Abstract
This case study analysis assesses the nature and extent of pharmaceutical industry payments to nonphysician clinicians in Australia and investigates the possible reasons for sponsorship.
Payments from pharmaceutical companies to physicians are pervasive and associated with poorer-quality prescribing and increased health care costs.1 Little is known about payments to nonprescribing clinicians, despite their vital role in patient care, medication management, and health care administration.2 Assumptions persist among clinicians and policy makers that marketing to nonphysicians is inconsequential because they do not prescribe3; however, emerging evidence suggests that nurses and pharmacists frequently interact with sales representatives.2
Australia’s pharmaceutical industry has a self-regulatory system of transparency reporting overseen by the pharmaceutical trade organization Medicines Australia. Since October 2015, companies have reported payments to all health care professionals, including nonphysicians. We assessed the nature and extent of payments to nonphysician clinicians and investigated the possible reasons for sponsorship through a case study analysis of highly paid recipients.
Methods
We downloaded 168 Payments to Healthcare Professionals reports from October 1, 2015, to April 30, 2018, from the Medicines Australia website and cleaned (to resolve inconsistencies in names of health care professionals and payment descriptions across different reports) and compiled the reports into a database. We matched recipient names with registered health care professionals in the Australian Health Practitioners Regulation Agency’s Register of Practitioners. This study was exempt from ethical review according to the guidelines of the University of Sydney Human Research Ethics Community, as the data were publicly available.
We included payments to physicians; nurses and midwives (combined in the category nurses); pharmacists; physiotherapists, exercise physiologists, and occupational therapists (combined in the category physiotherapists); psychologists, social workers, and counselors (combined in the category psychologists); dietitians and nutritionists (combined in the category dietitians); and other clinicians (eg, podiatrists and optometrists). We excluded payments to nonclinicians, payments reported in aggregate, and payments totaling less than AUS$10.
We calculated descriptive statistics on payment characteristics. Purpose of payment was determined from 2 variables: type of service and type of event. We identified companies with total payments of more than AUS$1 million and selected the company with the greatest proportion of spending for each nonphysician profession. We then identified the 5 individuals from that profession who received the highest payments from the corresponding company. Two of us (E.A.K. and Q.G.) independently searched online and used a predefined coding scheme to extract professional information including clinical role; therapeutic focus; and involvement in research, professional organizations, and patient groups.
Results
Nonphysicians accounted for 22.1% of recipients (3104 of 14 018) and 16.1% of payments (6351 of 39 327) but only 10.0% (AUS$6 261 086 of AUS$62 695 095) of spending. Nurses and pharmacists were the primary nonphysician recipients; nurses received AUS$5 185 604 (8.3% of total spending) and pharmacists received AUS$654 241 (1.0% of total spending) (Table 1). A total of 75.9% of payments to nurses and pharmacists (4557 of 6007) supported meeting attendance (vs 57.3% to physicians [18 890 of 32 979]), whereas speaker and advisory board engagements accounted for more than half of payments to psychologists (66 of 111 [59.5%]) and dietitians (42 of 65 [64.6%]).
Table 1. Characteristics of Payments to Health Care Professionals by Profession.
