A controversial study that’s sure to anger a lot of doctors found many physicians can be influenced to prescribe brand-name medication following free meals offered by the pharmaceutical companies. These meals cost less than $20 on average but seem to be most effective at increasing sales.

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Of course, it’s not the free sandwich itself that’s convincing many doctors to prescribe brand-name medication in favor of much cheaper generic alternatives. Sales representatives use free meals, either brought to the doctor’s office or at events where doctors are supposedly invited to learn about the “appropriate use of new medicines”, to have the door opened.

Once this happens, they have a couple of minutes to pitch their products and, statistically speaking, they eventually become successful, according to a study led by Adams Dudley, a professor of medicine and health policy at the University of California, San Francisco.

Dudley and colleagues access data from the government released due to a provision in the 2010 Affordable Care Act which forces drug and medicinal-device makers to list all the payments and gifts they make to physicians. For the analysis, four drugs were selected prescribed by 280,000 doctors for Medicare patients:  AstraZeneca PLC’s cholesterol-lowering Crestor; AllerganPLC’s Bystolic treatment for high blood pressure; Daiichi Sankyo Co.’s Benicar for high blood pressure; and Pfizer Inc.’s Pristiq, which treats depression.

For all of these drugs there’s a generic alternative available at a much lower price, and in some situations, insurers may only refund generics because these are seen as just as effective as the brand-name medicines.

What the researchers found was doctors who received only one meal from sales representatives were much likelier to prescribe brand-name medicine than those who hadn’t received anything. That’s 18% more likely for Crestor,  70% for Bystolic; 52% for Benicar; and 118% for Pristiq. Additional meals further increased the likelihood of the brand-name prescriptions, something that the researchers quoted by the Wall Street Journal called a “dose-dependent” relationship. “I think we were probably surprised that it took so little of a signal and such a low value meal…It has changed our thinking,” Dudley said.

“The consequences are this is distorting health-care spending in a way that is large and unnecessary,” Avorn said. “There has been a backing away from the really extravagant and frankly embarrassing giveaways of huge gifts of value. … That’s good, but what a lot of people fail to see is having doctors learn about what drugs to use by virtue of free meals in nice restaurants is still problematic,” Jerry Avorn, a professor of medicine at Harvard Medical School who was not involved in the research told the Washington Post.

The study itself does not, however, prove that free meals cause doctors to prescribe some brand-names more often. It may be possible that those doctors who are likelier to prescribe brand-name medicine for objective reasons are also more inclined to attend dinners with the drug makers.

Pharmaceutical Research and Manufacturers of America, an industry association, criticized the findings saying in a statement that it  “cherry-picks physician prescribing data for a subset of medicines to advance a false narrative”. Maybe, but it doesn’t sound like it. What these findings show is that even small gifts can interfere with the independence of physicians, be it a golf trip or a freakin’ sandwich.

“There are inherent tensions between the profits of health-care companies, the independence of physicians and the integrity of our work, and the affordability of medical care,” JAMA Internal Medicine editor-at-large Robert Steinbrook wrote in an editorial accompanying the paper. “If drug and device manufacturers were to stop sending money to physicians for promotional speaking, meals, and other activities without clear medical justifications and invest more in independent bona fide research on safety, effectiveness, and affordability, our patients and the health care system would be better off.”