The Hidden Cost Of Free Lunch

–Brand name prescribing increases when industry pays for the meals

Physicians who accept free meals from a drug company are more likely to prescribe that company’s brand name drugs, according to a new study in JAMA Internal Medicine.

The authors compared data from the Open Payments Database listing industry payments to physicians with Medicare prescribing information about those same physicians. They specifically looked at 4 drug categories— statins, cardioselective beta-blockers, ACE inhibitors/ARBs, and SSRIs/SNRIs— to determine which physicians were more likely to prescribe brand name drugs.

The four target drugs were rosuvastatin (Crestor; AstraZeneca), nebivolol (Bystolic; Forest Laboratories), olmesartan (Benicar; Daiichi Sankyo), and desvenlafaxine (Pristiq; Pfizer). All four branded drugs had multiple generic alternatives and “limited, mixed, or contrary evidence” of superiority over the generic alternatives.

The study focused on physicians who received meals but not other types of payment from industry among the 155,000 physicans who wrote at least 20 Medicare prescriptions in one of the 4 classes in the study. From 2% to 12% of these physicians also received industry payments. 95% of these payments were for meals, the mean value of which ranged from $12-$18.

Even physicians who accepted only one free meal were more likely to prescribe the brand name drug. The likelihood of prescribing the brand name drug increased with the number of meals they accepted. Physicians who accepted 4 or more meals were far more likely to prescribe brand names than physicians who accepted no meals:

• Rosuvastatin: 15.2% of prescriptions in the class vs 8.3%
• Nebivolol: 16.7% vs 3.1%
• Olmesartan: 6.3% vs 1.4%
• Desvenlafaxine: 1.7% vs 0.5%

Furthermore, physicians who accepted more expensive meals prescribed more brand name drugs than those who accepted less expensive meals.

The authors cautioned that because of the observational nature of their study they were only able to demonstrate an association but could not establish a cause-and-effect relationship. They acknowledged that if the meals inform physicians about “new evidence and clinical guidelines, then the receipt of sponsored meals may benefit patient care.” On the other hand, they write, “if, alternatively, meals change physicians’ prescribing practices as a result of promotional influence, either by encouraging future use or rewarding an ongoing preference for the promoted drug, this would be cause for concern.”

In an accompanying Editor’s Note, Robert Steinbrook writes that it may not be necessary to prove a causal relationship. “There are inherent tensions between the profits of health care companies, the independence of physicians and the integrity of our work, and the affordability of medical care. If drug and device manufacturers were to stop sending money to physicians for promotional speaking, meals, and other activities without clear medical justifications and invest more in independent bona fide research on safety, effectiveness, and affordability, our patients and the health care system would be better off.”

Related reading: Dollars for Heart Docs