-fda/warning-letters-and-notice-violation-letters-pharmaceutical-companies [/fn] and have paid billions of dollars to the Justice Department in settlement of civil and criminal fraud suits.[fn]Groener, Lena. "Big Pharma’S Big Fines ". Projects.Propublica.Org, 2022, https://projects.propublica.org/graphics/bigpharma [/fn],[fn]Companies don’t always receive warning letters for bad drugs. Here is an example of a drug the FDA knew was killing people, yet chose to look the other way. [fn]Nelson, Douglas C. “Vioxx Scandal Sparks Criticism of the FDA.” Loyola Law Review, Vol. 17, Issue 2, 2005. https://lawecommons.luc.edu/cgi/viewcontent.cgi?article=1234&context=lclr [/fn] Fines are a cost of doing business for them; this fraudulent behavior has been going on for decades.
7. The “problem” with targeting healthcare professionals
In her section titled “Healthcare Professionals: The Ultimate Catch,” Putka quotes MLM industry nemesis and author of the book Ponzinomics Robert FitzPatrick who said that nurses are among the most valuable MLM sellers:
"If you're a nurse, you would be targeted for two reasons," FitzPatrick said. "One is, you're a member of a close-knit profession. You're going to have a lot of colleagues. You're bound together and you get to know each other and you have to trust each other. If you're going to use that trust and relationship to market, you've got an advantage right there."
The second, he said, is to legitimize what are usually pseudo-scientific "wellness" products -- the best selling category of MLMs. Companies like Amare and Isagenix deal in herbal and nutritional products, which aren't regulated like medical devices or drugs, but are instead classified as dietary supplements.
"It can't even legally be called medical, but if it's sold by a nurse, that lends credibility to it," said FitzPatrick.
Doctors, nurses, and other HCPs are valuable assets to Big Pharma in the same way Fitzpatrick says nurses are to MLMs. They are members of a close-knit profession. They have a lot of colleagues. They’re bound together and get to know each other and have to trust each other. If they’re going to use that trust and relationship to market, they've got an advantage right there.
Pharma uses that advantage to pay doctors to promote their drugs to other doctors and HCPs at pharma-sponsored medical conferences (often held in vacation locations) and other venues. (Pharma also pays doctors to use their names as authors on ghost written clinical studies reports.)
The public is led to believe that because a doctor is prescribing a drug, it is safe, effective, and appropriate for them. As Frontline News has shown (see references linked to above), drug companies use the FDA and doctors to legitimize drugs that may not be safe or effective or have much benefit to them.
The pharmaceutical/medical model does not have a nutrition-oriented perspective (supplemental vitamins, minerals, and herbs are not patentable), so while FDA approved drugs can legally be called medical, this doesn’t, by definition, make supplements and other wellness products offered by MLMs “pseudo-scientific" or less safe and effective.
Interestingly, pharmaceutical companies such as Pfizer, GSK, and Novartis also manufacture dietary supplements.[fn] Cvetkovska, Ljubica. "38 Fundamental Pharmaceutical Statistics And Facts For 2021". Supplements101, 2021, https://supplements101.net/pharmaceutical-statistics/ [/fn]
Is this a case of the pot calling the kettle black?
8. Bad companies and brainwashed nurses
Putka included this story from a nurse:
One employee at a Midwest health system spoke to MedPage Today … She said a colleague in her department started selling Isagenix, which deals mostly in "wellness" products, and was among the companies that received an FTC warning in 2020 for earnings and health claims.
"She kind of convinced, or brainwashed, my manager," the employee said, noting the manager, who is a nurse, "sells the product or the memberships to many, many, many people -- like hundreds of people within our hospital system."
If Putka uses pharmaceutical drugs then she is quite disingenuous since she is using drugs manufactured by companies that have not only received warning letters, but have also paid huge fines for criminal and civil fraud.
Nurses, who are also “convinced or brainwashed” by Big Pharma, have great influence over the drugs and medical devices used by hundreds of doctors and patients in hospital systems.
Nurses interacted with industry in similar ways to doctors. They attended sponsored dinners, served as paid speakers for companies, met one-on-one with sales representatives and were offered free samples or small gifts.
But nurses also described daily contact with industry in the course of patient care. This included in-service education conducted by sales representatives, sales representatives providing product support in the operating theatre or presenting product information to purchasing committees.
…
Nurses frequently influence treatment decisions through recommending medications to patients and prescribers, as well as providing feedback on treatment outcomes. They play a vital role in medication adherence, ensuring that patients can fill and refill their medications.
Nurse managers oversee large departmental operating budgets. They play key roles in researching, evaluating and selecting the medical products, devices and equipment a hospital must purchase.[fn]Adetunji, Jo. "Invisible Influence: Why Sales Reps Are Forming Relationships With Nurses". The Conversation, 2016, https://theconversation.com/invisible-influence-why-sales-reps-are-forming-relationships-with-nurses-57061 [/fn]
Read more about the pharmaceutical industry using nurses to sell their drugs here and here.
9. Extra perks for HCPs and shady characters
In her section “Pitching Healthcare,” Putka was critical of MLM companies and others that specifically target healthcare professionals. She offered the following examples:
- MLMs offer HCP distributors additional product discounts.
