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Most US neurologists prescribing drugs for multiple sclerosis (MS) receive pharmaceutical industry payments, and those that do are more apt to prescribe that company’s drugs, especially if the payments involved are larger, sustained, and recent, a new analysis of Medicare data showed.

What was “somewhat striking” was how highly concentrated the payments were, lead author Ahmed Sayed, MD, with Ain Shams University, Cairo, Egypt, and Rochester General Hospital, Rochester, New York, told Medscape Medical News.

While the average industry payment per neurologist was $779, the top 10% of prescribers amassed nearly $156 million, suggesting that companies selectively target high-volume prescribers, Sayed explained.

“There was also a pretty clear association between payments and prescriptions — the more you prescribed, the more payments you received,” he said.

The study was published online on August 26 in BMJ Open.

Payments To Doctors Still Big Business?

MS is a leading cause of neurologic disability in young adults, requiring lifelong treatment with immunomodulatory drugs.

Brand-name disease-modifying therapies (DMTs) for MS are relatively expensive, with annual average costs per US DMT user ranging from about $57,000 to $93,000. As a result, MS drug prescriptions are Medicare’s largest neurologic drug expense, despite accounting for a relatively small portion of total claims. 

Using the Centers for Medicare and Medicaid Open Payments platform, investigators analyzed payments made by drug companies to neurologists from 2015 to 2019.

Their analysis included 7401 neurologists who had prescribed DMTs for at least 1 year and wrote a minimum of 11 prescriptions. They focused on 20 DMTs manufactured by 10 companies.

Between 2015 and 2019, 5809 (78.5%) neurologists received 626,290 distinct industry payments from at least one drug company, totaling $163.6 million. More than two thirds of neurologists (67.5%) received payments from two or more companies.

Higher prescription volume was associated with a greater likelihood of receiving payments, particularly for consulting services, nonconsulting services (such as speaking at an event), and travel or accommodation.

The amount of payment received was positively associated with prescription volume. Compared to neurologists who didn’t receive any payments from a drug company, those who did were 13% more likely to prescribe that company’s drug.

“Payments are preferentially going to high-volume prescribers, and these payments may have some modest-to-moderate impact on a physician’s prescriptions, though the latter can’t be definitively demonstrated by our study,” Sayed said.

Larger payments, longer durations of payments, and more recent payments were all associated with greater odds of prescribing a company’s drug.

“These findings raise concerns about excess pharmaceutical promotion efforts and their implications for physician prescribing for patients,” the researchers wrote.

“Promotional efforts to influence prescribing are especially concerning given the drugs’ substantial costs, particularly if more expensive brand-name drugs are being prescribed instead of appropriate, effective, generically available alternatives,” they added.

Is Transparency Failing?

The Physician Payments Sunshine Act of 2010, which led to the creation of the Open Payments database, was a step forward in making transparent the financial conflicts of interest among physicians receiving industry payments.

“However, it remains unclear whether increased transparency has mitigated these conflicts of interest and their impact on prescribing behavior or [has] simply given the public greater insight into the large scale of industry payments made to prescribers,” the researchers wrote.

The investigators cautioned that this was an observational study, and no firm conclusions can be drawn about cause and effect. 

Also, the study was limited to the prescribing of Part D-covered drugs and could establish neither the appropriateness of prescribing nor for which patients the more expensive brand-name drugs were most suitable.

“It’s difficult to be completely certain as to whether payments influenced prescriptions. Given this is an observational study, all we can do is demonstrate associations,” Sayed said. 

“We did see that physicians who got paid from a given company tended to prescribe more of its drugs (as a percentage of that physician’s total MS prescriptions). And we did see positive associations between prescriptions of drugs belonging to a given company and the amount of payments, their frequency, and their duration,” he noted.

How Payments May Shape Care

Industry payments to physicians isn’t limited to neurologists. As previously reported by Medscape Medical News, a 2024 analysis of the Open Payments database revealed that US physicians received $12.1 billion from pharmaceutical and medical device companies between 2013 and 2022.

That analysis showed that orthopedists received the largest amount of payments in aggregate, ie, $1.3 billion, followed by neurologists and psychiatrists at $1.2 billion and cardiologists at $1.29 billion.

“It’s well established that physicians respond to incentives. Frequent interaction with a benefactor can also make that benefactor’s products more salient,” said Adam C. Powell, PhD, president of Payer+Provider Syndicate, a healthcare consulting firm in Boston, who commented on the new findings for Medscape Medical News.

“In this context, the authors of this study have confirmed what legislators have long understood: Payments to physicians have the potential to shape care. While not surprising, they provide a helpful confirmation that this issue still exists even in an era of transparency,” said Powell, who was not part of the research.

He noted that while transparency under the Physician Payments Sunshine Act was a first step, several states have gone further. 

“In 2009, Vermont banned most payments from pharmaceutical companies to physicians. That same year, Massachusetts enacted restrictions that were narrower but in the same spirit,” Powell told Medscape Medical News.

The study received no specific funding. Sayed and Powell declared having no relevant disclosures.