When doctors accept meals from pharmaceutical salespeople, they are much more likely to prescribe the drugs the representatives are promoting than cheaper generic alternatives, UC San Francisco researchers found in a study published online June 20, 2016, in JAMA Internal Medicine.

Researchers said this marketing strategy may be leading to higher out-of-pocket costs for patients, since brand-name drugs are not always covered by insurance to the extent that generic drugs are. Previous studies have linked generic drugs to better adherence, since many patients, particularly seniors, cannot afford brand-name drugs.

In the current study, the researchers found that physicians who received just one meal, costing less than $20 on average, were up to two times as likely to prescribe the promoted brand-name drugs as physicians who received no meals. Doctors who received multiple meals were up to three times as likely to do so.

“Whether a formal dinner or a brief lunch in a doctor’s office, these encounters are an opportunity for drug company representatives to discuss products with physicians and their staff,” said Adams Dudley, MD, MBA, professor of medicine and director of the Center for Healthcare Value at the Philip R. Lee Institute for Health Policy Studies at UCSF, and the senior scientist on the study. “The meals may influence physicians’ prescribing decisions.”

Working with Dudley, Colette DeJong, a UCSF medical student, and Thomas Aguilar, MS, a UCSF statistician, took the lead in designing the study, collecting and analyzing data and writing up the study results for publication.

“A lot of the financial burden of using brand-name drugs instead of generic drugs falls on the seniors enrolled in Medicare, who pay an average monthly co-pay of $40 to $80 for brand-name drugs, but only $1 for generics,” said DeJong.

The UCSF study was made possible by public disclosures of payments from manufacturers to physicians that have been required since August 1, 2013, under the Physician Payments Sunshine Act, which is part of the Affordable Care Act.

While recent studies have shown that doctors who receive large payments from drug companies, such as speaking fees or royalties, are more likely to prescribe expensive brand-name drugs, the new study is the first to find an association between single meals and the prescribing behavior of physicians.

Before examining industry payments, the UCSF researchers first identified physicians from the 2013 Medicare Part D Prescriber file who wrote more than 20 prescriptions in any of four common drug classes. These included statins to lower cholesterol levels; beta-blockers, most often used to treat high blood pressure; angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs), also used to treat high blood pressure; and selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), approved for treatment of depression.

The researchers identified the most-prescribed brand-name drug in each category: the statin rosuvastatin, the beta-blocker nebivolol, the ARB olmesartan, and the SNRI desvenlafaxine. They then identified physicians who received industry-sponsored meals promoting one of the drugs.

The 279,669 physicians selected from the Medicare database based on the prescribing criteria received 63,524 payments associated with the four target drugs. Ninety-five percent of payments were for meals, at an average cost of less than $20. Within each of the four classes of drugs, the researchers found physicians who received just one industry-sponsored meal were more likely to prescribe the drug the sales reps were promoting instead of cheaper, generic alternatives.

The design of the study, involving the examination of a cross-section of data over a single time frame, did not enable the researchers to conclude that the free meals caused physicians to prescribe the drugs that were being marketed, only that there was a strong association between the two events.

The generics in these drug classes are thought to be as effective as brand-name drugs, and many insurers limit coverage for the more expensive drugs that are still under patent. The Department of Veterans Affairs does not include any of these brand-name drugs on its formulary.

“Our data raises questions about current practices, but it’s also worth noting that there is not yet a standardized way to get drug information out to doctors,” Dudley said. “The FDA, Medicare, or insurers could set up alternative means of educating doctors about drug developments, but they haven’t done that yet. Given how much extra money they are spending on brand-name drugs, either Medicare or insurers would certainly see plenty of savings even if they were to pay the full cost of an educational program about when and how to use new drugs.”

Other UCSF contributors to the JAMA Internal Medicine study were Grace Lin, MD, MAS, Assistant Professor of Medicine, and W. John Boscardin, PhD, Professor of Epidemiology and Biostatistics. In addition, Chien-Wen Tseng, MD, MPH, Associate Professor of Family Medicine and Community Health at the University of Hawaii John A. Burns School of Medicine, contributed to the study.

Funding was provided by the National Center for Advancing Translational Sciences, National Institutes of Health, and by the Hawaii Medical Service Association Endowed Chair in Health Services and Quality Research at the University of Hawaii.

UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland – and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.