In April 2025, Gilead Sciences paid $202 million to settle allegations that it paid kickbacks to doctors through speaker fees and lavish dinners in return for more written prescriptions for their drugs. This is the illegal version that made the news headlines.
And the legal version? It may be sitting in your medicine cabinet.
A recent survey found that nearly 1 in 3 Americans aren’t filling their prescriptions simply due to cost. And while health care costs in the United States have always been quite exorbitant, the more shocking truth underlying this is that the drug or drug brand on your prescription is increasingly shaped by people you will never meet. In 2016 alone, the drug industry spent more than $20 billion on marketing aimed not at patients but at the doctors who prescribe to them, including $5.6 billion on prescriber detailing and nearly a billion on direct doctor payments in the form of speaking fees, meals, travel fees, and more. Study after study shows that these financially driven marketing practices measurably influence what we as patients are prescribed, and in ways that often cost us much more than we gain, far beyond just higher co-payments for brand name over generic.
A landmark JAMA Internal Medicine study found that doctors who received even a single industry-sponsored meal prescribed the promoted brand-name drug at higher rates than doctors who didn’t, an effect that held for statins, blood pressure medications, and antidepressants alike. But the problem is that this finding isn’t an outlier; it’s the visible tip of a much larger system. And when a finding this concrete comes out of the state consistently ranked best in the U.S. for health care, we are left wondering what might be going on elsewhere. Elsewhere, costs begin getting measured in deaths, rather than in dollars.
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A 2018 study in JAMA Internal Medicine found that doctors who received any opioid-related marketing in 2014 wrote 9 percent more opioid prescriptions in 2015 than those who didn’t, even as national opioid prescribing rates were declining and overdose deaths were rising sharply. But the vast majority of that marketing wasn’t flamboyant consulting fees or extravagant speaker payments. It was meals, with a median value of a whopping $13. A follow-up study found higher county-level opioid marketing linked to higher county-level overdose deaths.
But some may ponder whether the opioid crisis was simply its own catastrophe, that should be considered entirely separately. The question may be: Aside from the devastating circumstances of the opioid crisis, isn’t the fact that drug marketing causes doctors to increase prescriptions for their drug just proof that the marketing is doing exactly what it is supposed to?
Yes, actually. And this is exactly where the issues arise for us as patients.
It has been consistently shown that drug marketing does not play “fair.” Specifically, drug marketing most commonly increases prescriptions to patients that are deemed high-risk and low-value, meaning the patients who are most likely to have adverse reactions to the drug, and are least likely to benefit from the drug. This holds true when studied for anticoagulants, when the patients being prescribed have dangerously high bleeding risks, but we see this trend in many other areas as well.
In the field of oncology, patients are more likely to receive low-value and non-recommended prescriptions after their doctors were marketed to, meaning that the increase in prescriptions were actually against clinical guidelines, showed no incremental benefit for patients, and were more expensive.
And a 2011 study titled “The Inverse Benefit Law: How Drug Marketing Undermines Patient Safety and Public Health” found similarly that drug marketing expands drug use to less severely afflicted patients, meaning more must be treated for one patient to show real benefit. As more people are exposed to the drug, adverse reactions increase meaningfully, thereby leading to a worsening benefit-to-harm ratio.
This finding argues that the drug industry isn’t marketing bad drugs to our doctors necessarily, but that this marketing lever turns previously evidenced good drugs into statistically proven bad drugs by extending their use beyond the appropriate evidence base. But a larger patient population being treated means a larger market to profit off of, so the financial incentive in expanding the patient market is crystal clear for pharma giants.
So, where do we go from here?
First, we must understand that this isn’t about the morality of individual doctors. Marketing is designed to bypass conscious deliberation, and drug companies know exactly what they’re buying when they “benevolently” pay for your doctor’s favorite lunch. But perhaps that is even more unsettling; even well-intentioned doctors can’t fully separate which influences shape their prescribing decisions.
So the fix, then, doesn’t require dismantling the drug industry that has provided us with ground-breaking advancements in medications and treatments (legislative changes that accelerated drug access between 1992 and 2002 alone saved an estimated 180,000 to 310,000 life-years), nor does it necessitate treating doctors as suspects. It starts with acknowledging that “education” funded by a company with a financial stake in the outcome isn’t education; it’s very simply just stealthily hidden advertising.
And it starts with the questions you can ask the next time your doctor reaches for the prescription pad. Is there a generic? Why this drug? Are there alternatives? We shouldn’t have to wonder whose voice is in the room when juggling something as fragile as our health and wellness. But until the system changes, asking out loud is the closest thing we can get to a meaningful answer.
Annika Seem is a graduate student.
