You have high cholesterol, and your doctor writes a prescription for Crestor. It will cost you around $200 to fill a month's supply. Or the prescription could be for Simvastatin, a generic cholesterol pill. A month's supply is around $10. We are not offering medical advice here. That is between the patient and his physician. But understand that a recent story in the Journal of the American Medical Association said that as little as a modest lunch - under $20 - bought by a pharmaceutical company for a doctor may influence his prescribing.
The JAMA story asserted that "[r]eceipt of industry-sponsored meals was associated with an increased rate of prescribing the brand-name medication that was being promoted."
The researchers also said that the vast majority of reported payments by pharmaceutical companies to physicians came in the form of meals. They concluded that when food was involved, doctors were 18% more likely to prescribe Crestor over other statins, that is, cholesterol pills. They were also 118% more likely to prescribe Pristiq over other antidepressants; 52% more likely to prescribe Benicar over other ACE inhibitors, a class of blood pressure lowering pills; and 70% more likely to prescribe Bystolic over other beta blockers, also a blood pressure lowering pill.
A generic ACE inhibitor, Lisinopril, is $4 for a month's supply at Wal-Mart. A month's supply of Benicar is $235 at Wal-Mart. Betagan, a generic beta blocker, is $12 for a month's supply; Bystolic is $120. Cymbalta, a generic antidepressant, is about $20; Pristiq is about $300 for a month's supply.
All of these drugs are of the kind that typically are taken for many years by patients. A drug like penicillin is taken for a short, specific treatment period. But drugs that are taken for chronic conditions like high blood pressure are ones that get bought month after month. Ka-ching, ka-ching.
Know this: the Pharmaceutical Research and Manufacturers of America (PhRMA), a Washington, D.C.-based trade group, loudly disputes the JAMAfindings. "This study cherry-picks physician prescribing data for a subset of medicines to advance a false narrative," said Holly Campbell, PhRMA's senior director of communications. "Manufacturers routinely engage with physicians to share drug safety and efficacy information, new indications for approved medicines and potential side effects of medicines. As the study says, the exchange of this critical information could impact physicians' prescribing decisions in an effort to improve patient care."
Here's the question: is bribery occurring? Glenn McGee, a bioethicist and professor of management at the University of New Haven, offered this comment: "Study after study tells us that small gifts like meals have an impact on physicians' choices about prescribing medicines. At one level, it shocks us to think that doctors - the most trusted professionals in the world - could be influenced by a steak dinner. But at another level, shareholders of the big pharmaceutical companies would be pretty unhappy if hundreds of millions were being spent on these gifts and they didn't work. "
McGee is not saying big pharma is breaking any laws. What they have done, said McGee, is "maximize the use of loopholes. These meals fit through the loopholes."
A federal anti kickback law governs what pharmaceutical companies can do, and shouldn't do, to promote drugs. But it is unlikely that a modest, free lunch would trigger the threshold for government action.
"The Justice Department won't prosecute someone for a free lunch under the anti kickback laws," said Brian Mahany, a Milwaukee-based whistleblower attorney who has been involved in cases against big pharma.
He added: "Big pharma has figured out ways to exploit gray areas."
Can as little as a Shake Shack lunch really persuade a physician to prescribe a pricey, brand-name drug? "Doctors who participate in educational seminars may be offered little other than a free lunch but still feel obligated to return the pharma rep's friendship in some substantive way - this may occur even unconsciously," said Dr. Bill Bithoney, chief physician executive for the BDO Center for Healthcare Excellence and Innovation.
Dr. Rachna Patel, a Walnut Creek CA physician, said: "As a physician I can tell you that gifts from pharmaceutical companies absolutely influences the prescribing practices of physicians. From a psychological perspective, these gifts indebt physicians to return the favor."
Bithoney added: "Such meals also keep the pharma company's drug at top of mind. Sometimes the doctor may forget a generic's name and thus will prescribe the drug at top of mind."
Want to know if your doctor has had contact with pharmaceutical reps? The U.S. government maintains the Open Payments Data website. Input a physician's name and you will see what, if any, interactions involving payments (including in kind such as meals) he has had.
Bottomline: when handed a prescription, don't be shy about asking your physician if there is a cheaper but equally effective alternative. And if there is, ask what the tradeoff is in going with the cheaper drug. Follow his advice, but make sure you know the whole score.
This article is commentary by an independent contributor. At the time of publication, the author held TK positions in the stocks mentioned.