Hostname: page-component-848d4c4894-p2v8j Total loading time: 0.001 Render date: 2024-06-02T19:04:33.856Z Has data issue: false hasContentIssue false

Effect of Financial Relationships on the Behaviors of Health Care Professionals: A Review of the Evidence

Published online by Cambridge University Press:  01 January 2021

Extract

Physicians, scholars, and policymakers continue to be concerned about conflicts of interests among health care providers. At least two main types of objections to conflicts of interest exist. Conflicts of interests may be intrinsically troublesome if they violate providers’ fiduciary duties to their patients or they contribute to loss of trust in health care professionals and the health care system. Conflicts of interest may also be problematic in practice if they bias the decisions made by providers, adversely impacting patient outcomes or wastefully increasing health care costs. This latter objection may be observed in differences in the prescriptions written, procedures performed, or costs billed by health care professionals who have conflicting interests, when compared to those that do not have such financial relationships.

Type
Symposium
Copyright
Copyright © American Society of Law, Medicine and Ethics 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Gonzales v. Raich, 545 U.S. 1, 31, 125 S. Ct. 2195, 2214, 162 L. Ed. 2d 1 (2005) (citing United States v. Moore, 423 U.S. 122, 96 S.Ct. 335, 46 L.Ed.2d 333 (1975); United States v. Doremus, 249 U.S. 86, 39 S.Ct. 214, 63 L.Ed. 493 (1919)).Google Scholar
American Medical Association Code of Medical Ethics § 8.03, available at <http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.shtml>(last visited July 12, 2012) [hereinafter AMA CODE].(last+visited+July+12,+2012)+[hereinafter+AMA+CODE].>Google Scholar
Ubel, P. A., “Commentary: How Did We Get into This Mess?” in Moore, D. A. et al. , eds., Conflicts of Interests: Challenges and Solutions in Business, Law, Medicine, and Public Policy (New York: Cambridge University Press, 2005): 142151, at 143–149. See also D. Katz, A. L. Caplan and J. F. Merz, All Gifts Large and Small, American Journal of Bioethics, 3, no. 3 (Summer 2003): 39-46 (collecting sources for the propositions that [m]any physicians deny the potential for the receipt of small promotional items to undermine their professional objectivity and [i]n fact, researchers have found that the more gifts a physician receives, the more likely he or she is to believe that they do not influence behavior).CrossRefGoogle Scholar
Orlowski, J. P. and Wateska, L., The Effects of Pharmaceuti¬cal Firm Enticements on Physician Prescribing Patterns, Chest 102, no. 1 (1992): 270-273.CrossRefGoogle Scholar
Research on the Comparative Effectiveness of Medical Treatments: Issues and Options for an Expanded Federal Role, 2007 CBO REPORT, available at <http://www.cbo.gov/ ftpdocs/88xx/doc8891/MainText.3.1.shtml> (last visited July 21, 2012) [citing Institute of Medicine, Learning What Works Best: The Nation's Need for Evidence on Comparative Effectiveness in Health Care, available at <http://www.cbo.gov/ ftpdocs/88xx/doc8891/MainText.3.1.shtml> <www.iom.edu/ebmeffectiveness> (last visited July 21,2012)]. (last visited July 21,2012)].' href=https://scholar.google.com/scholar?q=Research+on+the+Comparative+Effectiveness+of+Medical+Treatments:+Issues+and+Options+for+an+Expanded+Federal+Role,+2007+CBO+REPORT,+available+at++(last+visited+July+21,+2012)+[citing+Institute+of+Medicine,+Learning+What+Works+Best:+The+Nation's+Need+for+Evidence+on+Comparative+Effectiveness+in+Health+Care,+available+at+++(last+visited+July+21,2012)].>Google Scholar
