Minnesota Limit on Gifts to Doctors May Catch On

There are bagels and fruit in the morning, sandwiches at lunch, fresh cookies in the afternoon and an occasional restaurant dinner, but many of the doctors who routinely accept these goodies from pharmaceutical sales representatives say they see sales people for the educational messages they bring, not the food.

Maybe doctors in Minnesota are different.

Two years after Minnesota officials forbade drug makers to give doctors more than $50 worth of food or other gifts per year, drug company sales representatives there are having a far harder time marketing to doctors. The rule change was small and almost accidental — a state official decided to interpret a 1993 law differently from his predecessor. But the effect on drug makers has been profound.

The year after the change, the number of visits that Minnesota primary care doctors accepted from drug sales representatives decreased at about twice the rate of the decline reported by primary care doctors nationwide, according to a survey by ImpactRx, a New Jersey firm that tracks pharmaceutical marketing. A growing number of Minnesota hospitals and clinics have banned routine visits from them.

“We have an extended hallway, and the sales reps sit there now without anything except maybe Styrofoam cups filled with M&Ms. The 30 pizzas are gone,” said Dr. Michael Severson, a pediatrician in Brainerd, Minn. “It’s made the doctors think about whether to ban them.”

A 1997 study found that medical students saw gift-bearing drug sales representatives as helpful while viewing with suspicion those without gifts. This experiment is now being played out statewide in Minnesota.

Leslie Pott, a spokeswoman for AstraZeneca, said the company provided “modest meals” to doctors because “given a physician’s demanding clinical schedule, the most efficient time for doctors and medical staff to meet with representatives is often during lunch hour.”

“We believe it is important that physicians have access to the latest information on our drugs,” Ms. Pott said.

She would not comment on Minnesota’s food limit or its effect on her company.

Minnesota also requires drug makers to report all consulting payments made to doctors. Maine, Vermont and West Virginia have passed similar registry requirements, at least a dozen other states are considering them and Congress is considering a national one.

But no other state has adopted Minnesota’s limit on free food. That could change.

New Jersey’s attorney general, Anne Milgram, who announced on Sept. 18 the creation of a task force to examine ways to limit the gifts and money that drug and device makers give doctors, said in an interview that she planned to look closely at Minnesota’s food limit.

“When you see a doctor, you should have confidence that the advice you get is based on what’s best for you and not on some financial incentives or gifts that the doctor is getting,” Ms. Milgram said.

The interest in legislation to register or limit the food, gifts and money that drug and device makers lavish on doctors stems from growing concerns that these benefits lead doctors to prescribe more, and more expensive, drugs and devices, raising the costs of health care and changing care to patients.

Few studies have shown that patients are harmed when their doctors accept gifts or money from drug makers, in part because data comparing the prescribing trends of doctors who accept money and gifts with those who do not have for years been available only to drug makers, not to the public.

In one of the few public analyses of the prescription patterns of doctors, The New York Times found that Minnesota psychiatrists who received money from makers of atypical antipsychotics tended to prescribe the drugs to children the most often despite the profound risks from these drugs.

Drug makers have long argued that buying modest meals for doctors is simply a courtesy that allows doctors to take a moment out of their busy schedules to learn about medicines. Most doctors dismiss the notion that they can be influenced by food.

But the Minnesota experience suggests otherwise.

Dr. Samuel Carlson, chief medical officer of Park Nicollet Health Services, one of Minnesota’s largest private health systems, said that many of his system’s 20 clinics began asking to bar sales representatives after the food limit went into effect. Park Nicollet is considering further systemwide restrictions on sales representatives, Dr. Carlson said.

SMDC Health System of Duluth, Minn., a nonprofit system of 17 clinics and four hospitals, forbids drug sales representatives to make unannounced visits or provide free drug samples, gifts or food. By the end of the year, the system will place strict limits on consulting relationships between its 450 doctors and drug makers.

“No matter how you look at it, we’re all influenced by these marketing activities,” said Dr. Carl Heltne, chief medical officer for SMDC. “But patients come to us and they trust us to make decisions solely on their behalf. To uphold that trust, we can’t have even a perception that companies influence us.”

Michael Clements, the owner of a food-catering business in St. Paul, said the new rules had been disastrous for him. His business of taking lunches, paid for by drug makers, to doctors’ offices all but disappeared after the rule change, cutting his overall sales by two-thirds, Mr. Clements said.

Food has long been a pillar of drug makers’ marketing efforts. In data collected by the state of Vermont, drug makers spent nearly $778,000 last year buying food for Vermont doctors.

Food has not entirely disappeared from the marketing efforts of drug makers in Minnesota. The companies still rent out private dining rooms in restaurants and still hire influential doctors to deliver educational talks about drugs during dinner. But instead of doctors, the companies now invite nurses and secretaries to dine, drink and listen.

Sue Bikke, a geriatric nurse in St. Paul, said she was delighted when she and her nursing colleagues suddenly started receiving invitations to free meals — wine and cocktails included — at the area’s best restaurants.

“I don’t go to those places normally because they’re way too expensive for me,” Ms. Bikke said. “I’m so grateful that nurses are starting to get all these perks.”

Ms. Bikke said that many of her nursing colleagues were puzzled to receive these dinner invitations since they cannot prescribe drugs. But the nurses and secretaries may be ancillary to the companies’ principal target: the speakers at these events.

Those delivering the talks get training that involves learning drug makers’ most important marketing messages. And they receive anywhere from $500 to $5,000 for each talk they give, with some doctors earning more than $100,000 annually.

“This is the companies’ way of thanking high prescribers,” said David J. Rothman, president of the Institute on Medicine as a Profession at Columbia University. “Drug companies don’t really care who’s in the audience.”

When asked whether drug makers’ motivation for hiring doctors to educate secretaries may be to influence them instead of the secretaries, many doctors said they had never thought of that.

“That’s a good question,” answered Dr. Kent G. Brockmann, a psychiatrist from the Twin Cities, who earned more than $16,000 from 2003 to 2005 doing educational talks for drug makers. “Maybe they’re trying to keep me loyal to those drugs.”

Still, nearly all said that they were not influenced by the money they earned giving the talks