Although most doctors are incredibly honest, ethical people who only want to help patients, physicians are human and potentially vulnerable to influence from outside. Money is a prime suspect for undue influence, and it’s probably no surprise that pharmaceutical companies spend billions annually to influence physicians and other drug prescribers to write more prescriptions for their particular products.
Pharmaceutical marketing goes well beyond the half dozen commercials you might see during the nightly news. Ian Larkin, associate professor at the UCLA Anderson School of Management, has researched how pharmaceutical companies influence doctors’ prescribing habits, and says that much of the marketing budget for many of these companies is directed towards direct contact with doctors. “Pharmaceutical companies are spending something like double the amount that they spend on research and development [of new drugs] on marketing to doctors.” He says this is completely separate from the advertisements that we see on TV. That kind of marketing to consumers accounts for “only about 20 percent” of how much these companies spend on marketing their drugs, he says.
[See: 8 Questions to Ask Your Pharmacist.]
These days, direct marketing to physicians typically takes the form of what’s called detailing — a practice where pharmaceutical company sales representatives visit with individual doctors to tell them about their products. “The average detail visit is less than 15 minutes in length, and it usually involves giving some brief information, maybe a study or some pamphlets. And it quite often involves a small gift,” Larkin says. These gifts must be valued at less than $100, according to limits established by the Code on Interactions with Health Care Professionals created by the Pharmaceutical Research and Manufacturers of America. The code was developed by the industry itself and came into effect in 2002. It has been updated a few times since to help define ethical interactions between health care providers and pharmaceutical companies.
Prior to the implementation of this code, Larkin says that pharmaceutical marketing was a lavish business. “In the 1980s and 1990s, basically anything would go,” he says, and some physicians who frequently prescribed a particular medication would be put on retainer by the company that manufactured the drug. Back then, pharmaceutical companies could take physicians out for “golf games or fancy dinners or even pay for vacations. But the industry self-regulated to take out most of those types of more direct ways of influencing doctors.” Offsite meetings that weren’t educational in nature were eliminated and the value of acceptable gifts was reduced to $100 or less.
Today, these gifts typically take the form of lunch for the doctor and office staff, educational materials or small medical devices that the doctor can use when seeing patients. The key is that the items must be considered to have a patient benefit. “The idea was that doctors and staff are busy, and the doctor otherwise might not have time to eat or may not pay attention to eating. So their care will be better if the representative brings in a tray of sandwiches for the staff and sits with the doctor” while eating lunch. That’s the primary way that pharmaceutical companies have tried to influence doctors for the past 15 or 20 years,” Larkin explains.
Although doctors aren’t on retainer anymore, many physicians do still receive some form of “payment” from a pharmaceutical company. This information is now being tracked in a federally mandated database — the CMS Open Payments database created by the Centers for Medicare & Medicaid Services. The so-called Physician Payments Sunshine Act, a provision of the Patient Protection and Affordable Care Act of 2010, aka Obamacare, put in place measures to collect and make public any and all financial affiliations individual physicians have with pharmaceutical companies and manufacturers. The American Medical Association reports that the Sunshine Act “is designed to increase transparency around the financial relationships between physicians, teaching hospitals and manufacturers of drugs, medical devices and biologics.”
The idea behind the database, says Dr. Jathin Bandari, a urologist at the University of Pittsburgh, is not “intended to be pejorative or place blame. It’s instead just meant to enhance conflict of interest disclosures. There’s no repercussions for having high payments, for example, in the open payments database.” He says one of the issues surrounding disclosure of conflict of interest is that each institution and journal has a different way of handling it, so there’s really no standard way to make that information known to the general public. The database is a means of improving transparency.
Using that newly available information, a recent study in the Journal of the American Medical Association found that in 2015, 449,864 of 933,295 physicians in the U.S. (48 percent) accepted some kind of payment from a pharmaceutical or device manufacturing company. The average per-physician value of payments in a year was just $201, and 88.7 percent of these payments were for food or meals.
[See: 5 Common Preventable Medical Errors.]
Some doctors also accept consulting gigs with pharma companies. Fees from these arrangements are also disclosed in the CMS Open Payments database. In addition, the database captures “payments” that register when a doctor attends a conference or meeting that’s sponsored by a particular company. “It’s hard for us to go to any professional conference without some type of pharmaceutical representation there,” Bandari says. These companies “host some of these events, they provide funding, they advertise in our pamphlets. So you’re going to find virtually every provider getting some level of payment just by virtue of going to these conferences and being in the room,” he says.
