MMHA 6800 Walden Affordable Care Act in Indiana Health Service Paper Environmental forces and trends (i.e., competitors, new technologies, socioeconomic, p

MMHA 6800 Walden Affordable Care Act in Indiana Health Service Paper Environmental forces and trends (i.e., competitors, new technologies, socioeconomic, population and business factors, and changing regulations) can have a tremendous impact on the success of an organization’s marketing plan. Therefore, it is important for health care leaders to continuously assess the strengths, weaknesses, opportunities, and threats (SWOT) of these forces and trends to ensure that their organizations are applying the appropriate marketing strategies. For this Assignment, you need to conduct a SWOT analysis of an environmental force or trend and consider how it might impact your own health care organization.
To prepare:
Select a contemporary environmental force/trend, such as politics in health care, new technological advances in health care, the impact of recession/economic issues on utilization of health care, etc. Using the Walden Library, locate and review a scholarly article that discusses this force/trend.
Reflect on your own health care organization. Imagine you have been hired as a marketing consultant to help guide your organization in understanding evolving environmental forces/trends that may impact marketing. Note: If you do not currently work for a health care organization, you may select one that is of interest to you.
The Assignment

In a 4- to 5-page report, address the following:
Analyze the environmental force/trend you selected. Include how the organization in the article is using the force/trend to better understand itself.

With your selected health care organization in mind, conduct a SWOT analysis of the environmental force/trend you selected.Note: Be sure to use the SWOT Analysis Template in this week’s Learning Resources.
Analyze how the force/trend might impact the marketing of your organization. Recommend strategies to maximize opportunities and overcome threats.
Note: Your Assignment must be written in standard edited English. Be sure to support your work with at least five high-quality references, including two from peer-reviewed journals. Refer to the Essential Guide to APA Style for Walden Students to ensure that your in-text citations and reference list are correct. See the Week 2 Assignment rubric for additional requirements related to research and scholarly writing.
This Assignment is due.
Note: Synthesize the information you have gathered from your analysis so that each bullet point in the SWOT Analysis clearly represents the most significant considerations within each category. While the SWOT Analysis is a one-page document that might appear to be simple, each point must be the result of deep and critical thinking.FILLER TEXT Physicians under
the Influence:
Social Psychology
and Industry
Marketing
Strategies
Sunita Sah and
Adriane Fugh-Berman
It is easier to resist at the beginning
than at the end.
– Leonardo da Vinci’
P
hysicians often believe that a conscious commitment to ethical behavior and professionalism will protect them from industry infiuence.
Despite increasing concern over the extent of physician-industry relationships, physicians usually fail
to recognize the nature and impact of subconscious
and unintentional biases on therapeutic decisionmaking.2 Pharmaceutical and medical device companies, however, routinely demonstrate their knowledge
of social psychology processes on behavior and apply
these principles to their marketing. To illustrate how
pharmaceutical marketing strategies use psychological techniques to promote targeted therapies, we draw
on the relevant social psychology literature on confiicts of interest and on the six principles of infiuence
articulated by the eminent social psychologist Robert Cialdini.3 Hospitals, professional organizations,
medical educators, and other stakeholders must also
draw on social psychology to respond effectively to
commercial activities that compromise good medical
practice.
Believing Biased Information
An extensive literature describes how pharmaceutical firms use financial and nonftnancial inducements to infiuence health care providers’ attitudes
and decision-making.* Financial inducements include
honoraria, gifts, speakers’ fees, unrestricted education grants, sponsored research, and other funding
and resources. Nonftnancial inducements include
the use of deference, the opportunity to be revered as
an expert, and publication productivity facilitated by
industry-funded ghostwriters that furthers the health
care professional’s career.
Physicians often do not recognize their vulnerability to commercial information and subtle selling
techniques. Studies suggest that although physicians believe they can extract objective information
Sunita Sah, M.D., M.B.A., Ph.D., is an Assistant Professor of
Business Ethics at Georgetown University anda Research Fellow at the Ethics Center at Harvard University. Her research
focuses on institutional corruption, business ethics, and advice – in particular, how professionals who give advice alter
their behavior as a result of conflicts ofinterest and the policies
designed to manage them. Adriane Fugh-Berman, M.D., is
an Associate Professor in the Department of Pharmacology
and Physiology and the Department of Family Medicine at
Georgetown University Medical Center (GUMC). She directs
PharmedOut, a GUMC research and education project that
advances evidence-based prescribing and educates health care
professionals about pharmaceutical marketing practices.