For an example of this broader literature, see e.g., J. Kosecoff et al., Prospective Payment System and Impairment at Dis¬charge: The Quicker-and-Sicker Story Revisited, JAMA 264, no. 15 (1990): 1980-1983. (studying patients in 300 hospitals and finding that when Medicare switched to a prospective pay¬ment system in which hospitals were paid a fixed fee for each patient rather than based on the costs of care, patients were discharged sooner and in less stable condition); and Tickle, M. et al., Paying for the Wrong Kind of Performance? Financial Incentives and Behaviour Changes in National Health Service Dentistry, Community Dentistry and Oral Epidemiology 39, no. 5 (2011): 465-473 (examining a conflict of interest situation for dentists).CrossRefGoogle ScholarPubMed
For a discussion of these laws, see Krause, J. H., Following the Money in Health Care Fraud: Reflections on a Modern-Day Yellow Brick Road, American Journal of Law and Medicine 36, nos. 2 & 3 (2010): 365-369, at 343-69.CrossRefGoogle ScholarPubMed
See Burris, J. F. and Mroczek, W. J., Letter to the Editor, New England Journal of Medicine 324, no. 19 (1991): 1371-1373. (responding to the Hillman 1990 article discussed infra note at 12).Google Scholar
Mitchell, J. M., The Prevalence of Physician Self-Referral Arrangements After Stark II: Evidence from Advanced Diag¬nostic Imaging, Health Affairs 26, no. 3 (2007): 415.Google Scholar
Hillman, B. J. et al., Frequency and Cost of Diagnostic Imag¬ing in Office PracticeA Comparison of Self-Referring and Radiologist-Referring Physicians, New England Journal of Medicine 323, no. 23 (1990): 1604-1608.CrossRefGoogle Scholar
Id. This result was statistically significant at the .05 level, as are all other results discussed in this article, unless otherwise noted.Google Scholar
Hillman, B. J. et al., Physicians Utilization and Charges for Outpatient Diagnostic Imaging in a Medicare Population, JAMA 268, no. (1992): 2050-2054.CrossRefGoogle Scholar
Shreibati, J. B. and Baker, L. C., The Relationship Between Low Back Magnetic Resonance Imaging, Surgery, and Spending: Impact of Physician Self-Referral Status, Health Services Resource 46, no. 5 (2011): 1362-1381, available at <http:// onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2011.01265.x/ full> (last visited July 21, 2012).CrossRefGoogle ScholarPubMed
Id., at 11.Google Scholar
Id., at 16.Google Scholar
Shah, I B. R. et al. Association Between Physician Billing and Cardiac Stress Testing Patterns Following Coronary Revascularization, JAMA 306, no. 18 (2011): 1993-2000.CrossRefGoogle Scholar
Id., at 1993.Google Scholar
Id., at 1994.Google Scholar
Jacobsen, M. et al., How Medicare's Payment Cuts for Cancer Chemotherapy Drugs Changed Patterns of Treatment, Health Affairs 29, no. 7 (2010): 1391-1399.CrossRefGoogle Scholar
Id., at 1396.Google Scholar
Id. See also Bennett, C. L. et al., The Association Between Physician Reimbursement in the US and Use of Hematopoi¬etic Colony Stimulating Factors as Adjunct Therapy for Older Patients with Acute Myeloid Leukemia: Results from the 1997 American Society of Clinical Oncology Survey, Annals Of Oncology 10, no. 11 (1999): 1355-1359 (finding that reimbursement considerations are one of the most consistent determinants of use of colony stimulating factors for treatment of leukemia); and S. P. Elliott et al., Reduction in Physician Reimbursement and Use of Hormone Therapy in Prostate Cancer, Journal of the National Cancer Institute 102, no. 24 (2010): 1826-1834 (finding that excessive use of androgen sup¬pression therapy was reduced when the 2003 Medicare Mod¬ernization Act reduced reimbursement for such therapy).Google Scholar
Mitchell, J., “Urologists' Self-Referral for Pathology Of Biopsy Specimens Linked to Increased Use and Lower Prostate Cancer Detection,” Health Affairs 31, no. 7 (2012): 741.CrossRefGoogle Scholar
Id., at 741.Google Scholar
Id., at 744. For additional research examining self-referrals in the urology specialty see Tan, H. J., “Use of Ureteroscopy Before and After Expansion of Lithotripter Ownership in Michigan,” Urology 78, no. 6 (2011): 12871291 (finding that physician ownership of lithiotripters did not decrease utilization of the substitute procedure, ureteroscpy). Hollingsworth, J. M. Krein, S. L. Birkmeyer, J. D. et al. , “Opening Ambulatory Surgery Centers and Stone Surgery Rates in Health Care Markets,” Journal of Urology 184, no. 3 (2010): 967–971. Hollingsworth, J. M. Ye, Z. Strope, S. A. et al. , “Urologist Ownership of Ambulatory Surgery Centers and Urinary Stone Surgery Use,” Health Service Research 44, no. 4 (2009): 1370–1384.CrossRefGoogle Scholar