In addition, most doctors are visited from time to time by pharmaceutical detailers. Typically, detailers have a set list of doctors they call on and Larkin says on average, detailers visit each doctor on their list about once a month. That can vary widely, but the idea is that in just 15 minutes once a month, with some educational pamphlets and lunch thrown in, the pharmaceutical company positions itself to be top-of-mind for the doctor when it comes time to make that in-the-moment decision about which drug to prescribe to a patient. Whether this actually influences how much a doctor will prescribe a particular drug is still an active area of research, but Larkin says, detailing and gift giving by pharmaceutical sale representatives does seem to make a difference. “Doctors who accept more meals from industry from pharmaceutical detailers are more likely to prescribe drugs that are promoted by those pharmaceutical detailers. But the question is, is that correlation or causation?” — meaning do these things happen coincidentally, or does getting a sandwich and a visit from a sales rep once a month actually mean the doctor will prescribe that medication more often? And does it matter for patient health?
It might, Larkin says. In a recent JAMA study, Larkin and his team found that when gifts were removed from the equation, “there were reductions in the proportion of branded [versus generic] drugs prescribed after the pharmaceutical detailer couldn’t give gifts anymore. We think it’s pretty clean evidence that the gifts actually influence doctors,” and he says “the reductions were pretty large. The study suggested market share changes of 5 percent. That may sound small, but you have to remember that a 5 percent market share [in the drug classes they studied] is billions of dollars.”
However, it seems there could be quite a bit of variation in how marketing tactics influence prescribing behavior depending on the drug class and the number of options that are available to the prescriber. In many cases, especially with certain types of cancer therapies, there are limited options available to doctors, A recent study published in the journal Cancer found that when two medications for metastatic prostate cancer were compared, pharmaceutical marketing tactics did not seem to have a significant effect on which drug the doctor prescribed.
Using the CMS Open Payments database and comparing that to prescriptions written, Bandari, who was lead author on the study, says he and his team saw little to no correlation between pharmaceutical marketing and physician prescriptions. “We saw a weak correlation,” between marketing money spent and number of prescriptions with one of the medications they looked at. But the correlation was slight and did not bear out the usual assumption that doctors will be more likely to prescribe the drug they’ve been marketed.
He says physicians are often faced with marketing, just like the rest of us, and that for him anecdotally, it doesn’t change how be prescribes. The patient’s needs come first, he says. “There are advertisements everywhere a physician goes, but that does not necessarily mean that we’re incredibly invested in those advertisements or that we’re responding positively or negatively to those advertisements,” he says, likening it to a consumer walking through a mall and seeing posters or ads for certain products. “Undoubtedly some of those might affect you, because that’s the purpose of advertising — it’s meant to shape consumer behavior — but that doesn’t mean that every ad that’s listed is going to affect you.”
Bandari adds that prescribers can be influenced indirectly, too. “In academic circles and medical communities, our behaviors are often shaped by other people’s behaviors. So for example, if you go to a talk and you buy into a particular product, I might be influenced by your opinion and I might start prescribing more. But I wouldn’t be caught in that database as ever having received a payment” from that company, he says.
Determining whether there’s a harm to patients from these marketing tactics is still a little unclear. Answering this question is “the holy grail for research and practice” in this area, Larkin says. “We definitely know there’s a cost effect,” when the choice is between prescribing a generic versus a branded drug. Branded drugs can cost 10 times what the generic form costs, so when a doctor prescribes branded drugs as a result of pharmaceutical detailing, an argument could be made that there’s a harm to the patient. The cost of paying pharmaceutical sales representatives to manage these accounts is also significant and contributes to the high cost of health care as a whole.
In addition, Larkin says pharmaceutical detailing may contribute to the potentially dangerous phenomenon of overprescribing. “The thing I’m concerned about is that pharmaceutical detailing to doctors might sometimes cause doctors to prescribe in situations where they otherwise wouldn’t. All drugs have side effects, and you do wonder whether the side effects might not harm some patients.” However, he says the evidence isn’t entirely clear yet whether doctors are prescribing in situations where maybe it’s not warranted. From a patient care perspective, Larkin says he’s “less worried about choices between a generic drug and a branded drug,” but he’s continuing to investigate the potential harms of overprescribing, which some researchers say has contributed to the current opioid crisis.
[See: 10 Lessons From Empowered Patients.]
If you have a question about whether your own doctor has accepted payments from pharmaceutical companies, you can look it up in the database; the open payments website is exactly what it says it is — it’s open and anyone can access it. But Bandari urges caution in how you interpret what you find there. “The bottom line message to the patient is: You have a right to know. I would just be cautious in how you interpret it.” Just because your doctor is listed as having received a payment from a certain company “doesn’t mean that your doctor has a major conflict of interest.” The upside of pharmaceutical marketing is that it also helps raise awareness of new products that may treat disease better and improve chances of survival with fewer side effects than older or generic drugs.
If you do see something that makes you wonder, by all means, ask your doctor. “That might be an uncomfortable conversation for [the doctor] to have,” Bandari says, but having a good relationship with your doctor means you should be able to ask about anything that concerns you. “I’ve treated many patients, and I’ve not had a single one that’s asked me that. But I would be open to the idea of discussing it,” he says.
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Do Drug Company Payments to Doctors Influence Which Drugs They Prescribe? originally appeared on usnews.com