| Characteristic | No. (%) | |||||
|---|---|---|---|---|---|---|
| Physicians | Nurses | Pharmacists | Physiotherapists | Psychologists | Dietitians | |
| No. of payments (total = 39 327)a | 32 979 (83.9) | 5310 (13.5) | 697 (1.8) | 151 (0.4) | 111 (0.3) | 65 (0.2) |
| Reason for paymentb,c | ||||||
| Educational meeting attendance | 18 890 (57.3) | 4040 (76.1) | 517 (74.2) | 73 (48.3) | 37 (33.3) | 17 (26.2) |
| Educational meeting speaker or chairperson | 9504 (28.8) | 634 (11.9) | 73 (10.5) | 45 (29.8) | 54 (48.7) | 31 (47.7) |
| Advisory board or committee member | 3328 (10.1) | 476 (9.0) | 85 (12.2) | 21 (13.9) | 12 (10.8) | 11 (16.9) |
| Consulting services | 1251 (3.8) | 158 (3.0) | 22 (3.2) | 12 (8.0) | 8 (7.2) | 6 (9.2) |
| Total cost (total = 62 695 095), AUS$a | 56 437 514 (90.0) | 5 185 604 (8.3) | 654 241 (1.0) | 170 233 (0.3) | 174 011 (0.3) | 60 528 (0.1) |
| Travel and accommodationb | 33 229 899 (58.9) | 3 735 666 (72.0) | 405 285 (61.9) | 89 917 (52.8) | 72 088 (41.5) | 19 714 (31.2) |
| Service or consulting feesb | 20 270 096 (35.9) | 979 567 (18.9) | 173 156 (26.5) | 72 475 (42.6) | 90 720 (52.1) | 39 762 (65.7) |
| Registration feesb | 2 937 518 (5.2) | 470 371 (9.1) | 75 800 (11.6) | 7841 (4.6) | 10 999 (6.3) | 1880 (3.1) |
| Cost per payment median (IQR), AUS$ | 900 (567-1530) | 650 (375-1008) | 717 (521-1091) | 846 (500-1143) | 909 (550-1935) | 643 (364-1200) |
| No. of persons (total = 14 018)a | 10 915 (77.9) | 2491 (17.8) | 413 (2.9) | 80 (0.6) | 62 (0.4) | 44 (0.3) |
| No. of payments per personb,d | ||||||
| 1 | 5407 (49.5) | 1529 (61.4) | 286 (69.2) | 56 (70.0) | 43 (69.4) | 34 (77.3) |
| >5 | 1334 (12.2) | 169 (6.8) | 11 (2.7) | 4 (5.0) | 3 (4.8) | 1 (2.3) |
| Cost per person median (IQR), AUS$ | 1263 (664-3784) | 900 (575-1830) | 995 (642-1728) | 1037 (560-2021) | 1170 (526-2404) | 706 (348-1045) |
Abbreviation: IQR, interquartile range.
Percentages do not sum to 100 because payments to other health care professionals are not shown.
Reported percentages are column percentages.
Percentages for physicians and nurses do not sum to 100 because payments for participation in market research or unspecified purposes are not shown.
Percentages do not sum to 100 because the numbers of health care professionals receiving 2 to 5 payments are not shown.
The top contributing companies were Biogen (nurses and physiotherapists), Gilead (pharmacists), and Shire (psychologists and dietitians). Table 2 summarizes the characteristics of the 5 most highly paid individuals from each profession. Most of these individuals were involved in chronic disease management, practiced in hospitals (16 of 25 [64.0%]), held positions of clinical seniority (24 of 25 [96.0%]), participated in research (18 of 25 [72.0%]), or were influential in professional organizations (15 of 25 [60.0%]).
Table 2. Professional Characteristics of the 5 Most Highly Paid Individuals From Each Profession by Top Contributing Companiesa.
| Characteristic | Nurses (n = 5) | Pharmacists (n = 5) | Physiotherapists (n = 5) | Psychologists (n = 5) | Dietitians (n = 5) |
|---|---|---|---|---|---|
| Therapeutic areas (No.) | Multiple sclerosis (4), pediatric neuromuscular disorders (1) | HIV and hepatitis (4), oncology (1) | Pediatric neuromuscular disorders (5) | Eating disorders (3), ADHD (1), inflammatory bowel disease (1) | Parenteral nutrition (4), general and sports medicine, and bariatric surgery (1) |
| Clinical practice location: hospital | 5 | 2 | 4 | 1 | 4 |
| Clinical seniorityb | 5 | 5 | 4 | 5 | 5 |
| Leadershipb,c | 1 | 1 | 1 | 4 | 2 |
| Research involvementc | 4 | 3 | 3 | 4 | 4 |
| Leadershipc | 3 | 0 | 2 | 4 | 3 |
| University affiliation | 1 | 0 | 3 | 3 | 3 |
| Professor or associate professor | 0 | 0 | 0 | 2 | 1 |
| Professional organization influenced | 3 | 2 | 1 | 4 | 5 |
| Executive positiond | 2 | 0 | 0 | 2 | 2 |
| Consumer organization influenced | 2 | 1 | 1 | 3 | 0 |
| Executive positiond | 0 | 0 | 0 | 1 | 0 |
Abbreviations: ADHD, Attention-deficit/hyperactivity disorder; HIV, human immunodeficiency virus.
