Do Small Pharmaceutical Industry Payments Really Influence Doctors?

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I received the following question from reader Ximena:

“I appreciate how you always look to find out how much money different doctors have taken from pharmaceutical companies but I’m wondering, is there any proof that these payments actually influence doctors?”

This is a great question. One of the reasons that these payments go unchallenged is the general belief that doctors (and academics, and researchers) are “above influence” such that no matter how much money they might get from the industry, the things they say and the actions they take will not be swayed.

There is some research on this that I will go over. Before I do, one thing I want to point out is that I think it’s a red flag when someone who is in a position to make recommendations/prescriptions etc. around weight and weight loss is getting money from the weight loss industry. But when they aren’t very open and transparent about that (whether they are required to be by law or not,) I consider that a red flag on fire being waived from a parapet– that is someone who, as far as I’m concerned, cannot be trusted.

Let’s look at the research:

A 2016 study called Pharmaceutical Industry–Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries looked at data for 280,000 physicians and their prescribing habits around the most-prescribed brand-name drug in each of the 4 drug categories in Medicare Part D (statins, beta blocker heart medicines, ACE and ARB blood pressure pills, and SSRI-type antidepressants) during the last five months of 2013.

They found that “Physicians who received meals related to target drugs had a greater mean prescribing volume than those who did not (742.2 vs 470.1 statin prescriptions, 410.0 vs 299.8 β-blocker prescriptions, 562.7 vs 394.8 ACE inhibitor and ARB prescriptions, and 437.6 vs 269.5 SSRI and SNRI prescriptions; all comparisons.”

They found that  

“As compared with the receipt of no industry-sponsored meals, we found that receipt of a single industry-sponsored meal, with a mean value of less than $20, was associated with prescription of the promoted brand-name drug at significantly higher rates to Medicare beneficiaries. The differences persisted after controlling for prescribing volume and potential confounders such as physician specialty, practice setting, and demographic characteristics.”

They also found that more money was associated with higher rates of prescribing:

“Furthermore, the relationship was dose-dependent, with additional meals and costlier meals associated with greater increases in prescribing of the promoted drug. Our findings were consistent across 4 brand-name drugs, including rosuvastatin, the third-costliest drug in Medicare Part D ($2.2 billion in federal expenditures in 2013) after esomeprazole magnesium (Nexium) and fluticasone propionate/salmeterol (Advair Diskus)”

A 2016 analysis by ProPublica found that “doctors who receive payments from the medical industry do indeed tend to prescribe drugs differently than their colleagues who don’t. And the more money they receive, on average, the more brand-name medications they prescribe.”

A smaller study of 2,444 doctors in Massachusetts found that “For physicians with no industry payments listed, the median brand-name statin prescribing rate was 17.8% . For every $1000 in total payments received, the brand-name statin prescribing rate increased by 0.1%. Payments for educational training were associated with a 4.8% increase in the rate of brand-name prescribing; other forms of payments were not.”

Another 2016 study found that “for each of the 12 specialties examined the receipt of payments was associated with greater prescribing costs per patient, and greater proportion of branded medication prescribing.”

Each of these studies very specifically points out that their findings are correlational and not causational relationships – which is correct and which they should do (I just wish we could get the same kind of ethics and clarity in weight science research!)

This isn’t new information, a study from 2000 found that “Physician interactions with pharmaceutical representatives were generally endorsed, began in medical school, and continued at a rate of about 4 times per month. Meetings with pharmaceutical representatives were associated with requests by physicians for adding the drugs to the hospital formulary and changes in prescribing practice. Drug company-sponsored continuing medical education (CME) preferentially highlighted the sponsor's drug(s) compared with other CME programs. Attending sponsored CME events and accepting funding for travel or lodging for educational symposia were associated with increased prescription rates of the sponsor's medication. Attending presentations given by pharmaceutical representative speakers was also associated with nonrational prescribing.”

Update: Reader Samantha shared this 2021 Systematic Review with me. They found that “Payments were associated with increased prescribing of the paying company’s drug, prescribing costs, and increased prescribing of branded drugs.” While their findings are correlational, they also concluded that “The association between industry payments and physician prescribing was consistent across all studies that have evaluated this association. Findings regarding a temporal association and dose-response suggest a causal relationship.”

I was recently talking to a reporter about the author conflicts of interests for the AAP guidelines and he essentially blew them off because he felt like, for most of the authors, the amounts were “small.” Here we see that even small fees can matter, especially considering those fees often accompany “education” which is really just pharma marketing in disguise.

And that’s just a few bucks of free food. What about doctors who take payments (sometimes hundreds of thousands of dollars) for “consulting” or being on pharmaceutical company’s “speakers bureaus.” While I can’t find research on this, the fact is that in these cases, the doctors are literally being paid to represent a pharmaceutical company and, as we’ve seen, there is often no disclosure of that when they use their credentials/prestige/titles as doctors to promote the wares of those pharma companies in the media.

Remember that part of Purdue Pharma’s Oxycontin billion-dollar bankruptcy settlement (which, I want to say was completely inadequate and approved by a judge they essentially hand-picked) was that they had “paid kickbacks to providers to encourage them to prescribe even more of its products.” This is particularly notable as Novo Nordisk appears to be taking every page they can from Purdue’s Oxycontin playbook, including this one.

Common sense tells us that allowing pharmaceutical and medical device companies to give money to doctors compromises those doctors, the research we have backs that up, and given the pharmaceutical industry’s hyper-focus on profits, and the fortunes they invest in learning how to manipulate physician and patient behavior to increase those profits, I would wager, that if a few bucks didn’t have an impact, the pharmaceutical industry wouldn’t be spending them.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.

Note I don’t link to everything I discuss in this post because I don’t want to give traffic and clicks to dangerous media.