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.
“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.
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.