How You Pay for Your Doctor's Free Lunch

Your fate may depend on how well your doctor likes a free ham sandwich.

In the United States, the Open Payments program has tracked payments to physicians from drug companies. To no one's surprise, studies have found that doctors who receive consulting payments of US $2000 or more per year from drug companies tend to prescribe brand-name medications made by those companies. However, it doesn't take $2000 to change a doctor's opinion. A team of researchers from the University of California at San Francisco and the University of Hawaii have found that as little as a free lunch seems to encourage doctors to prescribe drugs made by the company that pays for the lunch.

267,669 Doctors Can Be Wrong

The research team analyzed industry data from the Open Payments program for 267,669 doctors in the United States. This data base identifies American doctors who receive payments from pharmaceutical companies, and how much they receive. The researchers compared payment data against prescriptions for patients receiving Medicare Part D, a prescription insurance option that can be purchased by Americans who are on Medicare.

Data analysis revealed that the 267,669 doctors in the program received 65,234 payments from drug companies, but 95 percent of those payments were for $20 or less, typically in the form of a free meal served at a seminar about a new medication. The researchers only studied doctors who wrote more than 20 prescriptions a year for a given brand-name drug, and only brand-name drugs that have been on the market for 5 years or more for which less expensive generic drugs are available. Then the researchers calculated how many lunches were necessary to persuade doctors to prescribe the more expensive but functionally equivalent medications.

The Relationship of Small Incentives to Prescriptions of Four Common Medications

One of the medications studied was Crestor, the cholesterol-lowering medication that is now available as generic rosuvastatin. When doctors didn't attend any luncheon seminars at all, Crestor accounted for on average 8 percent of all their prescriptions for statin drugs. When doctors attended at least one luncheon sponsored by the makers of Crestor, that figure jumped to 12 percent. When doctors were able to grab lunch and listen to a spiel about Crestor three times, the prescription rate increased to 14 percent, and for four lunches, the rate was 16 percent.

Another of the medications studied was Bystolic, which is available as a generic called nebivolol. This drug is a cardioselective beta-blocker. It lowers blood pressure by reducing nerve activity in the heart without as affecting nerve activity in other parts of the body. When doctors had not attended any lunch seminars sponsored by the maker of the drug, they prescribed it just 3 percent of the time when they prescribed any beta-blocker drug. If they had attended one lunch seminar, they prescribed it 8 percent of the time. If they had attended four lunch seminars, they prescribed it 16 percent of the time. That's a five-fold increase in prescriptions for the price of four sandwiches.

Can You Trust a Doctor Who Likes to Get a Free Lunch?

The researchers found similar trends for two other drugs they studied, Benicar (olmesartan), a drug for lowering blood pressure that doesn't cause dry cough like some other drugs in its class, and Pristiq (desvenlefaxine), a treatment for anxiety that is also the first non-hormonal treatment for hot flashes in menopause. Four sponsored meals was associated with a 400 percent increase in the rates of prescribing Benicar, and three free meals was associated with a 500 percent increase the rates of prescribing Pristiq. (A fourth meal was associated with lower rates of prescribing Pristiq, just a 300 percent increase from baseline.) For all four commonly prescribed drugs, for tens of thousands of doctors, eating a free lunch was associated with a greater likelihood of prescribing an expensive drug.

How much difference does this make for patients? In the US, if you are insured, a generic drug may be available for free or with a low ($2 to $20) copayment. If you are not insured, or if you are in the "gap" of your Medicare coverage, you may have to pay a great deal more for a brand-name drug than you would have to pay for a generic drug.

• A 30-day supply of Crestor costs $194 to $231, depending on where you buy it and whether your doctor can give you a discount coupon, but the same amount of generic rosuvastatin costs about $60. For Crestor and for most other drugs, lower prices can be found at mail order pharmacies or Canadian pharmacies, but not without risk of getting something other than the medication your doctor prescribed.
• A 30-day supply of Bystolic costs $130 to $150 if you have to pay cash, but the same amount of generic nebivolol costs $65 to $81.
• A 30-day supply of Benicar costs $227 to $264, but a 30-day supply of its generic equivalent olmesartan and hydrochlorothiazide costs $64 to $117.
• A 30-day supply of Pristiq costs $298-$350, while a 30-day supply of the generic venlefaxine costs $11-$13 with a coupon.

If you are paying for medications out of pocket, your doctor's free lunch can cost you a great deal of money, thousands of dollars per year. To be fair, there is no certain evidence that doctors prescribe these drugs out of any kind of gratitude to the drug company for a free lunch. It could be that they prescribe these drugs for the simple reason that the brand name comes to mind more quickly than the generic name after they have spent an hour with the drug salesperson. However pure the motives of the doctors in writing their prescriptions however, it is the patients who pay for the doctor's free lunch.

It never hurts to check out just how much money your doctor receives from drug companies from the Open Payments database. There's a link to the database posted below. Chances are that your doctor is in the 91 to 99 percent of doctors who each year receive payments of $100 or less, and there is very, very little chance of your doctor's professional integrity being compromised. If something seems a little strange about the way your doctor is prescribing drugs, however, check the database, and then don't be afraid to get a second opinion.