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Doctors who were fed meals costing even less than $20 later prescribed certain brand-name pills more often than rival medicines, according to a new analysis published on Monday of a federal database. And in most cases, costlier meals were associated with still higher prescribing rates for Medicare Part D drugs made by the same companies that provided the food.

The findings, published in JAMA Internal Medicine, are likely to intensify an ongoing debate over the extent to which ties between drug makers and doctors unduly influence medical practice and the nation’s health care costs. The issue has resonated over the years as prices for prescription medicines continue to rise, and many drug companies have paid civil and criminal fines for illegal marketing and kickbacks designed to boost prescribing.

“High rates of brand-name prescribing are a pressing issue for patients and taxpayers,” said Colette DeJong, a coauthor and research fellow at the Center for Healthcare Value at the University of California, San Francisco School of Medicine. She noted there were “great generic options” that physicians could have prescribed instead.

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“This is a huge issue for seniors receiving Medicare, who pay a median copay of $1 for generics and $80 for nonpreferred brand-name drugs [which cost patients more since insurers provide less coverage for these medicines]. Multiply this by 10 monthly medications, and it can become unaffordable for people to pick up the medicine they need,” DeJong said.

The study examined more than 63,500 payments made to nearly 280,000 doctors, nearly 95 percent of which were meals that cost between $12 and $18 each, and took place at restaurants, meetings, and physician offices. They also identified physicians who received meals promoting the most-prescribed brand-name drug in each class of medicine for treating high cholesterol, high blood pressure, depression, irregular heartbeats, and heart failure.

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The researchers analyzed data from the federal Open Payments program for the last five months of 2013, which was the first batch of data that was posted by the Obama administration. They also looked at prescribing data for individual doctors from Medicare Part D. Industry-sponsored meals, by the way, accounted for about 80 percent of the total number of industry payments to physicians.

The Open Payments database was created two years ago under the Sunshine Act provision of the Affordable Care Act in response to concerns over industry influence. The authors noted, for instance, that in the United States, in the last five months of 2013, 4.3 million industry payments totaling $3.4 billion were made to more than 470,000 physicians and 1,000 teaching hospitals

To be sure, industry marketing research has shown that industry outreach to physicians encourages doctors to prescribe new drugs. And there have been other studies in the past to examine prescribing habits and industry largess, but this is the first study to cull the data and to attempt to link prescribing habits with specific types of medicines.

A study published last month found that among 12 physician specialties, payments given to doctors were associated with greater prescribing costs per patient. And another recent study of 2,444 Massachusetts physicians found that for every $1,000 received from industry for any drug, the prescribing rate for brand-name statins increased by 0.1 percent.

“This study should be another nail in the coffin of the argument that there is no association between industry marketing to physicians — even meals worth as little as $20 — and wasteful physician prescribing practices,” said Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School and a faculty member at Brigham and Women’s Hospital in Boston, who co-authored the paper that examined Massachusetts doctors.

The JAMA researchers noted that the Pharmaceutical Research and Manufacturers of America have voluntary guidelines, which allow meals and gifts to physicians of up to $100 in value. By contrast, the American Medical Association policy prohibits industry-funded meals. But the findings suggest the industry guidelines may not be sufficient to alter industry influence and prescribing patterns.

“I think it’s inherently unethical for physicians to pass along [the] cost of their lunches to the American people in the form of higher prices. Doctors are highly compensated in this society and should pay for their own lunches,” said Eric Campbell, a Harvard Medical School professor and research director at the Mongan Institute for Health Policy at Massachusetts General Hospital, who has also studied the topic of physician-prescribing patterns .

Meanwhile, industry trade groups defended the meals.

“The more information prescribers obtain, the more they are likely to use a drug safely and effectively. Dinner meetings are regulated by the FDA to ensure that the information is consistent with the basic information about the drug and is not false or misleading in any way,” said John Kamp of the Coalition for Healthcare Communication, which represents ad agencies and medical publishers.

“The fact that the doctors have dinner as part of the process does not change the facts of the presentation in any way. Education informs effective prescribing,” he said.

A spokeswoman for the Pharmaceutical Research and Manufacturers of America, the industry trade group, wrote us that “this study cherry-picks physician prescribing data for a subset of medicines to advance a false narrative. Manufacturers routinely engage with physicians to share drug safety and efficacy information, new indications for approved medicines, and potential side effects of medicines. As the study says, the exchange of this critical information could impact physicians’ prescribing decisions in an effort to improve patient care.”

The JAMA authors noted, however, that they could not establish a cause-and-effect relationship between the prescribing and the meals.

However, one former congressional staffer said this may be beside the point.

A cause-and-effect relationship “is not necessarily what the federal government finds to be illegal,” said Paul Thacker, a former investigator with the US Senate Finance committee who probed drug company payments and helped draft the Sunshine Act.

“Prosecutions are based on whether a physician changes behavior after the payments start,” he said. “But nobody has looked at that yet. It’s not just whether the increased payments are associated with increased prescription numbers, but do those increased prescription rates follow the payments?”

As for the companies that fed the doctors, a spokeswoman for Pfizer, which sells the Pristiq antidepressant — one of the drugs specifically looked at in the JAMA study — wrote us that “it is important to note that physicians, teaching hospitals, and biopharmaceutical companies work together on research and share up-to-date information about our medicines for the benefit of patients. Pfizer does not pay health care professionals to prescribe our medicines.”