Mitchell, J. M. Scott, E., “Physician Ownership of Physical Therapy Services: Effects on Charges, Utilization, Profits, and Service Characteristics,” JAMA 268, no. 15 (1992): 20552059.CrossRefGoogle Scholar
In another study, drawing from two surveys of physical therapists, Mitchell and Sass sought to explore two alternative explanations as to why physicians purchase shares in physical therapy providers – to control the quality of services provided to the patients they refer or to profit from the physician's ability to steer patients by artificially inflating demand for a particular provider. Mitchell, J. M. Sass, T. R., “Physician Ownership of Ancillary Services: Indirect Demand Inducement or Quality Assurance?” Journal of Health Economics 14, no. 3 (1995): 263289. The researchers found that “a physical therapy clinic that receives all of its referrals from physician owners treats a patient for approximately 50 percent more visits than a clinic that receives no referrals from owners.” Id., at 285. Mitchell and Sass also observed that the differential is directly related to “increases in physician density, decreases in population density, and increases in the total number of owners,” which they argued were factors facilitating demand inducement.CrossRefGoogle Scholar
Swedlow, A. et al. , “Increased Costs and Rates of Use in the California Workers' Compensation System as a Result of Self-Referral by Physicians,” New England Journal of Medicine 327, no. 21 (1992): 15021506.CrossRefGoogle Scholar
Mitchell, J. M., “Do Financial Incentives Linked to Ownership of Specialty Hospitals Affect Physicians' Practice Patterns?” Medical Care 46, no. 7 (2008): 732737.CrossRefGoogle Scholar
Id., at 735. Similarly, in a 2005 article, Iglehart offered a case study documenting the impact of the opening of a specialty hospital in Oklahoma, near a university hospital. Iglehart reports that “the number of inpatients admitted for cardiac care plummeted at the university hospital after 16 surgeons and cardiologists on the clinical faculty began to refer all their patients to the specialty hospital as soon as it opened,” resulting over $11.6 million in lost income for the university hospital over two years. Iglehart, J. K., “The Emergence of Physician-Owned Specialty Hospitals,” New England Journal of Medicine 352, no. 1 (2005): 7884.CrossRefGoogle Scholar
Gabel, J. R. et al. , “Where Do I Send Thee? Does Physician-Ownership Affect Referral Patterns to Ambulatory Surgery Centers?” Health Affairs 27, no. 3 (2008): W165.CrossRefGoogle Scholar
Ellis, R. P. McGuire, T. G., “Provider Behavior Under Prospective Reimbursement: Cost Sharing and Supply,” Journal of Health Economics 5, no. 2 (1986): 129151. See also, McGuire, T., “Physician Agency,” in Cuyler, A. C. Newhouse, J. P., eds., Handbook of Health Economics (Amsterdam: North-Holland, 2000).CrossRefGoogle Scholar
Rodwin, M. A., Conflicts of Interest and the Future of Medicine: The United States, France, and (Japan. Oxford: Oxford University Press, 2011).Google Scholar
Shen, J. Brook, R. A. Kominski, G. Albert, P. S. Wenger, N., “The Effects of Payment Method on Clinical Decision-Making: Physician Responses to Clinical Scenarios,” Medical Care 42, no. 3 (2004): 297302.CrossRefGoogle Scholar
Hennig-Schmidt, H. Selten, R. Wiesen, D., “How Payment Systems Affect Physicians' Provision Behaviour — An Experimental Investigation,” Journal of Health Economics 30, no. 4, (2011): 637646.CrossRefGoogle Scholar
Hemenway, D. et al. , “Physicians Responses to Financial Incentives–Evidence from a For-Profit Ambulatory Care Center,” New England Journal of Medicine 322, no. 15 (1990): 10591063.CrossRefGoogle Scholar
