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Doctors, nurse practitioners, and physician assistants who were given meals, fees, grants, and other goodies by drug makers were much more likely to prescribe a larger number of medicines for each patient than health care providers who did not receive such payments, according to a new study. And often, the prescriptions were written for more-expensive, brand-name drugs.

The study examined $3.9 million in gifts and payments made to more than 1,100 Medicare Part D prescribers in Washington, D.C., in 2013, and found those health care providers prescribed 2.3 more claims per patient than providers who did not receive anything from drug companies. What’s more, the prescriptions cost $50 more per claim, and this trend was seen among six specialties in particular.

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  • Most of these issues, including alternative explanations, are included in the paper, which is open access and available here: Many more articles available at TW, I suggest you read Physicians under the Influence: Social Psychology and Industry Marketing Strategies, in the
    The Journal of Law, Medicine & Ethics, and Following the Script: How Drug Reps Make Friends and Influence Doctors in PLOS Medicine.

  • “Doctors, nurse practitioners, and physicians who were given meals, fees, grants, and other goodies by drug makers were much more likely to prescribe a larger number of medicines for each patient than health care providers who did not receive such payments, according to a new study. And often, the prescriptions were written for more-expensive, brand-name drugs.”
    1. Correlation is not causation. Which comes first, using the product for their patients or being compensated for services?
    Fees and grants are for speaking about the treatment to other HCPs, advising the company on various issues relevant to the product, or for conducting clinical trials. HCPs who find the product beneficial for their patients are identified – or self-identify – and are enlisted to speak, advise or be part of clinical trials.
    Even meals (this is almost always bringing in lunch for the office) can be plausibly argued as needing to prove causation. I admit this is more easily argued as likely to be causative, but HCPs generally don’t agree to rep visits with lunch just to get a bit of food – they do it for reps of products they like or want them and their staff to know more about (lunch is accompanied by a presentation and dialogue).
    2. What “other goodies” are there? All of the gifts and gratuitous practices of the past have been gone for many, many years. Even pens are no longer given out. The only things I’m aware of that could be called a “gift” are a meal (which is PhRMA-regulated as needing to be modest) or items for HCP education or patient care, which as you note, also need to be modest in cost.
    3. Of course they’re brand name drugs. Generic drugs don’t invest in promotion or education.
    4. “Doubt” is not evidence.
    I’m not arguing against causation, I’m asking for evidence beyond association.

    • Hi TW,

      Thanks for the note.

      I agree that correlation is not causation, however there have been numerous studies over the years indicating prescribing trends have reflected financial ties in the form of payments and gifts. Collectively, there appears to be an association, yes?

      To be sure, some fees or grants are legitimate. And it is difficult to climb into someone’s head to know their motivation with certainty. But one would have to be in denial not to notice the trend based on the studies (some of which are footnoted in the PLOS study or are easily found on a search engine).

      The PLOS study examined 2013, so there were more ‘goodies’ distributed at the time, which is why I used that word. I was describing those findings.

      Not sure if I’ve addressed all your points, but I appreciate that you took the time to stop by.

      ed at pharmalot

    • Ed, which “goodies” are you speaking of? in 2009, PhRMA guidelines stopped all giveaways other than modest meals, and patient care or HCP education items $100 or less. As far as I know, nothing has changed between then and now, including in 2013. Yes, the guidelines are voluntary, but the vast majority of pharma and biotech companies have complied since day one and continue to.
      100 studies showing association does not prove causation. As I noted, there is a very plausible explanation that HCPs favoring a medication brings the company to that HCP since they know that s/he is a fan.
      I’ve been following your writing for well over a decade Ed. The narrative has been consistent. Perhaps it’s time to label most of your articles as commentary rather than straight reporting. If not, then being more meticulous about avoiding insinuation would be appreciated.

    • Hi TW,

      To answer your question, the study noted cash payments. Perhaps I should have used the word cash instead of goodies. Meals, fees and grants were already cited in the study.

      One of the study authors told me the word ‘gifts’ was taken to include such things as tickets to an event, although that was not specified in the study. In any event, to me, a ticket qualifies as a goodie. And so is cash, which I didn’t specifically cite, but was highlighted in the study.

      Yes, I agree, there are various reasons that docs prescribe what they do. I talk to a lot of docs, actually. And as I noted earlier, I agree that correlation is not causation. But that does not negate the findings of the various studies or the need to keep watch over an issue that has generated legitimate concern.

      That said, there is no insinuation or intent to insinuate on my part, TW. I was reporting on a study that academics researched and, while its my name on the Pharmalot door, I did not interject my own opinion or conclusions. If I choose to do so, it will be apparent. Instead, however, I save that kind of exercise for the bi-weekly Pharmalot view column.

      Anyway, I enjoy the discussion.

    • Cash payments are bribes unless there is a service attached. Those services are either advisory (which has a formal definition and role and is highly regulated), or speaking to other HCPs (which can only be done using content that has been approved by the company’s Medical, Legal and Regulatory review, or as a grant for some study or research, for which a proposal was prepared and approved by the company.
      Tickets to events are outside of PhRMA guidelines since 2009.
      If the authors have evidence of tickets being given or payments of any kind being rendered that isn’t for an appropriate, contracted service, it should be documented with specifics, as these either violate guidelines or are illegal. I remain skeptical that either happened.

    • Hi TW,

      I understand your point. I’m going to step back for a moment and start at the top, which is this study suggests that financial ties appear to correlate with certain types of prescribing.

      This is not new, although the study did look at the physician payments data somewhat differently and, more interestingly, such data has not been analyzed concerning nurse practitioners and physician assistants, as far as I know.

      I agree that what occurred in 2013 may be different than in 2017, but since companies are not required to report transactions involving nurse practitioners and physician assistants, any influence on prescribing by these providers remains a relevant concern.

      It is what it is.

      ed at pharmalot

  • I would love to read the source material. I find this highly suspect. Pharmaceutical “gift-giving” went away years ago. I have never seen colleagues swayed by anything except cold hard science. If well designed studies backed up their claims, the drugs would get used. No amount of shilling on the part of drug companies can sway what is in the best interest of patients.

    • Hi J,

      Thx for your note.
      There is a link in the post to the study, which notes the source is data from OpenPayments and RxAccess.
      Payments for meals, consulting fees and the like continue to this day if you check Open Payments.
      In any event, one point to note is that payments to nurse practitioners and physician assistants aren’t required to be reported, eve though they write a chunk of prescriptions.
      That should be examined and rectified.

      Thx for stopping by.
      Ed at pharmalot

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