PAYING FOR
PRESCRIPTIONS

“Pharmaceutical companies offered gifts or payments on at least one occasion in the past year to 82 percent of physicians…”

United States Department of Health and Human Services, Office of the Inspector General Promotion of Prescription Drugs Through Payments and Gifts.(OEI-01-90-00480) (1991)
“Pharmaceutical companies offered gifts or payments on at least one occasion in the past year to 82 percent of physicians and on 5 or more occasions to 79 percent… Pharmaceutical companies were more likely to offer gifts and payments to physicians who were frequent prescribers than to those who were infrequent prescribers… Pharmaceutical companies offered gifts or payments explicitly defined by the current guidelines as being inappropriate on at least one occasion to 27 percent of physicians.”

The Pew Charitable Trusts, September 2014, What is your Doctor getting paid?
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Physicians Receive Payments From Industry

  • 84% of U.S. Physicians report receiving payments, gifts, meals, drug samples, or travel from industry.
  • More than $27 billion was spent on marketing to physicians by the pharmaceutical industry in 2012.
  • “Marketing tools such as gifts and free meals also influence clinical decision-making.” Austad et al., 2014, JAMA

Payments Influence Patient Care

  • When physicians received meals or speaking or consulting fees, prescriptions of a company’s drug increased by 17%
  • Use of promoted drugs fell by 34% when hospitals limited physicians’ contact with pharmaceutical company sales reps
  • 70% of consumers think that doctors should disclose payments from a company whose drugs they are about to prescribe
  • “A public record…could serve as a deterrent to inappropriate relationships and undue industry influence.”

Sources

1 Cegedim Strategic Data, “2012 U.S. Pharmaceutical Company Promotion Spending” (2013),
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2 Kristen E. Austad et al., “Association of Marketing Interactions With Medical Trainees’ Knowledge About Evidence-based
Prescribing: Results From a National Survey,” Journal of the American Medical Association 174, no. 8 (2014): 1283–90,
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3 Ian Larkin et al., “Restrictions on Pharmaceutical Detailing Reduced Off-label Prescribing of Antidepressants and Antipsychotics in
Children,” Health Affairs 33, no. 6 (2014): 1014–23
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4 Joseph Engelberg et al., “Financial Conflicts of Interest in Medicine,” University of California, San Diego (2014),
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5 Kevin McCarthy, “Consumers Wary of Doctors Who Take Drug-company Dollars,” Consumer Reports News, Oct. 19, 2010, http://www.consumerreports.org/cro/news/2010/10/consumers-wary-of-doctors-who-take-drug-company-dollars/index.htm.
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6 Institute of Medicine, “Conflict of Interest in Medical Research, Education, and Practice” (2009),
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Eastern Mediterranean Health Journal, 2014, Vol. 20, No.12: pages 812-819
Physicians’ attitudes towards interaction with the pharmaceutical industry. By: Alosaimi et al.
“As the majority of physicians were in the habit of accepting gifts, the majority found it ethical to interact with the pharmaceutical industry representatives and tended to overlook any potential influences on clinical decision-making.”
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United States Department of Veterans Affairs
A Report by the National Ethics Committee of the Veterans Health Administration (2003)
Gifts to Health Care Professionals from the Pharmaceutical Industry
“Some 80% of physicians report having been offered cash or gifts from pharmaceutical industry representatives…[a] significant number of patients believe that industry gifts bias their physician’s prescribing practices and ultimately drive up medical costs…In the context of a gift to a health care professional from a pharmaceutical industry representative, practitioners commonly understand that the hoped for reciprocation involves the health care professional writing more prescriptions for the drug(s) the representative is promoting.”
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“All expense paid” trips influence Doctor prescribing patterns

United States Congress. Advertising, marketing and promotional practices of the pharmaceutical industry: Hearing before the committee on labor and human resources. 101st Congress, 2nd Session.
Washington, DC: U.S. Government Printing Office; 1991.
Senator Edward M. Kennedy on P 2-3 “Pharmaceutical companies are spending larger and larger sums on questionable tactics that subvert basic medical standards, tempting doctors with lavish vacations, gifts and cash payments…Patients have the right to expect that a prescription drug they are taking is medically appropriate for their illness, not part of their doctor’s ‘frequest prescriber vacation plan.'”

