If you’re a cancer patient receiving a blockbuster drug, how much should the pharmaceutical company pay your oncologist to prescribe that drug?
What if you want to do something about your obesity and all its emerging complications? How much should big pharma pay your endocrinologist to prescribe a weight-loss drug?
Or take something even more ubiquitous such as high blood pressure and cholesterol: of hundreds of brands to choose from, what prompted your cardiologist to prescribe the ones you take? Could it be money?
In all these cases, you would hope the only factor in decision-making was straightforward: the specialist paired the right drug with the right patient and called it a day. It is also what every specialist wants to believe.
But when money influences so many decisions, why not pharmaceutical prescribing?
This is an old conundrum with new updates, the latest of which comes from Australian researchers.
Big pharma has long used payments to doctors to advertise its products. The payments are in the form of consultancy fees, advisory board meetings, educational sponsorship and coverage of travel, accommodation and entertainment.
In 2016, Medicines Australia, the peak body representing the biggest names in the pharmaceutical industry, mandated reporting of payments to doctors. It took some years (and a lot of courage) to subsequently launch an online repository to disclose the payments although only for three years from the date of first publication and excluding food, beverage and the broad term of “research”.
In the three years between 2019 and 2022 (coinciding with the peak of Covid when the world had hunkered down), 6,504 doctors (4.9% of all registered doctors in Australia) received at least one drug company payment. The payments ranged from $30 to $300,000 with the median payment being $1,500. The total tab was over AU$33m.
The specialists leading the list were haematology/oncology ($6m); cardiology ($3m) and endocrinology ($2m).
There will be no sympathy for the neurosurgeons (we don’t have data on how device companies woo them) and medical administrators at the bottom of the list, but spare a thought for the harried emergency doctors caught in the crosshairs of abusive patients with no monetary frills to make up for it.
Why does big pharma pay doctors?
A reasonable explanation is that big business is compensating doctors for time which would otherwise be spent earning an income elsewhere. Doctors maintain that consultancy and advisory board roles provide an “in” when it comes to patient access to drugs and clinical trials.
But what does the evidence show?
A systematic review funded by the US National Cancer Institute found that drug company payments to doctors had a consistent association with increased prescribing of the paying company’s drug, increased prescribing costs and increased prescribing of branded drugs. However, such observational studies do run the risk of bias.
Economists say that when a drug company pays a doctor it deems an influencer there is a spillover effect on the peers of that doctor. What is even more concerning is that payments increase prescriptions to both recommended and contraindicated patients.
When it comes to patient care, it is not apparent to me that doctors with “access” to drug companies serve their patients any better. And if they can achieve compassionate access to an otherwise unaffordable drug or obtain exclusive access to a new, yet unapproved therapy, it raises an important question of healthcare ethics.
Would you want your doctors to stay at arm’s length from drug company payments and rely on independent sources of information or have them view payments as incidental and unrelated to prescribing behaviour?
Despite a lot of hand-wringing and some regulation, the group most opposed to the idea that drug company payments affect prescribing behaviour are doctors who refuse to believe that even small gifts like pens and Post-it notes with branding have an insidious impact. This is because, in the end, we are all human and want to reciprocate perceived generosity.
The Pharmaceutical Benefits Scheme (PBS) is a taxpayer-funded gift to Australians.
So why doesn’t the public say something?
Because doctors retain enormous trust in society and the transactions happen outside public scrutiny. As a patient, I would be loath to even consider the idea that my doctor was being influenced by anything other than my best interest. When neither the patient nor society feels the impact of drug company payments to a few doctors, it seems safer to ignore the problem.
But the truth is that every payment matters. Each time a doctor prescribes a drug that is unnecessary or suggests a brand that is more expensive than the alternative, the cost is borne by the taxpayer. Every dollar misspent on health is a dollar not spent on housing, education or transportation.
Where hospitals and regulators have chosen to tread lightly, big pharma and individual doctors have used their discretion to behave as they see fit. To be clear, not all interactions are problematic but what constitutes problematic is highly subjective.
Interestingly, when I have written such columns in the past, I have heard from pharmaceutical industry professionals who attest to a problem and report feeling conflicted. I have yet to meet a doctor who accepts money and thinks there could be a problem.
Which makes me think that the solution to big pharma payments to doctors requires external oversight because it won’t be enough to say, “physician heal thyself”.
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is Every Word Matters: Writing to Engage the Public