Devlin, R. A. Sarmab, S., “Do Physician Remuneration Schemes Matter? The Case of Canadian Family Physicians,” Journal of Health Economics 27, no. 5 (2008): 11681181.CrossRefGoogle Scholar
Chaiz-Couturier, C. et al. , “Effects of Financial Incentives on Medical Practice: Results from a Systematic Review of the Literature and Methodological Issues,” International Journal of Quality in Health Care 12, no. 2 (2000): 133142.CrossRefGoogle Scholar
Town, R. et al. , “Economic Incentives and Physicians' Delivery of Preventive Care,” American Journal of Preventive Medicine 28, no. 2 (2005): 234240.CrossRefGoogle Scholar
Scott, A. et al. , “The Effect of Financial Incentives on The Quality of Health Care Provided By Primary Care Physicians,” The Cochrane Collaboration, The Cochrane Library, Issue 9 (2011).CrossRefGoogle Scholar
Echevin, D. Fortin, B., “Physician Payment Mechanisms, Hospital Length of Stay and Risk of Readmission: A Natural Experiment,” SSRN eLibrary (2011).Google Scholar
Mullen, K. J. Frank, R. G. Rosenthal, M. B., “Can You Get What You Pay for? Pay-for-Performance and the Quality of Healthcare Providers,” RAND Journal of Economics 41, no. 1 (2010): 6491. Testimony of Meredith Rosenthal, B., Ph.D., Hearing on Examining Pay-for-Performance Measures and Other Trends in Employer-Sponsored Health Care, U.S. House Subcommittee on Employer-Employee Relations (2005).CrossRefGoogle Scholar
Institute of Medicine, Rewarding Provider Performance: Aligning Incentives in Medicare, Washington D.C., 2006.Google Scholar
See Flodgren, G. et al. , “An Overview of Reviews Evaluating the Effectiveness of Financial Incentives in Changing Healthcare Professional Behaviours and Patient outcomes,” Cochrane Database of Systematic Reviews, the Cochrane Library (2011); see Mullen, Frank, Rosenthal, , supra note 49, at 85;.CrossRefGoogle Scholar
See Flodgren, et al. , supra note 51, at 2.Google Scholar
See Van Herck, P. et al. , “Systematic Review: Effects, Design Choices, and Context of Pay-For-Performance in Health Care,” Boston Medical Center Health Services Research 10 (2010): 247 Serumaga, B. et al. , “Effect of Pay for Performance on The Management and, Outcomes of Hypertension in the United Kingdom: Interrupted Time Series Study,” Boston Medical Journal 342 (2011): D108; see Scott, et al. , supra note 47, at 3.CrossRefGoogle Scholar
Barros, P. P., “Cream-Skimming, Incentives for Efficiency and Payment System,” Journal of Health Economics 22, no. 3 (2003): 419443.CrossRefGoogle Scholar
Dalton, A. R. H. Alshamsan, R. Majeed, A et al. , “Exclusion of Patients from Quality Measurement of Diabetes Care in the UK Pay-for-Performance Programme,” Diabetic Medicine 28, no. 5 (2011): 525531.CrossRefGoogle Scholar
Alshamsan, R., “Impact of Pay for Performance on Inequalities in Health Care: Systematic Review,” Journal of Health Services Research Policy 15, no. 3 (2010): 178184.CrossRefGoogle Scholar
See Mullen, Frank, Rosenthal, , supra note 49, at 85.Google Scholar
In addition to the foregoing sources, see Peterson, L. et al. , “Does Pay-for-Performance Improve the Quality of Health Care*?” Annals of Internal Medicine 145, no. 4 (2006): At 265272.Google Scholar
Williams, P. A. Cockerill, R. Lowy, F. H., “The Physician as Prescriber: Relations Between Knowledge about Prescription Drugs, Encounters with Patients and the Pharmaceutical Industry, and Prescription Volume,” Health and Canadian Society 3 (1995): 135164.Google Scholar
Peay, M. Y. Peay, E. R., “The Role of Commercial Sources in the Adoption of a New Drug,” Social Science in Medicine 26, no. 12 (1988): 11831189.CrossRefGoogle Scholar
Berings, D. Blondeel, L. Habraken, H., “The Effect of Industry-Independent Drug Information on the Prescribing of Benzodiazepines in General Practice,” European Journal of Clinical Pharmacolology 46, no. 6 (1994): 501505. See also, Peay, M. Y. Peay, E. R., “Innovation in High Risk Drug Therapy,” Social Science in Medicine 39, no. 1, (1994): 39–52.Google Scholar
