Drug Company Payments to Physicians May Be Influencing Prescribing

A look at national data on payments from pharmaceutical manufacturers to physicians supports the notion that such arrangements could be swaying prescribing behavior in the Medicare setting, although the study’s cross-sectional design limits the establishment of a cause-and-effect relationship.

Each additional payment with a median value of just $13 was associated with 94 additional days filled with marketed versus nonmarketed oral anticoagulants over a 17-month period and 107 additional days filled with marketed noninsulin diabetes medications, William Fleischman, MD (Yale University, New Haven, CT), and colleagues report in a study published online August 18, 2016, ahead of print in the BMJ.

For both classes of medication, stronger associations were observed when payments were made to specialists. For diabetes drugs in particular, the link was stronger for the sorts of payments typically given to “key opinion leaders” tasked with educating the clinical community, including speaker and consulting fees, honoraria, travel costs, and nonresearch grants.

“Our study’s findings, like those before it, suggest these payments may influence prescribing,” Fleischman told TCTMD in an email. “In the study, we intentionally chose not to comment on potential regulatory or legislative implications because of the complicated and controversial discussion this usually triggers. We would prefer physicians, regulators, and lawmakers to use these findings as they see fit.

“Having said that, many leaders in medicine have long pushed for physician education to be free from industry influence,” he continued. “My personal hope is that studies such as this can help bring clarity to that debate and lead to less biased continuing medical education.”

If payments from pharmaceutical companies to physicians are, in fact, having an effect on how drugs are prescribed, it could be a concern in terms of patient care, Fleischman said, noting that it could lead to patients taking more expensive or unnecessary medications.

“To be clear, we did not study nor do our findings show any patient harm resulting from industry payments,” he said. “However, my personal opinion is that clinicians should stay away from any unnecessary influence that can affect their decision-making, and payments from industry, especially when they are for physician education, are an unnecessary and undue influence.”

Commenting on the study for TCTMD, James Yeh, MD (Massachusetts General Hospital, Boston), said the link between industry payments and increased prescribing of marketed drugs is not surprising, citing similar previous studies.

As physicians, he said, “we as a profession need to think about how we’re regulating these kinds of payments,” and in particular whether payments for activities other than research should be banned or capped.

“The decisions that we make shouldn’t really be driven by these potential biases and motivations, whether that’s conscious or subconscious,” Yeh said.

Open Payments Data Mined

The Open Payments program, implemented as part of the Affordable Care Act, increases the transparency of physician-industry relationships by requiring companies to report payments to the Centers for Medicare & Medicaid Services. That information is now publicly available.

For the current study, Fleischman and colleagues examined Open Payments data covering August 2013 to December 2014, as well as Medicare Part D prescribing data for oral anticoagulants and noninsulin diabetes medications, which represent commonly prescribed and marketed drugs.

The analysis encompassed 306 hospital referral regions in the United States and included nearly 46 million prescriptions written by roughly 624,000 physicians for about 10.5 million patients. During the study period, pharmaceutical companies made about 977,000 anticoagulant-related payments totaling over $61 million to about 120,000 physicians and about 1.8 million noninsulin diabetes medication-related payments totaling over $108 million to about 112,000 physicians.

The authors note that the median value of the payments ($13) “encompasses only the value transferred to the physician and not the overall cost to the manufacturer, which includes the development of promotional material and the salary and travel expenses of the detailing representative, among others. Thus, it is not possible to calculate the ‘return on investment’ based solely on Open Payments data.”

Chicken or the Egg?

Fleischman cautioned that the study cannot establish a causal relationship between industry payments and physician behavior.

“This study does not prove that payments cause prescribing changes,” he stressed. “While it shows that payments and prescribing are tied at the regional level, it does not, however, answer whether the proverbial chicken or the egg came first. For example, it’s possible that pharmaceutical companies target their marketing in regions that already prescribe more of their drugs.”

Nevertheless, the findings suggest that industry payments could influence prescribing behavior, despite a belief among most physicians that they do not, he added.

“My personal opinion is that my fellow physicians should realize that we are just as prone to be influenced by money as everyone else,” Fleischman said.

Source:

• Fleischman W, Agrawal S, King M, et al. Association between payments from manufacturers of pharmaceuticals to physicians and regional prescribing: cross-sectional ecological study. BMJ. 2016;Epub ahead of print.

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