Biogen (nurses and physiotherapists), Gilead (pharmacists), and Shire (psychologists and dietitians).
Clinical seniority indicates advanced practice, specialist, consultant, sole private practice owner, or leadership. Leadership indicates manager; director; owner or founder of clinic, clinical institute, or pharmacy, or head of department.
Research involvement indicates publications, assisting in research studies, and leadership. Leadership indicates director of research group and clinical trial coordinator.
Influence indicates committee membership, consultancy, spokesperson roles, and executve position. Executive position indicates president or chair, vice president, secretary, or treasurer.
Discussion
Nonprescribing clinicians received substantial payments from pharmaceutical companies, although physicians were the primary recipients. Nonprescribers may be valued as “channels” with influence at multiple points in the chain leading from product to prescriber to patient,4 particularly as their scope of practice expands.5,6 Our analysis suggests that payments to nonphysicians may be associated with the promotion of recently subsidized, expensive medicines for the treatment of chronic diseases, particularly those requiring high adherence, such as Gilead’s HIV and hepatitis antivirals and Biogen’s multiple sclerosis immunotherapies. The data also suggest that nonphysicians may serve as thought leaders, broadening the traditional perception of that role beyond the academic physician.
Our data do not include all pharmaceutical companies, research-related payments, or product details associated with the payment. However, to our knowledge, this study provides the first comprehensive account to date of payments to nonphysicians. In contrast to the high scrutiny and regulation of physician-industry relationships, interactions with nonphysicians remain relatively hidden and unregulated. In light of the expanding roles of nonphysicians in chronic disease and medication management, our findings suggest there is an urgent need to extend mandatory transparency reporting and institutional policies to all health care professionals.
References
- 1.Yeh JS, Franklin JM, Avorn J, Landon J, Kesselheim AS. Association of industry payments to physicians with the prescribing of brand-name statins in Massachusetts. JAMA Intern Med. 2016;176(6):763-768. doi: 10.1001/jamainternmed.2016.1709 [DOI] [PubMed] [Google Scholar]
- 2.Grundy Q, Bero L, Malone R. Interactions between non-physician clinicians and industry: a systematic review. PLoS Med. 2013;10(11):e1001561. doi: 10.1371/journal.pmed.1001561 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Grundy Q, Bero LA, Malone RE. Marketing and the most trusted profession: the invisible interactions between registered nurses and industry. Ann Intern Med. 2016;164(11):733-739. doi: 10.7326/M15-2522 [DOI] [PubMed] [Google Scholar]
- 4.Applbaum K. Getting to yes: corporate power and the creation of a psychopharmaceutical blockbuster. Cult Med Psychiatry. 2009;33(2):185-215. doi: 10.1007/s11013-009-9129-3 [DOI] [PubMed] [Google Scholar]
- 5.Institute of Medicine The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. [PubMed] [Google Scholar]
- 6.Giberson S, Yoder S, Lee M Improving patient and health system outcomes through advanced pharmacy practice: a report to the US Surgeon General 2011. Office of the Chief Pharmacist, US Public Health Service. https://www.accp.com/docs/positions/misc/improving_patient_and_health_system_outcomes.pdf. Published December 2011. Accessed February 12, 2019.