INSTITUTIONAL CORRUPTION AND THE PHARMACEUTICAL INDUSTRY • FALL 2013
665
SYMPOSIUM
from sales pitches, they routinely fail to distinguish
between correct and incorrect information provided
by sales representatives.^ One study found that physicians’ beliefs regarding two commonly used drugs
correlated more strongly with promotional than
with scientific materials, despite the physicians’
claim that they accorded scientific materials more
weight.^
People are more strongly infiuenced by messages
delivered with confidence and do not take the trouble
to ascertain the accuracy of these messages if doing
so requires effort or money.^ Moreover, people often
serving bias.’^ Educational interventions to reduce
bias generally succeeded in convincing people only
that their negotiating opponent could be biased, not
that they themselves could be. Even people who conceded that they could be biased tended to drastically
underestimate how biased they were.”
Professionalism and Cognitive Dissonance
Professionalism may help to avoid intentional corruption, but cannot reduce unintentional subconscious
bias. While articulating and believing in the importance of scientific objectivity, physicians’ biases to
Physicians’ mistaken belief that they are immune to marketing aligns with
research showing that people rationalize and believe what they want to
believe. For example, studies consistently show that promotion increases the
prescription of targeted drugs, yet research also finds that physicians believe
their own prescribing behavior is unaffected by industry influence, although
they concede that other physicians are susceptible to such influence.
arxhor on initial information given to them even after
discovering it to be inaccurate or irrelevant.^ These
cognitive biases may explain the overuse of expensive branded drugs, including the over prescription
of second-generation antipsychotics in the face of
research showing that first-generation antipsychotics
are equivalent or superior.»
Self-Serving Biases
Physicians’ mistaken belief tbat they are immune to
marketing aligns wdth research showing that people
rationalize and believe what they want to believe.>°
Eor example, studies consistently show that promotion increases the prescription of targeted drugs,”
yet research also finds that physicians believe their
own prescribing bebavior is unaffected by industry
infiuence, although they concede that other physicians are susceptible to such infiuence.’^ As Jason
Dana and George Loewenstein note, “It cannot both
be true that most physicians are unbiased and that
most other physicians are biased.”” Social psychology
research confirms that people have a “bias blind spot”;
namely, they are more likely to identify the existence
of cognitive and motivational biases in others than in
themselves.'”* Furthermore, educating people about
their own self-serving biases does not eliminate those
biases.’^ Similar outcomes have been documented in
experimental bargaining settings tbat examine self-
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accept industry gifts create cognitive dissonance; that
is, discomfort that arises from a discrepancy between
confiicting beliefs, or between beliefs and behaviors.
Competing cognitions create pressure that must be
resolved. Cognitive dissonance theory specifies three
methods — not mutually exclusive — by which people
manage or reduce dissonance: ‘^ (l) changing one of
the dissonant beliefs, opinions, or behaviors (possibly
a difficult or painful process that requires sacrificing a
pleasurable behavior or treasured belief); (2) lowering
the importance of one of the discordantfactors Cwhich
can be accomplished by denial — forgetting or rejecting the significance of one or more of the confiicting
cognitions); and (3) adding consonant elements that
resolve or lessen dissonance (this may involve rationalizations to buffer the dissonance between confiicting cognitions).
Susan Chimonas and colleagues’» identified various denials and rationalizations used by physicians to
reduce cognitive dissonance regarding their relationships with drug reps. Denial included (a) avoiding
thinking about the conflict of interest, (b) rejecting
the notion that industry relationships affect physician
behavior, and (c) disavowing or universalizing responsibility for problems that arose from confiicts of interest (“there’s always a confiict of interest…”). Rationalizations included (a) asserting techniques that would
help maintain impartiality and (b) reasoning that
JOURNAL OF LAW, MEDICINE & ETHICS
Sah and Fugh-Berman
meetings with drug reps were educational and benefited patients.
personal sacrifices and whether such sacrifices justify
accepting gifts.
Implicitly reminding physicians of the burdens of
medical training and their working conditions more
than doubled their reported v^dllingness to accept
gifts, from 22 percent in the control group to 48 percent. Providing the explicit potential rationalization
boosted reported vwUingness to accept gifts to 60 percent, despite the fact that the majority of physicians
Sense of Entitlement
Most physicians view the favoring of self-interest over
profession obligations with repugnance. Physicians
express indignation at the suggestion that accepting gifts or compensation affects therapeutic choices
because they understand that such an exchange would
mean they have made a deliberate decision to act unethically.^«
Physicians, who would never, for
Michael Oldani, an anthropologist and former
example, engage in a quid pro quo
exchange of money for prescripdrug rep, says that “the importance of developing
tions, may believe that such a conloyalty through gifting cannot be overstated.”
scious and genuine commitment
As he explains, “The essence of pharmaceutical
to ethical behavior renders them
immune to commercial infiuence. ^^
gifting is…’bribes that aren’t considered bribes.'”
