There’s no such thing as a free lunch.
It was true when the phrase was coined a hundred years ago and it’s true now. This idiom came into use in response to the practice of bars offering free food, such as this from The Commercial Advertiser in June, 1850:
“At The Crescent…
Can be found the choicest of Segars, Wines and Liquors…
N. B. – A free lunch every day at 11 o’clock will be served up.” (1)
The idea was that if you offered something for nothing, you’d get it paid back in another way—in the case of this advertisement, alcohol and cigars.
Findings of a study published last month in the Journal of the American Medical Association-Internal Medicine (JAMA) prove the same practice goes on today—but the implications are much more serious and far-reaching than promoting booze and tobacco for personal consumption.
What researchers endeavored to discover was if American doctors are more likely to prescribe drugs manufactured by a company that provided them with some form of “gift”.
Bottom line: oh, yeah.
Under the Physician Payment Sunshine Act (part of the Affordable Care Act), drug company payments and prescribing records for Medicare patients have recently become available to the public, enabling this kind of research into patterns. In the period from August 2013 to December 2014, these payments were in the amount of almost ten BILLION dollars. (2) Eighty percent of that went toward physicians’ meals.
We see no “sunshine” here.
Here is a condensed version of the study’s results:
“A total of 279,669 physicians received 63,524 payments associated with the 4 target drugs. Ninety-five percent of payments were meals, with a mean value of less than $20…Physicians who received a single meal promoting the drug of interest had higher rates of prescribing rosuvastatin over other statins…nebivolol over other β-blockers…olmesartan over other ACE inhibitors and ARBs… and desvenlafaxine over other SSRIs and SNRIs…Receipt of additional meals and receipt of meals costing more than $20 were associated with higher relative prescribing rates.” That is, “the more money doctors receive…the more brand-name drugs they tend to prescribe.”(3)
So maybe doctors are human, after all.
Of different similar drugs from different manufacturers, doctors are more likely to prescribe those from a company that has given them a free lunch. Or pen, or mug, or a box full of samples. Conflicts of interest and questionable prescribing practices are becoming more of a public concern as studies such as this are released. While professional ethics guidelines provide for “meals and gifts to physicians of up to $100 in value, our findings indicate that even payments of less than $20 are associated with different prescribing patterns.” (Ibid.)
Robert Steinbrook, MD is an Editor-at-Large with JAMA and has published commentaries on the practice of prescribing drugs as well as more general articles on medical ethics in the United States. In response to this new study on prescription practices, he asks some very incisive and provocative questions:
“Is it necessary to prove a causal relationship between industry payments to physicians and the prescribing of brand-name medications? Other than research support, product development, and bona fide consulting related to specific research programs and projects, it is already evident that there are few reasons for physicians to have financial associations with industry. Outright gifts, such as meals, may be legal, but why should physicians either expect or accept them?” (4)
“No Free Lunch”
Pharmaceutical companies peddle their most recent wares, which also happen to be the most expensive, with implications for healthcare (especially Medicare) costs.
An organization called “No Free Lunch” was formed by “health care providers who believe that pharmaceutical promotion should not guide clinical practice. Our mission is to encourage health care providers to practice medicine on the basis of scientific evidence rather than on the basis of pharmaceutical promotion. We discourage the acceptance of all gifts from industry by health care providers, trainees, and students. Our goal is improved patient care.” (5) Bravo!
Dr. Steinbrook’s concern for the welfare of those receiving healthcare from trusted sources goes beyond these most recent statistics. From a paper published in 2012, he calls into question the research that goes in to the modern practice of health care:
“Physicians and patients rely on medical journals as trusted sources of medical information. Unfortunately, conflicts of interest (this article primarily considers financial conflicts of interest) may undermine the credibility of the medical literature. Improved policies and practices at journals should address the conflicts of interest of authors, reviewers, editors, and journals. Medical journals should manage and eliminate conflicts, not just improve the disclosure of financial relationships.” (6)
There is no room for sponsor bias when health is concerned.
Like any other business, a company must advertise a new product to get people to buy it. What better way than “free” samples? It’s a known marketing strategy that has been proven to work, as this new study clearly shows.