Gift-bearing drug reps can influence a doctor's prescription
Doctors prescribed fewer brand-name drugs when hospitals put barriers between the doctors and pharmaceutical companies, according to a new study co-authored by a Carnegie Mellon University researcher.
The study, published Tuesday by the Journal of the American Medical Association, suggests visits from pharmaceutical company representatives to doctors offices are contributing to people spending more money on drugs, said CMU professor of economics and psychology George Loewenstein, who co-led the research team that published the study.
“Patients are not yet in a position to have any confidence that the drugs being prescribed to them – that the prices of drugs or even the quantity of drugs – are not influenced by the physician's financial interests as opposed to their health needs,” Loewenstein said.
After academic medical centers enacted policies to limit visits from drug salespeople, doctors prescribed more generic drugs and alternatives sold by companies that didn't send salespeople to their offices, according to the study. Generics are generally cheaper than brand-name drugs.
Pharmacy representatives, who Loewenstein said are often young and attractive, visit some doctors and their staff once a week or more, regularly bringing them meals and presenting information about new drugs. Sometimes they take them out to dinner.
“They are very popular people,” Loewenstein said.
Researchers analyzed prescribing by about 2,100 doctors at 19 academic medical centers – including UPMC – that enacted policies restricting visits from pharmaceutical salespeople from 2006 to 2012. They looked at eight common drug types, comparing prescriptions of drugs featured by the salespeople with generic and branded alternatives. For comparison, the study included doctors who worked in the same areas as the doctors at the medical centers.
The medical center policies were associated with an overall market-share decrease of the featured drugs of 1.67 percent. Market share of the alternative drugs increased by 0.84 percent, according to the study.
While the study doesn't prove the visits are the cause of the change – unaccounted-for factors could have influenced prescribing during the study years – it presents new evidence of the influence the drug salespeople play and what academic medical centers can do to limit the influence, Loewenstein said.
“It's a very significant change,” he said. “It's big materially, economically, and the policies weren't even all that radical.”
Pharmaceutical Research and Manufacturers of America, an industry group, implemented voluntary limits on its corporate members in 2002 and updated them in 2009. The organization bans branded items such as pens and notepads but allows meals and educational gifts, according to the study.
A PhRMA spokeswoman said the visits are an important way for drugmakers to educate clinicians about the efficacy and safety of new drugs.
“It is important to consider the potential positive impact on patient health outcomes as a result of these interactions,” the spokeswoman said in a statement.
Policies varied across academic medical centers. Eleven of the 19 centers that enacted policies restricted gifts as well as salesperson access to doctors offices and included enforcement mechanisms. UPMC, the region's largest hospital system and the only Pennsylvania medical center included, was one.
UPMC implemented its policy in 2008, said Dr. Barbara Barnes, UPMC's vice president of sponsored programs, research support and continuing medical education.
The policy has helped curb influence that often happens on a subconscious level, Barnes said. The salespeople, who in the past would bring meals from caterers or Panera to doctors offices, have familiar faces and build trust with doctors, who might end up prescribing their drugs a little more often, she said.
“Lacking these policies, there's often a lack of awareness of some of the implications of the relationships,” she said.
Doctors can invite the salespeople to their offices for a specific purpose, but the reps can share only information that is relevant to the physician's need, she said.
UPMC also prohibits doctors from giving out free branded samples, she said, which can help steer patients to branded prescriptions when cheaper alternatives are available.
Academic medical centers across the country improved conflict-of-interest policies during the study period, the study noted. The American Medical Student Association ranks policies on a website that compares the centers.
Loewenstein said the pharmaceutical salespeople likely have more influence at hospitals that aren't academic medical centers, which were not included in the study.
Allegheny Health Network, the region's second-largest hospital system, did not provide an interview or specifics on its conflict-of-interest policies.
“The Allegheny Health Network has in place and enforces strict conflict of interest and vendor interactions standards, and we take very seriously our commitment to these standards,” spokeswoman Stephanie Waite said in a statement. “Furthermore, AHN absolutely agrees that clear restrictions should be in place to safeguard against outside vendors unduly influencing doctors' prescribing patterns. The network has implemented various policies and procedures that govern vendor interactions as well as onsite access; these policies are in place in an effort to ensure that the pharmaceutical industry does not in any way detract from our number one priority – giving patients the right care, at the right place, at the right time.”
The doctors offices associated with St. Clair Hospital, based in Mount Lebanon, have varying policies, said Dr. G. Alan Yeasted, St. Clair's chief medical officer. Yeasted said other changes in health care, including insurer policies that encourage doctors to prescribe generics, are contributing to a decline in branded drug prescriptions.
He said the study might prompt physicians' committees for the doctors offices to take another look at their policies.
“There are new medications that do reach the market that you would have difficulty keeping up with without some educational benefit from the pharmaceutical rep,” he said. “They do have a purpose, but we need to balance that with influence of brand-name drugs.”
Westmoreland County-based Excela Health Medical Group implemented a policy in 2014 banning all gifts and free drug and device samples, spokeswoman Robin Jennings said in a statement. The policy requires companies to arrange any visits and includes enforcement mechanisms.
Jennings said the system enacted the policy based on “evidence that interaction of providers with industry representatives leads to increased cost, potential patient safety issues and diminished confidence and respect among peers and patients.”
Wes Venteicher is a Tribune-Review staff writer. Reach him at 412-380-5676, firstname.lastname@example.org or via Twitter @wesventeicher.