Hundreds of Maryland doctors have accepted fees, some exceeding six figures, from pharmaceutical companies in the past two years to promote their drugs to other doctors — a practice that is not illegal but raises ethical questions about the industry's influence over patient care.
Large companies such as Merck and Eli Lilly have disclosed $258 million in payments nationwide in 2009 and the first half of 2010, with about $6 million going to Maryland physicians and a handful of nurses. There were more than 450 Maryland recipients from Johns Hopkins, the University of Maryland, a half-dozen Baltimore-area community hospitals, private practices and other institutions around the state.
The disclosures come as medical institutions and lawmakers have worked to rein in potential conflicts of interest, curbing these payouts as well as company-funded dinners and cruises. Ethicists and consumer groups say industry wouldn't pay if it weren't getting a return, like a boost in sales. And patients don't usually know that their doctors might have a monetary incentive to prescribe certain drugs.
"The more money you take, the more likely you are to present their drugs in a positive light, and the more likely you are to do research that is favorable to the drugs," said Dr. Carl Elliott, a professor in the University of Minnesota Center for Bioethics and the author of a book on ethics in medicine. "For whatever reason, doctors like to pretend the money has no effect on them."
But doctors who have received the money defend the paid speeches as educational for fellow physicians. And they say they are not influenced in caring for patients.
Gene Ransom, chief executive of MedChi, the Maryland State Medical Society, which represents more than 22,000 Maryland physicians, said: "Doctors take an oath to do no harm. Doctors, for a couple of hundred or a couple of thousand dollars, aren't going to risk their livelihoods or the lives of their patients."
The extra pay doctors collect for speeches and consulting from seven drug companies — whose sales make up about a third of the market — were compiled in a database by reporters at ProPublica, an independent investigative journalism organization that partnered with several media outlets. But there are more than 70 other companies that have not disclosed whether they are making payments to doctors. Those totals and recipients could remain a secret until 2014, when the federal health care reform law will require such disclosure.
The known payout to Maryland doctors constitutes just over 2 percent of the nationwide total in ProPublica's database. Seven doctors in the state joined 384 nationwide in earning more than $100,000; Most earned substantially less.
Since the database became available in recent days, officials at the University of Maryland School of Medicine and elsewhere say they are reviewing information to see if new guidelines are warranted.
The university's conflict-of-interest policy, just 18 months old, seeks to address speaking fees at industry events that aren't certified as continuing medical education. Doctors are allowed to participate if they get approval from their department chairs, but they can't read speeches or put their names on journal articles written by the industry. Their own talks must not be considered promotional. And drug company pay must be "fair market value."
"We're still learning how well the policy is working," said Dr. Nancy Lowitt, Maryland's associate dean for faculty affairs and professional development, who helped develop the policy. "What we need to do now is be aware of the data coming out and respond more to what we're learning. There's still risk, and we have to be aware of it and respectful of it."
Lowitt said she believes doctors regularly turn down paid speaking invitations, more often since the policy became effective. And she said chairs take their oversight role "very seriously." Still, at least two dozen university doctors accepted money, according to the database.
Of the seven doctors in Maryland who accepted six-figure payouts, five did not respond to efforts to contact them, couldn't be reached or declined to comment.
Dr. Robert DiBianco, a Rockville cardiologist who earned $142,436 from GlaxoSmithKline and Pfizer during the time period, said he declines to speak if products are not backed by proper studies or if companies want him to use their slides and talking points. He says money doesn't influence him when he does speak — recently about GlaxoSmithKline's Lovaza, an FDA-approved drug made with omega-3 fish oil to reduce triglyceride levels.
"People are worried that if the physician is being paid they will lean toward that drug," said DiBianco of Cardiovascular Consultants. "But I don't think physicians are influenced that much by that."
Dr. Jerald Insel, chief of the division of cardiology at Good Samaritan Hospital, won't usually talk about drugs in his lectures, which means he doesn't always get invited back by drug companies — including GlaxoSmithKline and Eli Lilly, which paid him $184,834 to talk about drugs including Avandia, a diabetes drug restricted recently because it appears to increase risk of heart attacks.
He said he frequently talks for free, but there's not enough university and hospital-backed continuing education, and education is a "mission" to him. He said he only takes industry money, which largely goes to charity, so he can get access to more doctors who will go to nice restaurants for a talk but will no longer come to the once-routine grand rounds where specific patients' problems and treatments are discussed.
"The company thinks they're getting someone jumping up and down about their drug, but I talk about diabetes," said Insel, adding that he doesn't prescribe drugs for diabetes, a risk factor for heart disease. "If I had my way, hospitals and universities would pay for more education, or everyone would give away the money and talks would be in less fancy restaurants. But we live in the real world, and we need more education of doctors."