Wazana, A., “Physicians and The Pharmaceutical Industry: Is A Gift Ever Just A Gift?” JAMA 283, no. 3 (2000): 373380. Manchanda, P. Honka, E., “The Effects and Role of Direct-to-Physician Marketing in the Pharmaceutical Industry: An Integrative Review,” Yale Journal of Health Policy, Law and Ethics 5, no. 2 (2005): 785–812. Lexchin, J., “Interactions Between Physicians and the Pharmaceutical Industry: What Does the Literature Say?” Canadian Medical Association Journal 149, no. 10 (1993): 1401–1407.CrossRefGoogle Scholar
Roughead, E. E. Harvey, K. J. Gilbert, A. L., “Commercial Detailing Techniques Used by Pharmaceutical Representatives to Influence Prescribing,” Australia New Zealand Journal of Medicine 28, no. 3 (1998): 306310.CrossRefGoogle Scholar
Dana, J. Loewenstein, G., “A Social Science Perspective on Gifts to Physicians from Industry,” JAMA 290, no. 2 (2003): 252255.CrossRefGoogle Scholar
Campbell, E. G. Rao, S. R. DesRoches, C. M. Iezzoni, L. I. Vogeli, C. Bolcic-Jankovic, D. Miralles, P. D., “Physician Professionalism and Changes in Physician-Industry Relationships from 2004 to 2009,” Archives of Internal Medicine 170, no. 20 (2010): 18201826.CrossRefGoogle Scholar
Halperin, E. C. Hutchison, P. Barrier, R. C. Jr. “A Population-Based Study of the Prevalence and Influence of Gifts to Radiation Oncologists from Pharmaceutical Companies and Medical Equipment Manufacturers,” International Journal of Radiation Oncology, Biology, Physics 59, no. 5 (2004): 14771483.CrossRefGoogle Scholar
McNeill, P. M. Kerridge, I. H. Henry, D. A. Stokes, B. Hill, S. R. Newby, D. et al. , “Giving and Receiving of Gifts between Pharmaceutical Companies and Medical Specialists in Australia,” Internal Medicine Journal 36, no. 9 (2006): 571578.CrossRefGoogle Scholar
Saito, S. Mukohara, K. Bito, S., “Japanese Practicing Physicians' Relationships with Pharmaceutical Representatives: A National Survey,” PLoS 5 (2010).Google Scholar
Chren, M. M. Landefeld, C. S., “Physicians' Behavior and Their Interactions with Drug Companies: A Controlled Study of Physicians Who Requested Additions to a Hospital Drug Formulary,” JAMA 271 (1994): 684689.CrossRefGoogle Scholar
Lurie, N. Rich, E. C. Simpson, D. E. et al. , “Pharmaceutical Representatives in Academic Medical Centers,” Journal of General Internal Medicine 5, no. 3 (1990): 240243.CrossRefGoogle Scholar
Rutledge, P. Crookes, D. McKinstry, B. Maxwell, S. R., “Do Doctors Rely on Pharmaceutical Industry Funding to Attend Conferences and Do They Perceive That This Creates a Bias in Their Drug Selection? Results from A Questionnaire Survey,” Pharmacoepidemiol Drug Safety 12, no. 8 (2003): 663667.CrossRefGoogle Scholar
Campo, K. De Staebel, O. Gijsbrechts, E. van Waterschoot, W., “Physicians' Decision Process for Drug Prescription and the Impact of Pharmaceutical Marketing Mix Instruments,” Health Marketing Quarterly 22, no. 4 (2005): 73107.CrossRefGoogle Scholar
Bowman, M. A. Pearle, D. L.,“Changes in Drug Prescribing Patterns Related to Commercial Company Funding of Continuing Medical Education,” Journal of Continuing Education in the Health Professions 8 no. 1 (1988): 1320.CrossRefGoogle Scholar
Orlowski, J. P. Wateska, L., “The Effects of Pharmaceutical Firm Enticements on Physician Prescribing Patterns,” Chest 102, no. 1 (1992): 270273.Google Scholar
Austad, K. E. Avorn, J. Kesselheim, A. S., “Medical Students' Exposure to and Attitudes About the Pharmaceutical Industry: A Systematic Review,” PLoS Medicine 8, no. 5 (2011): e1001037.CrossRefGoogle Scholar
Sandberg, W. S. Carlos, R. Sandberg, E. H. Roizen, M. F., “The Effect of Educational Gifts from Pharmaceutical Firms on Medical Students' Recall of Company Names or Products,” Academic Medicine 72, no. 10 (1997): 916918.Google Scholar