- MLMs hold webinars specifically for HCPS, such as Optavia once did, inferring that this is an objectionable practice. One of the coaches at the webinar, she made sure to mention, was [a] "physical therapist, Mark Blankespoor, [who] was charged the following year (in a case unrelated to Optavia) with defrauding investors of millions of dollars in what a U.S. attorney called a "Ponzi-like scheme."
- Guidebooks available on Amazon that explain how to recruit doctors into MLM companies, which Putka says are “titled candidly”. She names books such as “How to Recruit Doctors into your MLM or Network Marketing Team” and “Recruit Doctors into your Network Marketing Business: Step-By-Step Fgxpress System.” The second book explains why physicians are particularly valuable. It
… promises a system "for recruiting doctors and medical professionals that is easy to follow and implement while creating a massive, very lucrative downline," prompting sales reps to dress in scrubs, and to appeal to a doctor's ego by suggesting that they could be featured in a newsletter.
Big Pharma is not to be outdone by MLMs.
- Drug reps offer doctors free samples and other “freebies.”
Kevin Connolly, writing for drugwatch.com, explained that giving out free samples and other freebies changed doctors prescribing practices and more.
- Free samples made doctors “significantly” more likely to prescribe a specific drug
- Freebies led doctors to ask the drug be placed on formularies (hospitals’ official lists of drugs that can be prescribed)
- Accepting a free trip to a drug-company-sponsored conference guided doctors to write more prescriptions of the company’s drugs, a spike of 80 to 190 percent
- Doctors who ate pharma-sponsored meals “occasionally” were two to three times more likely to ask that the sponsor’s drug be placed on a hospital formulary.
Connolly illustrates (see image below) that every pharma dollar spent on providing free samples reaps huge profits.[fn]Connolly, Kevin. "How Big Pharma Influences Doctors". Drugwatch.Com, 2022, https://www.drugwatch.com/news/2012/01/18/pharmaceutical-companies-bribing-doctors/ [/fn]
2. Drug companies target healthcare professionals, wining and dining them, and more. Studies found that the more money they received, the more brand name drugs doctors prescribed for their patients.[fn]Adetunji, Jo. "We Can't Trust Drug Companies To Wine, Dine And Educate Doctors About The Drugs They Prescribe". The Conversation, 2016, https://theconversation.com/we-cant-trust-drug-companies-to-wine-dine-and-educate-doctors-about-the-drugs-they-prescribe-56990 [/fn]
Furthermore, a ProPublica analysis, as reviewed by Jessica Huseman for NPR, identified “… at least 2,300 doctors who received industry payments between August 2013 and December 2015 despite histories of misconduct.” Some were minor offenses, while others were more serious, including “… providing poor care, inappropriately prescribing addictive medications, bilking public insurance programs and even sexual misconduct.”[fn] Huseman, Jessica. "Doctors Get Disciplined For Misconduct; Drug Firms Keep Paying Them". NPR, 2016, https://www.npr.org/sections/health-shots/2016/08/23/490675125/doctors-get-disciplined-for-misconduct-drug-firms-keep-paying-them [/fn]
Coaches for MLM companies aren't the only ones accused of Ponzi schemes, either. Pharma mogul Martin Shkreli, who gained notoriety for inflating the price of a life-saving drug over 5,000%, had faced up to 45 years behind bars for mismanaging money at his hedge funds according to the judge. He'll get six months credit for time served in a Brooklyn federal jail.
He was convicted on August 5, 2017, of securities fraud and conspiracy in what prosecutors said amounted to a Ponzi scheme.[fn]Smith, Aaron. “Martin Shkreli sentenced to 7 years in prison for fraud”. CNN, Money, 2018, https://money.cnn.com/2018/03/09/news/martin-shkreli-sentencing/index.html[/fn]
Watch Palki Sharma for WION explain how he scammed the public below:
3. There may not be guidebooks on Amazon, but pharma strategies for marketing to doctors, other HCPs, and patients can be found on the internet. Here are several:
Marketing Drugs by Marketing Sex–Cheerleader Sales Reps
Drug Sales Reps As Pharmaceutical Whistleblowers
Insys, Whistleblowers revealed, hired both an escort manager and a former stripper without any relevant education as a sales rep; prescribing doctors were taken out to strip clubs and shooting ranges.
Pharma Marketing: How to Successfully Market in the Pharma Industry
5 ways pharma sales reps can virtually engage HCPs during the sales process
How to Sell Pharmaceuticals to Doctors: 4 Tips to Teach Your Team
10. Final thoughts and considerations for now
As is apparent, there is much to be said for the ability of doctors to ensure long-term care for their patients, which should include them being able to offer very safe and promising alternatives to pharmaceutical drugs. Based on the data and information coming to light and presented here, there is much to be concerned about the orthodox management of long-term patient care with pharmaceuticals, which have been recognized as the third leading cause of death in the U.S. and Europe. Therefore, physicians and clinicians should seriously contemplate the risk/benefit perspective of supplementing first before prescribing hard drugs for preventive and long-term health care management. Patients as well, should be made aware of the issues raised within as they are the end-consumers and bear the ultimate risk.
In the second part of this series, America's Frontline News will review Putka's article disparaging doctors who join MLMs and provide wellness products to their patients.
Read part 2 here.
Updated Oct. 20, 2022