This righteous but vwong assumption derives from not knowing that
many psychological processes occur
below conscious awareness.
responded negatively to the rationalization itself. This
A famous slogan in advertising history, cosmetic
implies that rationalizations rejected on a conscious
company L’Oréal’s “Because I’m worth it,” coined in
level can nevertheless help us unconsciously rational1973, was a daring declaration of confident entitleize questionable behavior.
ment.22 In a recent article, Sunita Sah and George
Loewenstein investigated a self-serving rationalizaPrinciples of Influence
tion for the acceptance of gifts and industry compenRobert Cialdini and his colleagues identified six prinsation: physicians’ sense of entitlement and belief that
ciples of influence and persuasion: reciprocation,
“they are worth it.”23 Both implicit and explicit ratiocommitment (and consistency), social proof, liking,
nalizations were shov^Ti to alter physicians’ sense of
authority, and scarcity.^^^ Social psychology research
entitlement to industry-funded benefits.
has demonstrated that these principles are used to
In the study, family medicine and pediatrics resisubtly infiuence decisions.
dents were randomized to one of three online surveys
that asked the same questions but ordered differently.
Reciprocity
Doctors in the “implicit reminders” group were first
The norm oi reciprocity — the obligation to help those
asked about sacrifices they had made in pursuit of
who have helped you — is one of the guiding principles
their medical education and about their working conof human interaction.^^ In many cultures, accepting a
ditions, then asked about the acceptability of receivgift without reciprocation is socially unacceptable. The
ing industry-funded gifts such as sponsored continurelationship between physicians and industry exhibits
ing medical education, sponsored research, payment
noticeable similarities vrith the formalized gift-giving
for talks, and office and personal gifts. Doctors in the rituals of leaders negotiating confiict settlements doc”explicit rationalization” group were also first asked
umented by anthropologist Marcel Mauss.^^ Physiabout their sacrifices and working conditions and
cians pay back industry gifts through changes in their
were then asked to indicate their level of agreement
practice.^” Michael Oldani, an anthropologist and forwith the statement: “Some physicians believe that
mer drug rep, says that “the importance of developing
the stagnant salaries and rising debt levels prevalent
loyalty through gifting cannot be overstated.”^^ As he
in the medical profession justifies accepting gifts and
explains, “The essence of pharmaceutical gifting is…
other forms of compensation and incentives from the
‘bribes that aren’t considered bribes.”’29
pharmaceutical industry.” Finally, they were asked the
Gene Carbona, another former drug rep, tells the
questions about the acceptability of accepting indusstory of how he persuaded Astra Merck, his employer,
try-funded gifts. Doctors in the control group were
to pay for a practice management consultant to advise
asked first about gift acceptability and then about
a multispecialty practice of 50 physicians on how to
maximize its profits.^” The consultant was told that “if
INSTITUTIONAL CORRUPTION AND THE PHARMACEUTICAL INDUSTRY • FALL 2 0 1 3
667
SYMPOSIUM
he were successful there would be more business for
him in the future, and by successful, we meant a rise in
prescriptions for our drugs.” The consultant reminded
the doctors of the valuable service Carbona had provided to them and the grateful doctors did indeed
reciprocate; their prescriptions for Astra Merck drugs
increased.
Anthropologists view gift-giving as an economic
exchange between different, often opposing, groups;
it is not “voluntary, spontaneous, or disinterested.”^’
Industry provides gifts of many forms at all levels.
At the national level, for example, there are industry
grants to national medical organizations and publicprivate partnerships, in which industry co-funds projects with federal agencies. At the institutional level,
industry provides educational grants for grand rounds
and journal clubs (meetings in which physician trainees analyze articles from the medical literature), and
also funds continuing medical education.^^ Medical device companies also regularly provide travel
expenses to surgical residents so they can visit facilities
to practice implanting the company’s medical devices.
Finally, at the individual level, fees for research, consulting, or speaking, and gifts of meals, medical equipment, and books are commonplace.
Gifts associated with a subtle implicit request may
be more likely to achieve compliance than gifts that
call for an explicit reciprocation. The pens, pads,
mugs, and other inexpensive “reminder” items that the
pharmaceutical industry lavished on physicians until
2008, when the Pharmaceutical Research and Manufacturers Association revised its Code on Interactions
with Healthcare Professionals,^^ kept brand names
uppermost in physicians’ minds (known as “top of
mind” by industry) while triggering reciprocity norms.
