When Physicians Get a Free Lunch, Who Pays?

When patients fill a prescription from their physicians, they implicitly trust that the prescribed drug was chosen with their best interests in mind. Patients assume that medical expertise decided which patient would benefit most from which drug. However, a recent study published in JAMA suggests that in addition to their medical training, physicians may be making prescription decisions dependent on who bought their last meal.

A team based at the San Francisco School of Medicine cross-referenced data from the Open Payments Program and the 2013 Medicare Part D Prescriber file. The researchers focused on the most-prescribed brand-name drugs in each of four Medicare Part D drug categories for in 2013 – rosuvastatin (statins), nebivolol (selective B-blocker), olmesartan (ACEIs and ARBs) and desvenlafaxine (SSRIs and SNRIs) – and found a positive association between the number of prescriptions individual physicians wrote for these drugs and whether these physicians had received a meal from the drugs’ respective parent companies. The team also found that this association strengthened as the price and number of meals the physicians received increased.

As a cross-sectional study, this research cannot demonstrate causality. Furthermore, because the data used was a summary of prescriptions written within a year, it cannot be determined whether receipt of a meal preceded, coincided, or succeeded a higher number of brand-name prescriptions. It is also unknown if industry events provided relevant clinical information that shaped provider behavior or if providers were simply more likely to attend events sponsored by companies whose drugs they already favored.

Still, the possibility that the pharmaceutical industry may be influencing patient care through providers is a genuine concern and this study fills a gap in previous research. While several studies have found a general association between the frequency of brand-name drug prescriptions and industry payments to physicians, this investigation is notable for its focus on individual drugs and the seemingly innocuous payment of a single meal. By clarifying the association, this research strengthens the idea that physicians may be consciously or unconsciously swayed by conflicts of interest when making patient care decisions.

This Policy Prescriptions^® review is written by José Dominguez as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine. Mr. Dominguez is a first year medical student.

Abstract

IMPORTANCE: The association between industry payments to physicians and prescribing rates of the brand-name medications that are being promoted is controversial. In the United States, industry payment data and Medicare prescribing records recently became publicly available.

OBJECTIVE: To study the association between physicians’ receipt of industry-sponsored meals, which account for roughly 80% of the total number of industry payments, and rates of prescribing the promoted drug to Medicare beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of industry payment data from the federal Open Payments Program for August 1 through December 31, 2013, and prescribing data for individual physicians from Medicare Part D, for all of 2013. Participants were physicians who wrote Medicare prescriptions in any of 4 drug classes: statins, cardioselective ?-blockers, angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers (ACE inhibitors and ARBs), and selective serotonin and serotonin-norepinephrine reuptake inhibitors (SSRIs and SNRIs). We identified physicians who received industry-sponsored meals promoting the most-prescribed brand-name drug in each class (rosuvastatin, nebivolol, olmesartan, and desvenlafaxine, respectively). Data analysis was performed from August 20, 2015, to December 15, 2015.

EXPOSURES: Receipt of an industry-sponsored meal promoting the drug of interest.

MAIN OUTCOMES AND MEASURES: Prescribing rates of promoted drugs compared with alternatives in the same class, after adjustment for physician prescribing volume, demographic characteristics, specialty, and practice setting.

RESULTS: A total of 279?669 physicians received 63?524 payments associated with the 4 target drugs. Ninety-five percent of payments were meals, with a mean value of less than $20. Rosuvastatin represented 8.8% (SD, 9.9%) of statin prescriptions; nebivolol represented 3.3% (7.4%) of cardioselective ?-blocker prescriptions; olmesartan represented 1.6% (3.9%) of ACE inhibitor and ARB prescriptions; and desvenlafaxine represented 0.6% (2.6%) of SSRI and SNRI prescriptions. Physicians who received a single meal promoting the drug of interest had higher rates of prescribing rosuvastatin over other statins (odds ratio [OR], 1.18; 95% CI, 1.17-1.18), nebivolol over other ?-blockers (OR, 1.70; 95% CI, 1.69-1.72), olmesartan over other ACE inhibitors and ARBs (OR, 1.52; 95% CI, 1.51-1.53), and desvenlafaxine over other SSRIs and SNRIs (OR, 2.18; 95% CI, 2.13-2.23). Receipt of additional meals and receipt of meals costing more than $20 were associated with higher relative prescribing rates.

CONCLUSIONS AND RELEVANCE: Receipt of industry-sponsored meals was associated with an increased rate of prescribing the brand-name medication that was being promoted. The findings represent an association, not a cause-and-effect relationship. 

DeJong, C, et al. JAMA Intern Med. 2016; 176 (8): 1114-10.

PMID: 27322350