Understanding the Nature and Extent of Pharmaceutical Industry Payments to Nonphysician Clinicians

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.

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.

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%]).

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%]).

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.

Accepted for Publication: March 25, 2019.

Corresponding Author: Lisa Bero, PhD, Charles Perkins Centre (D17), School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia (lisa.bero@sydney.edu.au).

Published Online: June 10, 2019. doi:10.1001/jamainternmed.2019.1371

Author Contributions: Dr Karanges had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Karanges.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Karanges.

Supervision: Grundy, Bero.

Conflict of Interest Disclosures: Dr Grundy reported receiving grants from the Canadian Institutes of Health Research during the conduct of the study. No other disclosures were reported.

Additional Contributions: Alice Fabbri, MD, PhD, Jane Williams, PhD, Lisa Parker, MD, PhD, and Barbara Mintzes, PhD, The University of Sydney, worked on the initial data set (updated for this study; initial extract available at: doi:10.4227/11/59d551c49233a). Stephanie Beshara, BPharm, The University of Sydney, collected the preliminary data. The contributors did not receive compensation outside of their normal employment.