Cutrona, S. L. Woolhandler, S. Lasser, K. E. Bor, D. H. McCormick, D. Himmelstein, D. U., “Characteristics of Recipients of Free Prescription Drug Samples: A Nationally Representative Analysis,” American Journal of Public Health 98, no. 2 (2008): 284289.Google Scholar
Morelli, D. Koenigsberg, M. R., “Sample Medication Dispensing in a Residency Practice,” Journal of Family Practitioners 34, no. 1 (1992): 4248; Westfall, J. M. McCabe, J. Nicholas, R. A., “Personal Use of Drug Samples by Physicians and Office Staff,” JAMA 278, no. 2 (1997): 141–143.Google Scholar
Alexander, G. C. Zhang, J. Basu, A., “Characteristics of Patients Receiving Pharmaceutical Samples and Association between Sample Receipt and Out-of-Pocket Prescription Costs,” Medical Care 46, no. 4 (2008): 394402.Google Scholar
Thomson, A. N. Craig, B. J. Barham, P. M., “Attitudes of General Practitioners in New Zealand to Pharmaceutical Representatives,” British Journal of General Practice 44, no. 382 (1994): 220223.Google Scholar
Fugh-Berman, A. Ahari, S., “Following the Script: How Drug Reps Make Friends and Influence Doctors,” PLoS Medicine 4 (2007): e150.CrossRefGoogle Scholar
Adair, R. F. Holmgren, L. R., “Do Drug Samples Influence Resident Prescribing Behavior? A Randomized Trial,” American Journal of Medicine 118, no. 8 (2005): 881884.CrossRefGoogle Scholar
Hartung, D. M. Evans, D. Haxby, D. G. Kraemer, D. F. Andeen, G. Fagnan, L. J., “Effect of Drug Sample Removal on Prescribing in a Family Practice Clinic,” Annals of Family Medicine 8, no. 5 (2010): 402409.CrossRefGoogle Scholar
Boltri, J. M. Gordon, E. R. Vogel, R. L., “Effect of Antihypertensive Samples on Physician Prescribing Patterns,” Family Medicine 34, no. 10 (2002): 729731.Google Scholar
Brewer, D., “The Effect of Drug Sampling Solicits on Residents' Prescribing,” Family Medicine 30, no. 7 (1998): 482486.Google Scholar
Chew, L. D. O'Young, T. S. Hazlet, T. K. Bradley, K. A. Maynard, C. Lessler, D. S., “A Physician Survey on Effect of Drug Sample Availability on Physicians' Behavior,” Journal of General Internal Medicine 15, no. 7 (2000): 478483.CrossRefGoogle Scholar
Pinckney, R. G. Helminski, A. S. Kennedy, A. G. MacLean, C. D. Hurowitz, L. Cote, E., “The Effect of Medication Samples on Self-Reported Prescribing Practices: A Statewide, Cross-Sectional Survey,” Journal of General Internal Medicine 26, no. 1 (2011): 4044.Google Scholar
Peay, M. Y. Peay, E. R., “The Role of Commercial Sources in the Adoption of a New Drug,” Social Science in Medicine 26, no. 12 (1998): 11831189.CrossRefGoogle Scholar
Avorn, J. Chen, M. Hartley, R., “Scientific Versus Commercial Sources of Influence on the Prescribing Behavior of Physicians,” American Journal of Medicine 73, no. 1 (1982): 48.CrossRefGoogle Scholar
Ziegler, M. G. Lew, P. Singer, B. C., “The Accuracy of Drug Information from Pharmaceutical Sales Representatives,” JAMA 273, no. 16 (1995): 12961298.Google Scholar
Hodges, B., “Interactions with the Pharmaceutical Industry,” CMAJ 153, no. 5 (1995): 553559.Google Scholar
Blumenthal, D., “Doctors and Drug Companies,” New England Journal of Medicine 351, no. 18 (2004): 18851890.CrossRefGoogle Scholar
See e.g., Shreibati, Baker, supra note 15.Google Scholar
See Sohn, S., “Intrinsic Motivational Drivers in Medical Networks from a Neuroscientific Perspective,” Journal of Neuroscience Psychology and Economics 4 no. 3, (2011): 192 (studying physicians and finding four different primary motivational factors).CrossRefGoogle Scholar
See supra notes 3–5.Google Scholar
For an analysis of this dynamic in the context of legal professionalism, see Bradley Wendell, W., “Nonlegal Regulation of the Legal Profession: Social Norms in Professional Communities,” Vanderbilt Law Review 54, no. 5 (2001): 1955.Google Scholar
See generally, Mechanic, D. Schlesinger, M., “The Impact of Managed Care on Patients' Trust in Medical Care and Their Physicians,” JAMA 275, no. 21 (1996): 16931697.CrossRefGoogle Scholar
See generally, Robertson, C. T., “Biased Advice,” Emory Law Journal 60, no. 3 (2011): 653.Google Scholar