p-153 “We invited Abbott, CIBA-GEIGY, Wyeth-Ayerst and Hoffman-LaRoche to appear at today’s hearing to respond to these allegations, but all four companies declined to appear.”

p-154 “…why did Abbott sponsor an all-expenses-paid symposium at Disneyworld for doctors and spouses, devoted entirely to unapproved uses of Lupron?”
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Chest, 1992; 102; 270-273
The effects of pharmaceutical firm enticements on physician prescribing patterns. There’s no such thing as a free lunch. By: Orlowski & Wateska
“The physicians in this study did not feel that the largesse of an expense-paid trip to a resort to attend a seminar concerning a drug would influence their prescribing of that drug. Nevertheless, a significant and substantial increase in the prescribing of that drug occurred subsequent to the inducement…Such efforts clearly influence behavior, despite our feelings to the contrary.”
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Canadian Medical Association Journal, 1993 Nov 15; 149(10): 1401–1407
Interactions between physicians and the pharmaceutical industry: what does the literature say?
By: Dr. Joel Lexchin, M.D.
“Of 20 physicians interviewed before they went to conferences none felt that their prescribing behaviour would be affected…[Their acceptance of the “all-expenses-paid” trip]…demonstrated a significant increase in prescribing the drugs that had been the subjects of the symposia…some 77% of physicians favoured the commercial view of a product rather than the scientific view…Conclusions: Physicians are affected by their interactions with the pharmaceutical industry.”
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Journal of Medical Education, 1980; 55:453-455
Teaching drug promotion abuses to health profession students.
By: Palmisano & Edelstein
This study found that 85% of medical students believe it is improper for politicians to accept a gift, whereas only 46% found it improper for themselves to accept a gift of similar value from a pharmaceutical company.
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Journal of the American Medical Association, 2000, Vol. 283, No. 3: pages 373-380
Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?
By: Dr. Ashley Wazana, M.D.
“Conclusion The present extent of physician-industry interactions appears to affect prescribing and professional behavior and should be further addressed at the level of policy and education.”
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United States Congress. Advertising, marketing and promotional practices of the pharmaceutical industry: Hearing before the committee on labor and human resources. 101st Congress, 2nd Session.
Washington, DC: U.S. Government Printing Office; 1991.
Testimony of Dr. Sidney M. Wolfe, M.D., Director, Public Citizen Health Research Group.

p-49 “If a judge sitting on an important case were bribed by one or two of the parties involved in the case in order to influence his or her decision, we would all be outraged, and the judge, if discovered, would be criminally prosecuted. To the extent that physicians are in a real sense judges of what is wrong with patients and what tests or treatments to prescribe, doctors’ decisionmaking must be shielded from influences other other than what is in the best interest of the patient.”

p-50 [Regarding Wyeth-Ayerst frequent prescriber/free flying doctor program] “They worked out a deal with American Airlines wherein any time a doctor who participated in their frequent flier program prescribed this drug, he would get 1,000 frequent flier bonus miles on American Airlines. Fifty prescriptions of 50 “tricks,” so to speak for the company, and a doctor would get a free coach ticket on American Airlines anywhere in the United States…American Airlines said they would not tell how many doctors participated, but that it was “a very successful program from our standpoint.”

p-52 “The drug companies and the doctors whom they bribe are classic examples of white-coated and white-collared crime.”

p-80 “We have the majority of American drug companies involved in what I think is clearly criminal activity in some way or other to try and influence doctors ro prescribe their drug.”
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“Doctors fear drug companies like bookies fear the mob…”