“Reps know that gifts create a subconscious obligation
to reciprocate,” states Shahram Ahari, a physician and
former drug rep. “Gifts are used to enhance guilt and
social pressure.”^*
The common belief that low-value gifts, such as calendars and coffee mugs, are not enough to influence a
doctor’s professional behavior reflects the misperception that professionals consciously trade off the risk
of bias against the benefit of receiving the gift. In fact,
gifts of negligible value can influence the gift recipient
in ways which they are not aware of.^^ An experimental study conducted by Ulrike Malmendier and Klaus
Schmidt,^*’ for example, revealed that a small gift
strongly affected recipients’ decisions in favor of the
gift-giver, even at the expense of a third party. Even
subjects aware that the gift was given with the intention of influencing behavior reciprocated. Another
study demonstrated that raffle tickets were much
more likely to be bought by participants who received
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the trivial gift of a soft drink than by those who did not
receive a gift.^^ Unlikable characteristics in a gift-giver
reduced, but did not eliminate, the perceived obligation to reciprocate.
Hershey Friedman and Ahmed Rahman conducted an experiment in a restaurant to determine
the effects of being greeted upon entry and receiving a small gift (either a cup of yogurt or an inexpensive key chain). Customers who received a greeting
and either of the two gifts spent considerably more
money (on average, 46 percent more), rated the restaurant more highly, and recommended the establishment more strongly than those who received no
gift or greeting.38 But while a gift to a restaurant
patron may increase the patron’s own bill, a gift to a
physician ends up increasing the bill for patients and
insurance providers.
Commitment and Consistency
The pharmaceutical industry is well aware of the
power of small commitments, which is why drug
reps ask, for example, “Will you try my drug on your
next five patients with diabetes?” Agreeing to a small
request like that increases the likelihood that the
physician will start using the targeted drug. Physicians who agree to such statements casually — maybe
even just to make the sales rep go away — may then
feel an obligation to keep their word.^s Drug reps
are able to track physicians’ prescribing,*° and those
physicians who have not yet honored their commitments may be reminded and encouraged yet again to
try the drug.
Consistency is highly valued in our society and associated vidth rationality and stability.*’ After committing to a decision or opinion, people justify that choice
or opinion by remaining consistent with it. Bettors at
a racetrack are much more confident that their horse
will win after they have bet on it.*^ By extension, a physician will be more positive about a drug after rather
than before prescribing it. Written commitments —
and a prescription is a written commitment — are
even more effective than oral commitments in changing behavior.« After prescribing a drug several times,
a physician may persuade himself or herself that the
drug really is the best choice.
A significant commitment becomes more likely in
the wake of a small commitment or even of agreement vwth a statement. In one experiment, the number of people who agreed to let a representative of
the Hunger Relief Committee visit their homes to sell
cookies nearly doubled when the telephone solicitor
first asked, “How are you feeling this evening?” and
waited for the inevitable response of “Fine” or “Good,”
compared to a control statement of “I hope you are
JOURNAL OE LAW, MEDICINE & ETHICS
Sah and Fugh-Berman
feeling well this evening.” The refiexive statement
attesting to one’s own well-being subconsciously
made it harder to subsequently refuse to help the less
fortunate.**
Social Proof
If accepting industry gifts is a cultural norm in medicine, physicians will continue to do so. The opinions
of colleagues are often used by industry representatives to sway physicians to adopt a particular therapy.
Social proof, also referred to as social validation or
conformity, is the practice of deciding what to do by
looking at what others are doing.*^
Social proof can also augment — or undermine —
official academic policies. Trainees in an institution,
for example, are affected by the institution’s stated
policies but also — and sometimes more so — by what
they see their mentors do. A recent study of 14 U.S.
medical schools that restricted industry gifts found
that physicians who had graduated from the schools
after the gift restriction policies had been implemented were less likely to prescribe two of three newly
introduced psychotropic medications than those who
had graduated prior to the gift restrictions.*^ Another
study found that Lipitor (atorvastatin) promotional
items favorably affected implicit attitudes towards
Lipitor amongst fourth-year medical students at the
University of Miami, Miller School of Medicine, but
negatively affected implicit attitudes towards Lipitor
amongst fourth-year students at University of Pennsylvania School of Medicine, which has strong restrictive policies on pharmaceutical marketing.*^
A systematic review of 32 studies that examined
medical students’ interactions with industry found
that student attitudes towards industry generally
aligned with the policies of their schools, and students
in schools that restricted industry access were more
skeptical about marketing messages than students in
schools that did not restrict industry access.^^ Conversely, eight studies found that the frequency of contact between students and industry representatives
correlated with favorable attitudes toward industry
interactions.
Disturbingly, however, students’ attitudes tended
to become more favorable towards industry as their
training progressed from the preclinical to the clinical years. Only 29 to 62 percent of preclinical students
reported that promotional information provides useful information about new drugs, but 53 to 71 percent
of clinical students did. « This apparent attitude drift
may help explain why graduates of programs that limit
or p…
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