The ProPublica database shows that Maryland doctors and nurses accepted 650 payments, ranging from a few hundred dollars to more than $200,000. Many doctors received more than one fee, and the biggest recipients were internists, oncologists and psychiatrists. At least one doctor works in bioethics.
It wasn't possible to determine if the doctors who received company payments were following their institutions' conflict of interest policies.
For example, at Lifebridge Health, which owns three Baltimore-area hospitals and a rehabilitation center, physicians must disclose ties to drug or equipment manufacturers. Doctors making drug purchasing decisions must recuse themselves from votes involving companies they have relationships with. Speeches must be done on personal time.
At the Johns Hopkins University School of Medicine, where at least four dozen doctors and nurses accepted fees, speeches related to a doctor's research are reviewed for conflicts. And if a doctor's research is sponsored by a company, his fees for speaking are limited.
Julie Gottlieb, the associate dean of policy coordination, said that because Hopkins is an academic center, companies ask many of its doctors to talk about their research or diseases in which they have an expertise. The university believes these speeches provide educational benefit. Promotional speeches are problematic.
"Promotional spending for drug companies — where the purpose of the talk is to promote a company's product — is contrary to physicians' primary obligation, which is to provide the best possible care for their patients, including objective decisions about treatment," Gottlieb said in an e-mailed response to questions.
Peter Terry, faculty member of the Johns Hopkins Berman Institute of Bioethics, said he believes doctors' primary reason for speaking for drug companies is money.
"Academic institutions don't pay physicians as well, so they may look the other way, allowing them to gain some other means of financial reward so they won't leave and go into private practice where they can make more money," he said.
The money is just becoming public. ProPublica developed its database from information posted online by Eli Lilly and Co., Pfizer Inc., AstraZeneca, GlaxoSmithKline, Merck & Co. Inc., Johnson & Johnson and Cephalon Inc. The disclosure data isn't consistent, but all companies made payments in at least some quarters between January 2009 and June 2010.
Some don't believe the transparency will help curb the speeches, or the influence.
Elliott, the Minnesota ethicist and author of "White Coat, Black Hat," said Minnesota has had a public database of drug company payouts since the mid-1990s and dollar figures have not decreased. Further, he said, academic institutions will continue to allow the practice because they do not want to upset doctors — or alienate an industry that provides them with research dollars. This sometimes remains the case even when the doctors have been cited for bad behavior.
He said no nongovernmental institutions ban doctors from accepting money for speeches and few have caps on compensation. As for the doctors, he said many view the speaking requests as an honor and a reflection on their achievement.
Everyone, he said, likes the idea of disclosure because it allows them to keep taking money, "as if a bribe is not a bribe unless it's secret." The problem, he said, is that doctors promote new drugs that might be more expensive or less effective.
Elliott believes doctors will only stop accepting payments when they are held accountable for drugs that harm a patient, even if they never prescribed the drugs themselves. Pharmaceutical companies have settled criminal and civil action by paying millions of dollars when it's discovered they didn't disclose potentially damaging drug information.
In the meantime, Elliott and others say it's not clear what patients will do with the disclosure information. Consumer Reports Health found that nearly four out of 10 Americans believe a payment as small as $10 could taint a doctor's decision-making. About 77 percent said they would be concerned about the quality of treatment they received from a doctor who took payments.
Dr. John Santa, director of the Consumer Reports Health Rating System and an internist for 30 years, said in his practice of 100 physicians, those who gave industry-sponsored speeches were more likely to prescribe their drugs.
"In many people's minds, it raises the questions about whether these physicians can, in fact, make decisions in the best interest of the patient," Santa said. "If a doctor has gotten $100,000 from a drug company, can he really be neutral?"
The ProPublica database is available at http://www.propublica.org
States with the most payments compared with Maryland:
California 3,000 payments worth $26.4 million
New York 2,761 payments worth $23.6 million
Florida 2,166 payments worth $17.2 million
Texas 1,946 payments worth $18.1 million
Pennsylvania 1,693 payments worth $14 million
Maryland 650 payments worth $6 million
Maryland's big earners
Here are the doctors in Maryland who accepted more than $100,000 in 2009 and the first half of 2010 form seven pharmaceutical companies:
Dr. Louis E. Kopolow, Gaitherburg psychiatrist, $100,952
Dr. Richard t. Kenney, Gaithersburg internist, $127,800
Dr. Robert DiBianco, Rockville internist, $142,436
Dr. Arnold Willis, Greenbelt urologist, $142,750
Dr. Jerald Insel, Baltimore internist, $184,834
Dr. Michael Naslund, Baltimore urologist, $197,315
Dr. Ralph Boccia, Bethesda internist, $208,600