The American Prospect, 2001, Vol. 4; No. 9
Pharma Buys a Conscience
By: Dr. Carl Elliott, M.D., Ph.D.
“Doctors fear drug companies like bookies fear the mob…”
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The Israel Medical Assocation Journal, 2011 Jul;13(7):389-93.
The physician’s relationship with the pharmaceutical industry: caveat emptor…buyer beware!
By: Albersheim & Golan
“When money is given or a favor promised in order to influence judgment or conduct of a person in a position of trust, this is a bribe.”
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The Lancet, 2005 Jul 30-Aug 5;366(9483):422-4.
Should journals publish industry-funded bioethics articles?
By: Dr. Carl Elliott, M.D., Ph.D.
“Even discussions of conflict of interest have become tainted by questions of conflict of interest—or at least the perception of a potential conflict. The American Journal of Bioethics recently published an article on the ethics of taking gifts from the pharmaceutical industry which was itself funded by Pfizer…Newspapers have understood this for years. Financial columnists are not allowed to accept money from the companies they write about, and film critics are not allowed to accept money from the studios producing the films they review.”
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Alliance for Human Research Protection, November 13, 2010
Medical Journals Complicit in Corruption of Medicine. By: Vera Hassner Sharav
“Doctors “on the take” are encouraged to promote and widely prescribe clinically worthless drugs for untested uses, without regard for the serious harm caused patients.”
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Referees are not permitted to accept benefits or gifts from team owners.
Police are not allowed to accept benefits or gifts from crime suspects.
Judges are not permitted to accept benefits or gifts from litigants.
Professors are not allowed to accept benefits or gifts from students.
Journalists are not allowed to accept benefits or gifts from their subjects.
This is because referees, police officers, judges, professors and journalists are obligated to exercise their judgment impartially according to professional standards.

Annals of Family Medicine, 2005, Jan; 3(1): 82–85
The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives
By: Dr. Howard Brody, M.D., Ph.D.
“The goal of the pharmaceutical industry is to increase its profits, which includes persuading physicians to prescribe more of the most expensive drugs…systematic reviews of the literature confirmed a direct relationship between the frequency of contact with reps and the likelihood that physicians will behave in ways favorable to the pharmaceutical industry.5,6 Physicians who spend more time with reps are less likely to prescribe rationally.”7
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5. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283:373–380. [PubMed]

6. Reviews: What impact does pharmaceutical promotion have on behavior? Drug Promotion Database. Available at: http://www.drugpromo.info/read-reviews.asp?id=4. Accessed 29 April 2004.

7. Figueiras A, Caamano F, Gestal-Otero JJ. Influence of physician’s education, drug information and medical-care settings on the quality of drugs prescribed. Eur J Clin Pharmacol. 2000;56:747–753. [PubMed]

The American Journal of Bioethics, 2003, Volume 3, Number 3
Large or Small, a Gift Is a Gift Is a Gift. By: Dr. John J. Paris, S.J., Ph.D.
“The purchase of physicians’ behavior with the dispensing of gifts is not *de minimis [*too trivial or minor to merit consideration, especially in law]. Nor ought the behavior continue to be thought of us such.
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Family Practice, 2009; 26: 169–170.
Pharmaceutical representatives do influence physician behaviour. By: Dr. Gwyn Harris, M.D.
“It is a not a truth universally acknowledged that pharmaceutical representatives influence physician behaviour. However, the pharmaceutical industry clearly believes they do…This study adds to our knowledge of the subject and reminds us that there is no such thing as a free lunch; these visits really do result in increased sales.”
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Food and Drug Law Journal, 2010, Vol. 65, No.1; pages 141-157
Mirror, Mirror on the Wall—Evaluating Fair Market Value for Manufacturer-Physician Consulting Arrangements. By: Fred Eaton and Jaimee Reid
These cases show the abusive practices that Medical companies engage in that are often disguised as consulting contracts, royalty agreements, or gifts.
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1. The DOJ [Department of Justice] alleged that Medtronic made kickbacks such as inequitable consulting and royalty agreements; trips for doctors, their spouses and families; meetings at lavish venues and company-sponsored adult entertainment… Medtronic denied any wrongdoing but was accused of paying kickbacks to physicians to induce physicians to select Medtronic’s products… As part of this settlement, Medtronic paid $40 million as part of the settlement and signed a five-year CIA. [Corporate Integrity Agreement]
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2. The U.S. Attorney’s Office for the District of New Jersey conducted an industrywide investigation of orthopedic companies and physician consultants. As a result, the U.S. Attorney’s Office entered to parallel settlements with five companies that made up for nearly 95 percent of the market in hip and knee surgical implants. All five major medical device manufactures settled with the government over federal fraud and abuse claims…The suits alleged that the companies had inappropriately paid physician consultants millions of dollars. As a part of the settlement, the companies agreed to pay $311 million to settle the Anti-Kickback Statute and the False Claims Act allegations.
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U.S. Attorney Christopher J. Christie
“This industry routinely violated the anti-kickback statute by paying physicians for the purpose of exclusively using their products…we expect doctors to make decisions based on what is in the best interests of their patients – not the best interests of their bank accounts.”

