The pharma industry, physicians and lawmakers have long engaged in a delicate dance around what constitutes appropriate gift-giving.
Lavish wining and dining, and even branded swag, are supposed to be relics of the past thanks to more stringent anti-remuneration and disclosure policies including the federal Anti-Kickback Statute, the federal Physician Payments Sunshine Act (which tracks industry payments to physicians) and ethics guidelines from organizations like the AMA and PhRMA. But the line between educating healthcare professionals and wooing them can still be fuzzy.
Rules vary by state and many ethics codes are voluntary. Plus, providing educational materials, like free textbooks, and offering “modest” meals in clinical settings or paying market-rate consulting fees are still generally permissible.
But even these more toned-down forms of gift-giving can negatively influence prescribing, according to a new Cochrane review of 93 studies examining pharmaceutical industry interactions with prescribers.
For the review, researchers looked at clinicians who received advertising and education (such as sales rep visits), direct gifts and payments or free drug samples, and compared prescribing outcomes to prescribers who had little or no exposure to those interactions. The review found that pharma gifts and payments were strongly linked to what they described as “inappropriate prescribing,” such as selecting treatments that patients may not need or that could cause harm. Gifts and payments were also tied to increased prescribing costs, which researchers defined “as the monetary cost of medicines prescribed per physician,” and an increased volume of prescriptions.
Pharma advertising and education were also associated with less appropriate prescribing and higher prescription costs, and probably with a higher number of prescriptions, though the study evidence was less certain on that point than for gifts and payments.
Although the authors noted that they couldn’t establish a causal link, they maintained they were “confident that inappropriate prescribing was higher among doctors who received gifts and payments and that they wrote more prescriptions than doctors who did not.”
They also said that the data pointed to a consistent pattern: The more interactions doctors had with pharmaceutical companies, the less appropriate their prescribing became and the more prescriptions they wrote.
On the flip side, limiting interactions between pharma reps and prescribers curbed these negative prescribing patterns. Institutional conflict-of-interest policies — such as those at hospitals affiliated with Harvard University and Stanford University — are “probably associated with improved prescribing appropriateness [and] may be associated with a decreased quantity of prescriptions,” the authors wrote.
But institutional limitations hold little meaning if physicians are unaware of them, and many aren’t. A quarter of physicians didn’t know whether their institutions had policies against pharma interactions, found another survey published earlier this year in the journal Clinical Pharmacology & Therapeutics.
The ‘cost of doing business’
Pharma companies spend billions of dollars marketing to physicians to raise awareness about their drugs. The tactic is working.
“When physicians accept payments or free meals from the pharmaceutical industry, we can see evidence in the data that physicians prescribe more of the promoted drug,” study co-author Quinn Grundy said in a statement.
And if the industry’s strategies trigger anti-kickback penalties, some pharma companies may simply consider it the “cost of doing business,” according to another study published earlier this year.
Writing in JAMA Network Open, researchers examined 64 resolved cases alleging Anti-Kickback Statute violations by pharmaceutical manufacturers between 2000 and 2025. Complete penalty and U.S. revenue data were available for 46 of those settlements; in the examined cases, companies paid a median penalty equal to 2.2% of U.S. revenue from the implicated drugs during the alleged violation periods.
For instance, Takeda Pharmaceuticals agreed to pay $13.7 million in May to resolve allegations it paid speaker honoraria and high-end meals to doctors to induce prescriptions of its antidepressant Trintellix. The company pulled in $28.5 billion in revenue last year.
On a federal level, there has been very little new action to further curb pharma gift-giving. But some states are making moves to address the concerns, including Maryland, where lawmakers introduced a bill earlier this year to cap gifts from drug and medical device companies to a combined retail value of $50 per physician per calendar year. The bill received a House hearing in March but did not advance before the 2026 regular session ended in April.
Other states including Minnesota and Vermont already restrict certain industry gifts to healthcare professionals. Similar efforts have failed across the country, including in California in 2017. After intense industry lobbying, the bill’s pharma gift restrictions were ultimately gutted, and the bill eventually passed without any mention of the pharma industry at all.
In the meantime, critics continue to scrutinize pharma gift-giving, including the Cochrane review authors, who said it’s likely driving up higher healthcare costs overall.
“This practice can increase the overall costs to our health system, and to patients through higher co-pays and out-of-pocket costs, when they are prescribed a brand name drug even though cost-effective alternatives exist,” Grundy wrote.
