Health care professionals who received gifts from the pharmaceutical industry not only wrote more prescriptions, but also more costly ones (including more brand name medications), than colleagues who did not receive such gifts. That’s the main takeaway from a study published last week looking at the prescription practices of nearly 3,000 healthcare professionals in the District of Columbia during 2013.
The study is unique in two ways. First, it looks at not just physicians but also physician assistants, nurse practitioners, and other prescribers across a wide range of specialties. Second, by combining information from local and federal databases, researchers were able to directly link prescriptions and gifts for individual prescribers under Medicare Part D (the federal prescription subsidy plan for seniors and the disabled).
Here are some of the major findings:
- Nearly 40 percent of prescribers received gifts ranging in value from $7 to $200,000 (2013 gift total = $3.9 million of meals, trips, honoraria, and other gifts)
- Gift recipients wrote more prescriptions than non-gift recipients (892 vs. 389)
- Gift recipients prescribed 7.8 percent more brand name drugs than those who did not receive gifts.
- Prescribers receiving smaller gifts (under $500/year) issued both more prescriptions (30% vs 26%) and more expensive ones ($114 vs $85)
- Prescribers receiving larger gifts (over $500/year) had the highest average prescription cost ($189) and percentage of brand-name prescriptions (40%)
Although the study cannot definitively establish cause-and-effect between a provider receiving such gifts and any subsequent upturn in their prescribing, it does make a significant contribution to a growing body of literature documenting how drug company largesse is clearly linked — either consciously or otherwise — to the way in which health care providers prescribe.
And I think it leaves consumers with two very important questions that those of us writing about this issue should address more often and more clearly.
“I thought doctors couldn’t take gifts? Who regulates this?”
There are no federal laws which prohibit drug companies from giving — or doctors receiving — gifts.
But if the commenters on the New York Times’ coverage of the study are any indication, many people think there is such a law. They incorrectly point to the Open Payments program that was created as a part of the Affordable Care Act called the ‘Physician Payments Sunshine Act’ (Section 6002, ACA). Some excerpts from those comments:
- “What gifts? Gifts haven’t been allowed for years. Not even pens are given out anymore.”
- “A very foolish (and very vague) article. It’s been illegal for many years for a pharmaceutical rep to give a gift of any significance to a physician.”
- “This is a big reason why it is illegal in many states for drug reps to give gifts to doctors. These laws have been in affect [sic] for a number of years.”
But it’s not a law that prohibits doctors from taking industry gifts. It simply requires drug and medical device companies to report payments to physicians and teaching hospitals for gifts, meals, speaking fees, and travel.
It’s an attempt at transparency and it’s unclear how many consumers know they can use the search tool in the Open Payments database to look up how much doctors and teaching hospitals are receiving, as well as how much companies are paying out.
And there are no state laws either. There are states such as Minnesota, Vermont, and New Hampshire (to name a few) who do place limits on certain gifts (mostly meals) – but no outright prohibition on taking industry gifts. And there are no regulations addressing how much industries can give. Each biomedical company may have their own code of conduct regarding the type and amount of gifts, but none prohibit this lucrative strategy that is undoubtedly in their best interest. It’s often defended as either educational in intent, or critical to advancing further research and development.
And what qualifies as a gift? Is paying a doctor to speak at an industry-sponsored event simply an appropriate compensation of expertise, or a clever way of getting thought leaders to advance the agenda of certain drug companies?
“Paying a physician to speak is sometimes meant to sway the physician and sometimes meant to sway the audience,” says Adriane Fugh-Berman MD, co-author of the study and a Professor of Pharmacology and Physiology at Georgetown University. She’s also director of Pharmed Out, a project dedicated to evidence-based prescribing, and educating health care professionals about pharmaceutical marketing.
“When a physician is invited to speak to five of his friends at a steak restaurant, that is simply a thinly disguised bribe to the speaker. Talks to larger audiences may affect the prescribing practices of both the speaker and the audience.”
“OK, big money changes hands. But can this really affect me?”
Daniel Golderberg thinks so.
Goldberg is a PhD researcher and lawyer with the Center for Bioethics and Humanities at the University of Colorado – Anschutz Medical Campus.
“I see the gift exchange impacting two areas that have a direct impact on patient care,” says Goldberg.
“First, in situations when the evidence is imperfect, and the decisions are subtle, as is so often true in medicine. In these ambiguous situations the evidence clearly suggests that gifts can sway doctors in one direction, even if there’s no evidence to support that as the best decision. Second, it frames decisions in pharmaceutical terms, even when there may be other options — proven to be better — that have nothing to do with drugs.
Drugs are just one tool. But we have ‘pharmaceuticalized’ health care to a point where many patients are conditioned to equate health with access to drugs.”
In other words, if doctors are (knowingly or unknowingly) acting on biased information, then they are not acting in the best interest of the patient.
When questioned, many doctors adamantly claim that such marketing tactics don’t influence their prescribing practices. But research doesn’t bear this out.
Also, these doctors should stop and think: Why would drug companies invest a mere $3 billion dollars marketing to consumers (2012 figures) but an estimated $24 billion marketing directly to physicians?
But perhaps the most important question all of us need to ask is: Who really benefits from these relationships? If your answer is ‘patients’ may I respectfully suggest a job as a drug rep?
Oh, and if you’ve ever wondered which companies, drugs, or devices make up the majority of the payments to doctors — and just how much is doled out — then this is a must-see list compiled by ProPublica.
Although many have asked for it, there is still no firewall between drug and device manufacturers and those entrusted with delivering our health care.
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