Gary Heuer, Special Agent in Charge of the HHS-OIG in New York
“Patients in federal health care programs deserve the best available treatment from physicians and surgeons without the corrupting influence of kickbacks…”

Journal and Proceedings of the Northern Ireland Ethics Forum, 2008; 5, pages 42-49.
Ethical concerns regarding misleading drug promotion/marketing by the pharmaceutical industry
By: Ayomide Esan & Petr Mansfield
“The selective use of information presented to physicians reduces their ability to make weighted decisions based on all the available evidence, resulting in sub optimal usage of potentially useful drugs…and is most often due to confirmation bias resulting from the conflict of interest involved in evaluatory studies on drugs, sponsored by the pharmaceutical companies which produce them…For the time being, the onus remains on healthcare professionals to ensure that when educating themselves on pharmaceutical products, they only make use of objective sources, among which promotional materials from the pharmaceutical industry cannot in good conscience be counted.”
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Health Economics, Policy and Law, 2012, Volume 7; Issue 02: pp 175-195
Pharmaceutical lobbying under postcommunism: universal or country specific methods of securing state drug reimbursement in Poland? By: Ozierański et al.
“…Sometimes, when I listen to acknowledged professors singing praises of a medicine during a meeting organised by the firm, I keep saying to myself: ‘Gosh, I would never sell myself like this for any money.’ ’’
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The Guardian, September 23, 2011, “Cambridge University report finds pharmaceutical firms pay doctors to use their products”

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PLoS Medicine, 2011, 8(4): e1000431.
Strategies and Practices in Off-Label Marketing of Pharmaceuticals: A Retrospective Analysis of Whistleblower Complaints. By: Kesselheim et al.
This study stated that Pharmaceutical manufacturers encouraged: “off-label use through direct financial incentives to physicians… Lavish gifts or honoraria were mentioned in most complaints (35/41, 85%), with many whistleblowers reporting strategies to target these gifts to physicians who were high off-label prescribers (18/41, 44%). In some cases, physicians might be invited to serve in focus groups or as consultants to the manufacturer…not to obtain expert advice, but to provide money to prescribers to positively reinforce off-label use.”
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The New York Times Dr. Drug Rep, November 25, 2007, By. Dr. Daniel Carlat, M.D.
“…one recent study indicates that at least 25 percent of all doctors in the United States receive drug money for lecturing to physicians or for helping to market drugs in other ways.”
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media-medical-propagandaMedia Medical Propaganda

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last-week-tonight-with-john-oliver_%20marketing-to-doctors-hboMarketing to Doctors

gifts-to-doctors-from-big-pharma-are-commonGifts to doctors from big pharma are common

pharmaceutical-companies-influence-education-with-gifts-and-fundingPharmaceutical companies influence education with gifts and funding

prescriptions-are-not-the-answerPrescriptions are not the answer

people-just-take-too-many-pillsPeople just take too many pills

pharmaceutical-sales-rep-tacticsPharmaceutical Sales Rep Tactics

dr-peter-gotzsche-exposes-big-pharma-as-organized-crimeDr Peter Gotzsche exposes big pharma as organized crime

fda-approval-is-often-based-on-conflicts-of-interestFDA approval is often based on conflicts of interest

doctors-are-heavily-marketed-toDoctors are heavily marketed to

doctors-are-unduly-influenced-by-pharmaceutical-companiesDoctors are unduly influenced by Pharmaceutical companies