Under the Influence

A new analysis by ProPublica found that doctors who receive money from drug companies do, in fact, tend to prescribe more brand name drugs, and that the more money they got, the more brand name prescribing they did.

I trust that no one is surprised by these results.

ProPublica looked at prescribing patterns from five specialties -- cardiovascular, family medicine, internal medicine, ophthalmology, and psychiatry -- with the restriction that individual physicians had to have had at least 1,000 Part D prescriptions in the study period (2014).  Overall, about three-fourths of physicians took some money from a drug company, although there was wide variation by specialty and geography -- e.g., nearly 9 of 10 cardiologists took payments, just as around 90% of physicians took such payments in Nevada, Kentucky, Alabama, and South Carolina.

Conversely, in Minnesota and Vermont the percentage was closer to 25%.

The amount of the payments appeared to have an impact.  Internists who received no payments had brand-name prescribing rates of about 20%, while those getting more than $5,000 had rates of around 30%.  For ophthalmologists, the corresponding rates were 46% versus 65%.

As usual, the defenses from physician organizations and the drug industry make for fun reading.  Dr. Richard Baron, the president and chief executive of the America Board of Internal Medicine, protested that doctors nowadays almost have to go out of their way to avoid taking these kinds of payments,  I can just picture the poor physicians telling their drug rep, "please don't make me take your money!"

The president of the American College of Cardiology suggested the patterns were re-enforcing; the more they learn about a drug, the more they tend to use it, and the more they use it, the more drug companies pay them to be speakers and consultants.  Dr. Baron had a similar theory: "If you are out there advocating for something, you are more likely to believe in it yourself and not to disbelieve it."

A spokesperson for The Pharmaceutical Research and Manufacturers of America noted that many factors influence prescribing patterns, and quoted results of a 2011 PRMA survey that found, not surprisingly, that 9 of 10 physicians felt that a "great deal of their prescribing was influenced by their clinical knowledge and experience,"

Seriously, these are their defenses?

HealthGrove conducted a similar analysis late last year, with similar results.  They found that the highest prescribing physicians, measured by number of prescriptions and by prescription costs per patient, were much more likely to receive payments from drug companies.  Both the median payment and the percent receiving payments went up as number of prescriptions went up.

Just to be sure, they also drilled down on the data and confirmed that the high prescribers of a specific drug were more likely to receive payments from the maker(s) of that drug.  Amazingly, it doesn't look like it takes much to influence physician behavior; physicians who prescribed over $500,000 of a drug had a median payment of only $137.

I don't know about you, but I would have hoped it would take a lot more than $137 to influence a physician's prescribing patterns.

HealthGrove did a separate analysis on how much drug companies spend on "food and beverage" payments to physicians, i.e., how much they spent literally wining and dining docs.  They profiled ten companies with the highest spending in this category.  AstraZeneca led the pack, with $17 million spent in this category, some 24% of their overall payments to physicians.  

As HealthGrove asked: "If you knew your doctor was prescribing a drug made by a pharmaceutical company that frequently took her out to expensive dinners, could you trust this was an unbiased choice?"

We've been learning a lot more about how pervasive industry payments -- not just pharmaceutical companies but also medical device and other heath care suppliers -- are since the advent of the Open Payments initiative, created as part of ACA.  We're talking about over $6.5b in payments in 2014, made to over 600,000 physicians and 1100 hospitals.  I wrote about this last summer, and the new ProPublica analysis certainly should rattle any remaining doubts anyone might have had about the potential impact of such payments.

True to form, last fall the AMA called for a ban on DTC advertising.   That's right, they don't seem disturbed about the $6.5b physicians are getting, but they think that the ads that we see are bad.  There's a certain logic to that; it has long been suspected that these ads help drive consumer demand.  That's why companies do advertising, after all.  

Austin Frakt, of The New York Times, recently challenged this conventional wisdom.  For one thing, he notes that while drug ads do cause an increase in sales for the advertised drug, they also increase sales of other drugs in the same class, using Prozac as an example.  Seeing drug ads may help "normalize" the condition being treated, making getting treatment for it more acceptable, and may also help encourage patients to continue with existing prescriptions.  We don't always blindly go for the brand-name drug being advertised either; he references research that shows we might demand a prescription but we still take into account our much cost-sharing for it would be.

Mr. Frakt points out that it is not only the drug companies who benefit from drug advertising, but also physicians.  Every $28 in drug advertising results in an additional doctor visit; someone has to do the prescribing, after all.  And, of course, the DTC spending is dwarfed by the direct-to-physician "promotions" -- Mr. Frakt estimates drug companies spend seven times more on these than on DTC advertising.

So we're back to the ProPublica analysis.

We all say we're appalled by the impact lobbyists and campaign contributions have on politicians.   As Bernie Sanders has charged, "If these contributions from Wall Street and other powerful special interests have no influence over the candidate, why are these special interests making huge campaign contributions?"

So it is with health care, and not just with contributions to politicians.  Drug companies and device manufacturers are lobbying physicians, not with campaign contributions but with the kinds of spending Open Payments attempts to at least report on.  It simply is not plausible to maintain that these efforts are not influencing physicians' decisions, and that they may not always be in the best interests of patients.  As Bloomberg put it last summer: the payments "seek to convince doctors that second choice is OK."
 
Well, I don't know about you, but that is not OK with me.