Psychiatrists Dominate List of Big Pharma Payments
& Does It Influence Prescribing?
Psychiatrists dominate a list of physicians receiving the most in payments from pharmaceutical companies, according to a free, interactive database of such payments launched by investigative journalism group ProPublica, in partnership with other US media outlets
So far, the database includes payments made by 7 of the biggest pharmaceutical companies — some of which the US Department of Justice has required to disclose physician payments as part of settlement agreements over illegal drug marketing — which account for a boggling $258 million in payments to roughly 17,700 physicians. The plan is to add 70 more companies. These doctors represent only a small fraction of the doctors who actually speak for pharmaceutical companies in the U.S. Most estimates place the number of physician speakers somewhere in excess of 100,000.
Any US physician is searchable by name in the database.
"Receiving payments isn't necessarily wrong," says the homepage for the Dollars for Docs, "but it does raise ethical issues." The payments covered by the project include fees for such items as speaking, consulting, meals, and travel; the different types of payments from different companies have been compiled, streamlined, and tallied by ProPublica.
Dollar Value of Psychiatric Drugs Is Enormous
The preponderance of psychiatrists on the ProPublica list may reflect the proportion of prescription activity involving psychiatric drugs. In 2009, the dollar value of antipsychotic drugs came to $14.6 billion, topping all other therapeutic classes, according to research firm IMS Health. Antidepressants occupied the number 4 spot on the list, valued at $9.9 billion. IMS Health put the total US prescription market in 2009 at $300.3 billion.
Top-Paid Psychiatrist Says Payments Do Not Cloud Clinical Judgment
ProPublica researchers also compiled a list of physicians who were paid more than $100,000 (typically from more than 1 company) during the past 18 months, turning up 384 names, including 41 who earned more than $200,000 through speaking or consulting arrangements and 2 who earned more than $300,000 from 1 or more of the 7 companies.
More psychiatrists are listed in the database than any other kind of specialist. Of the 384 physicians in the $100,000 group, 116 are psychiatrists. Leading all psychiatrists was Roueen Rafeyan, MD, an assistant clinical professor at Rush University Medical Center in Chicago, who received $203,936 from Eli Lilly, AstraZeneca, Johnson & Johnson, and Pfizer, mostly for professional education programs.
In an interview with Medscape Medical News, Dr. Rafeyan said that compensation from pharmaceutical companies does not cloud his clinical judgment at the expense of patients. "The day I'm influenced by that is the day I'm not fit to practice medicine," Dr. Rafeyan said. He noted that the majority of the drugs he prescribed were generics. "If someone looked at my prescribing patterns, it would be the opposite of the [pharmaceutical] money I receive," said Dr. Rafeyan.
Dr. Rafeyan said that although the extra income is always welcome, patient well-being was his prime motivation to talk to other physicians about brand-name psychiatric drugs. "When you educate other physicians, hopefully 1 patient will benefit from it."
Differing Views: Education vs. Profit
Carol Bernstein, MD, president of the American Psychiatric Association, told Medscape Medical News that the thorny issue of pharmaceutical industry compensation went beyond her specialty. Research has shown, Dr. Bernstein added, that heavy pharmaceutical marketing indeed influences physician prescribing.
The hard reality about doctor speaking is that though doctors believe that they are recruited to speak in order to persuade a room of their peers to consider a drug, one of the primary targets of speaking, if not the primary target, is the speaker himself. NPR recently talked to former and current representatives, 18 in all, and two are quoted in this story. “Mathew Webb” recently left the drug business and doesn't want us to use his real name out of fear of financial repercussions. Another representative extensively interviewed, Angie Maher, left the industry two years ago after becoming a whistle-blower in a lawsuit.
According to Webb and Maher, doctors’ view that speaking is educational is not at all accidental. Drug companies train representatives to approach a narrow set of doctors in a very specific way, using language that deliberately fosters this idea that the doctors who speak are educators, and not just educators, but the smartest of the smart. But some drug representatives, like Maher, have a more cynical view of why drug companies choose the doctors they choose. It's not about how well respected the doctor is, according to Maher; it's about how many prescriptions he writes. Webb points out that the people recruited to speak are almost always high prescribers with incredibly high patient populations. The fact is that the top 20 doctors in a representative's territory prescribe the vast majority of the medication. According to Webb, the top 20 percent prescribe as much as the lower 80. So if you want to sell more of your product, and every representative is required to sell more, those are the physicians to target.
Here's how the money works out, at least for Webb. It's hard to know whether he's typical because there haven't been any published studies of this subject. But according to Webb, he would give a high-prescribing doctor about $1,500 to speak. That's where reps look for a real increase in prescriptions — after a speech. Following that speech, Webb would see the speaking doctor write an additional $100,000 to $200,000 in prescriptions of his company's drug. To calculate return on investment, companies look at how much money was spent on a doctor compared with how much the company made from him in prescriptions. According to Maher and Webb, this is something companies monitor very closely. Drug companies buy the doctors' prescription data from firms like IMS Health that use pharmacy records to track the prescriptions of almost every doctor in the U.S. "So the way we could get to tell honestly if a speaker event was productive is you could look at their four-week data and see how many prescriptions more he wrote than he used to write," Webb says. "That's how we knew."
Do Doctors Know Their Prescribing Habits Change?
All of this raises a very thorny moral question: Do the doctors who do the speaking know that their prescribing habits have changed? If they do know, then in a sense they're being bought — they are taking money to write prescriptions. If they don't, then they're unwittingly being played.
But Maher says it's almost impossible for a doctor to keep up his guard. She points out that before doctors speak to their peers about a drug, they review slides provided by the company and talk to the company medical officers. And this process, she says, focuses the doctor on the most positive aspects of a drug.
David Switzer, a doctor in Virginia, writes about the interaction between doctors and reps on a popular website called cafepharma. As someone who has thought a lot about these issues, he says that he does not believe that most of the doctors who speak are conscious that their prescription-writing changes. "The majority of doctors, I think, would honestly say, 'Oh that stuff doesn't work on me,' " Switzer says. This attitude, he says is essentially programmed into them in medical school, where they're taught to think critically, and they're also taught that they have been taught to think critically. Which, in a way, Switzer says, handicaps them when it comes to drug reps. "They come to the table with the belief that because they have gone through this rigorous academic training that they are somehow impervious," Switzer says. "I don't think that we're as good at that as we think that we are."
-From “Psychiatrists Dominate ‘Doctor-Dollars’ Database Listing Big Pharma Payments”, by Shelley Wood and Robert Lowes, Medscape Medical News, October 22, 2010, http://www.medscape.com/viewarticle/731028, retrieved 10/25/10 and “How To Win Doctors And Influence Prescriptions”, by Alix Spiegel, All Things Considered, National Public Radio, October 21, 2010, http://www.npr.org/templates/story/story.php?storyId=130730104 retrieved 10/25/10.
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