Hey, doc, how about a burger with a side of branded drug scripts?

pill spoon

They say there’s no such thing as a free lunch, and for doctors fed by drug companies, the old adage might be true. Even cheap meals provided by pharmaceutical sales reps were associated with higher prescription rates for the brands being promoted, a new JAMA Internal Medicine study concluded.

Researchers delved into data from the U.S. Open Payments database, mandated by the Sunshine Act, and matched it with Medicare Part D prescribing information on more than 276,000 doctors. They focused specifically on meals, rather than speaking fees or research payments.

They also focused on four on-patent drugs from four different drug classes, three treating cardiovascular issues and one antidepressant. AstraZeneca’s Crestor represented statin meds; Forest Laboratories’ Bystolic represented beta blockers; Daiichi Sankyo’s Benicar, ACE inhibitors and angiotensin receptor blockers; and Pfizer’s Pristiq, SSRI and SNRI antidepressants.

All four competed with generic meds in the same class, and the researchers argued that there’s “limited, mixed, or contrary evidence about the superiority of these 4 drugs over generic alternatives.”

What they found was this: Doctors who received even one industry-sponsored meal--with a mean value of less than $20--prescribed the promoted brand-name med “at significantly higher rates” to Medicare patients.

Other studies have analyzed script numbers for doctors receiving pharma payments--and found that higher payments are linked to bigger script numbers--but this is the first to zero in on meals.

Specifically, doctors who received meals from Crestor reps showed higher script numbers for that drug--a mean of 742.2 prescriptions, compared with 470.1 among those who didn’t receive those meals. For Bystolic, the doctors entertained by reps wrote a mean of 410 scripts compared with a mean of 299.8 scripts for those who weren’t. Benicar scripts came in at 562.7 from doctors who accepted meals, compared with 394.8 among those who didn’t. And docs fed by Pristiq reps wrote 437.6 brand scripts, versus 269.5 for those who weren’t.

Plus, the rate of brand prescribing--measured as a percentage of a doctor’s scripts in that drug class--increased with the number of meals doctors accepted. For Crestor, the script rate was a bit more than 8% for doctors who didn’t accept meals, compared with almost 14% for those entertained three times, and more than 15% for those entertained four times. The difference in prescribing rates was even larger for Bystolic, at about 3% for doctors who didn’t eat pharma meals, and more than 16% for those entertained four or more times.

Pricier meals boosted brand scripts more than cheap ones, too, for all of the drugs except Pristiq.

“The differences persisted after controlling for prescribing volume and potential confounders such as physician specialty, practice setting, and demographic characteristics,” the study states. “Furthermore, the relationship was dose dependent, with additional meals and costlier meals associated with greater increases in prescribing of the promoted drug.”

Drugmakers say their speaking programs provide a valuable educational service, and providing free meals--lunch in a doctor's office, for example--gives physicians time to sit down and learn about new products from pharma reps. The industry association PhRMA has defended pharma's financial ties with physicians, saying that drugmakers help inform better decision-making by paying expert-caliber speakers to spread their knowledge.

Still, the practice of paying doctors to speak on behalf of drugs has grown controversial in recent years, partly because of some high-profile scandals involving highly paid physicians. Buying lunch--even coffee--for doctors isn't critic-free either; Massachusetts briefly instituted a ban on free meals for physicians, a move unpopular with restaurateurs. Some drugmakers ratcheted back their payments to doctors after the Open Payments database went public, as ProPublica research has shown. GlaxoSmithKline ($GSK) went so far as to back off of doctor-speakers altogether, as of January 2016.

The new study had its limitations; the Open Payments data only covered 5 months, whereas the Medicare script information covered a full year, for instance. And the approach only showed an association, rather than proving that the meals actually caused the increased script numbers.

The same caveat applied to a previous study limited to Massachusetts doctors; overall, doctors in the state prescribed branded statins 22.8% of the time. Doctors who collected no money from pharma prescribed brands at a rate of just 17.8%. Doctors who did saw their percentage of brand prescribing rise with every $1,000 in pharma payments reported, that JAMA Internal Medicine study said.

ProPublica, which has conducted multiple analyses of the Open Payments data, found similar associations in a broader study of Medicare Part D data. They found that the doctors who took payments and gifts from drugmakers in 2014 were more likely to prescribe branded drugs that year. Even small handouts--such as free meals and payments worth $100 or less--tweaked branded scripts upward. Doctors who participated were two to three times more likely to prescribe brands than those who didn't.

- see the JAMA article

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