A spokeswoman for AstraZeneca, which sells the Crestor cholesterol pill — also examined by the study investigators — said “AstraZeneca does not offer anything of value to health care providers in exchange for prescribing AstraZeneca medicines. AstraZeneca strongly believes that transparency is an important component of our industry’s commitment to patient health and provides physician payment data in accordance with Federal Open Payments and state reporting guidelines.”

A spokeswoman for Daiichi-Sankyo, which sells the Benicar high blood pressure drug, one of the drugs examined by the JAMA researchers, wrote this: “It is important to note that the kinds of meals described in the article take place within an educational setting where pharmaceutical companies help physicians stay current on the latest treatments, new indications, and emerging safety risks.

“It is our responsibility to ensure prescribers are fully aware of the risks and benefits of our medicines and to obtain information about how future potential medicines may help them and their patients. In turn, physicians share firsthand knowledge with pharmaceutical professionals about patient experiences with their medicines — feedback that is critical to improving patient outcomes.”

We also asked for comment from Allergan, which sells the Bystolic heart drug, and will pass along any reply.

This story was updated to note that the American Medical Association policy prohibits doctors from accepting meals and gifts. The JAMA study cited an older policy that meals up to $100 are permitted.

  • I probably am missing the point here, but it seems to me that maybe these “studies” are showing that big Pharma has successful marketing plans. Now, if I owned stock in those companies, I’d be happy to know that. That IS what marketing is about…increasing sales…umm…isn’t it?

    • Marketing may be about increasing sales, but medicine is — or at least should be — about making decisions in the best interest of the patient (not the pharma company) based on evidence (not gifts).

    • Robert, your choice of the term ice berg is prescient. I once attended a product launch meeting in which the open bar featured a 25′ x 50′ ice sculpture with the name of the drug that obscured everything else in sight.

  • Contrary to what your picture shows, the most we have gotten was pizza for the office staff. This was inadequate compensation for spending our lunch hour listening to the benefits of a new product. I suppose the sales reps salaries and their budget should be better spent to enrich an already powerful television media and the Boston Globe. (Just how much did Medicare save by the pharmaceutical tv advertising with the words “ask your doctor” attached to them?)
    As physicians, we do not have the fortitude of the average Ivy League school who is bankrolled by Middle Eastern oil money or, let us say, a secretary of state who receives $400000 for a 25 min speech to Wall Street while apparently attacking these same donors.

    • Hi M. Douek,

      Thanks for taking the time to write. Here’s a question – why do you feel you should be compensated for taking the time to learn about a new product? Why is it unreasonable to expect physicians to learn, on their own time, about new products and procedures as part of their work?

      I’m interested to know your point of view.

      Thanks,
      ed at pharmalot

    • Since doctors usually close their offices for lunch it s money that is not being made anyway. Since it’s a waste of you time ask the rep to purchase you a journal subscription or a textbook. Goldman- Cecil Textbook of Medicine list for $177 but with a group practice you can get under the $100 limit. That assumes you still read up on your patients.

  • “Cherry-picking” or not, the question remains: if there’s no connection between meals and gifts to physicians and their prescribing behavior, why have pharma reps (whose compensation depends entirely on whether physicians prescribe their drug) continued this practice for over five decades?

  • Article seems to have an agenda to suggest that doctors who have a lunch or dinner are swayed in a negative way to use a new drug. Having first hand knowledge of this process most physicians have little time during their busy day to learn about new drugs or talk and share experiences with other doctors who may be prescribing the drug. Why not do an article that interviews a group of doctors on why they would use a new drug? In the vast majority of cases there are legitimate reasons that a new drug offers some significant treatment benefit which significantly increases the patient quality of life that was not being met with a current medication.

    • Hi BL Stein,

      Thanks for the note. I’m not sure if you were referring to the JAMA paper or the post here, but for the record, there is no agenda involved in reporting this study. Simply tried to present the findings along with interpretations and reactions, from both sides of the fence, so to speak.

      In any event, thanks for taking the time to discuss this.

      Regards,
      ed at pharmalot

    • We do interview doctors in groups using focus group techniques. The Pharma.guys sit behind one way mirrors and observe. Problem is they have to be run at night, the doctors must travel to the studio and you have to feed them anyway.

  • The dinner meetings are excellent educational opportunities for community based physicians to hear lectures by prominent physicians in their field. The $20 dinners are not a bribe. This type of sponsored educational meetings occur in every type of human endeavors from lawyers, accountants to plumbers and electricians. Stop fixating on doctors.
    The problem with outrageous drug prices is not with the doctors, it is with the fact that Medicare is prohibited by law from negotiating drug price and must pay whatever prices the drug companies set for Medicare approved drugs, which is usually 10 to 100 times the prices for the same drugs in Europe, India or Canada.
    Fix Medicare pricing system, and see the cost of drug drop rapidly.

  • Is it reasonable to consider that perhaps the physicians practice of prescribing could possibly be related to increased awareness and knowledge of pharmaceuticals with better safety and efficacy profile?

  • Correlation is not causation. Could it be that the reps providing meals were aimply “selling”…aka, doing their jobs? As i understand it, many thinga out of sight are out of mind. Aggressively selling a product should result in higher sales, as I understand it.

    • Yes, aggressive selling should increase sales. But increased use of a medicine should depend upon actual evidence that using that medicine is in the best interest of patients, not on aggressive selling.

  • Given the drek I’ve eaten at these dinners the food should be a disincentive. As for lunches the doctors don’t care about the food; they barely have time to eat. The food is mostly to pacify the office staff. The food us soon forgotten; it’s the metric ton of reminder ads and other “leave behinds” that are more important.

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