Author Affiliations: Department of Medicine, Harvard Medical School, Cambridge, Massachusetts (Drs Campbell, Vogeli, and Iezzoni); Mongan Institute for Health Policy, Massachusetts General Hospital, Boston (Drs Campbell, Pham-Kanter, Vogeli, and Iezzoni); and Edmond J. Safra Center for Ethics, Harvard University, Cambridge, and Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora (Dr Pham-Kanter).
Prescribing brand-name drugs when generic drugs are available generates unnecessary medical expenditures, the costs of which are borne by the public in the form of higher copayments, increased health insurance costs, and higher Medicare and Medicaid expenses.1,2 Pharmaceutical companies aim to stimulate patients' requests for brand-name medications and increase the likelihood physicians will honor such requests.3,4 Presently, little is known about how frequently physicians comply with such a request or the factors predicting this behavior.
The data come from a national survey of 3500 randomly sampled physicians in 7 specialties. Additional information on the sampling, survey administration, and analyses for this study are described at length in several other published articles.5- 7 Of the 3500 physicians in the original sample, 2938 were eligible for the survey (others were ineligible because they were on leave, not actively practicing, practicing in a nonsampled specialty, out of the country, or deceased). Of the remaining eligible physicians, 1891 participated in the survey, representing a 64% overall response rate.
The results of the multivariable analyses of prescribing behavior as a function of physician characteristics are given in the Table. The multivariable regression shows that 43% of physicians in practice more than 30 years sometimes or often give in to patients' demands for brand-name drugs compared with 31% physicians in practice for 10 years or less (P = .001). Among the various specialties, pediatricians, anesthesiologists, cardiologists, and general surgeons were significantly less likely to acquiesce to patient demands relative to internal medicine physicians (P < .001). Physicians working primarily in solo or 2-person practices were significantly more likely to acquiesce to patient demands than those working in a hospital or medical school setting (46% vs 35%; P = .04).
Two specific forms of industry relationships were associated with significant differences in the percentage of physicians who acquiesced to patient demands. More than a third who received free food and/or beverages in the workplace honored patient requests sometimes or often compared with those who had not received food and beverages (39% vs 33%; P = .003). Similar significant differences were found among those receiving drug samples (40% vs 31%; P = .005). Also, physicians who sometimes or often met with industry representatives to stay up to date were significantly more likely to comply with patients' demands than those who did not (40% vs 34%; P = .007).
Approximately 4 of 10 physicians report that they sometimes or often prescribe a brand-name drug to a patient when a generic is available because the patient wanted it. These numbers suggest that the unnecessary costs associated with this practice to the health care system could be substantial.
We found that certain physician-industry relationships were significantly, positively associated with accommodating patient requests for brand names. Physicians who received industry-provided food and/or beverages in the workplace and samples were significantly more likely to accede to patient demands for brand-name drugs. Also, physicians who meet with industry representatives to stay up to date are more like to give in to patient requests for brand names. These findings are likely the result of the fact that industry gifting of food and beverages coincides with “up-to-date meetings” with drug representatives; thus, these factors work together to increase the likelihood that physicians will prescribe a brand name and clearly serve a marketing function.
Potential interventions that could dramatically reduce this practice include having a closed health system (such as the Veterans Health Administration or Britain) that gives the pharmacy primary control over these decisions, with override capability for rare situations when it is necessary (eg, allergy to generic additive, idiosyncratic responses). Also, hospitals and health systems could consider policies that prevent individual physicians from receiving samples and instead require samples be given to a pharmacy or other appropriate office in a hospital or health system. Finally, payers such as Medicare or commercial insurers who are interested in increasing the use of generic drugs may consider banning physicians from accepting food and beverages in the workplace. Any potential interventions should be targeted toward older physicians, internists, and those in solo or 2-person practices.
Our study has several limitations. First, because of social desirability bias, our results likely represent a lower-bound estimate of the actual frequency of physicians prescribing brand-name drugs at the patients' requests. Second, we were unable to adjust the result for the frequency with which physicians were asked by patients fora specific brand-name drug. Finally, our study was not able to examine whether a brand-name drug was actually dispensed at the pharmacy, given that some states have laws that allow pharmacists to substitute a generic for a brand-name prescription.
Correspondence: Dr Campbell, Mongan Institute for Health Policy, Massachusetts General Hospital, 50 Staniford St, Ninth Floor, Boston, MA 02114 (firstname.lastname@example.org).
Published Online: January 7, 2013. doi:10.1001/jamainternmed.2013.1539
Author Contributions:Study concept and design: Campbell, Pham-Kanter, and Vogeli. Acquisition of data: Campbell. Analysis and interpretation of data: Pham-Kanter, Vogeli, and Iezzoni. Drafting of the manuscript: Campbell. Critical revision of the manuscript for important intellectual content: Campbell, Pham-Kanter, Vogeli, and Iezzoni. Statistical analysis: Pham-Kanter. Obtained funding: Campbell. Study supervision: Campbell.
Conflict of Interest Disclosures: None reported.
Funding/Support: This research was supported by a grant from the Institute on Medical Professionalism at Columbia University.
Role of the Sponsors: The funders had no significant role in the conceptualization, analyses or reporting of this manuscript.
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