Prescription for concern

Pharmaceutical companies' payments to doctors raise questions amid soaring U.S. drug costs

In the past two years, Tennessee doctors and other health professionals have pocketed more than $7.2 million in payments from pharmaceutical companies, often in exchange for speaking to colleagues about the uses and benefits of prescription drugs, according to a database compiled by investigative news nonprofit ProPublica.

Twenty-nine health professionals in Chattanooga were listed as receiving some level of money from drug companies, ranging from less than $1,000 to tens of thousands in payments.

One Chattanooga psychiatrist took in $126,522 in payments from pharmaceutical companies in the past two years, more than any other local doctor, according to the disclosures.

The payments aren't illegal but, at a time when U.S. prescription drug usage is skyrocketing, drug companies' relationships with doctors are facing heightened scrutiny from federal regulators, medical ethicists and even patients.

Some worry that paying doctors to speak or for consulting work is a fundamental conflict of interest and evidence of the flaws in a market-driven health care system.

"The pay is often exceedingly good," said Daniel Callahan, co-founder of the nonprofit Hastings Center, a Garrison, N.Y.-based research group focused on bioethics. "It seems to me, if [doctors are] paid a lot of money it's in great part because they're probably expected to have a pretty great impact [on prescribing levels]. ... It all begins to look very fishy after a while."

Pharmaceutical companies argue that training and hiring doctors who have clinical experience with their products is a responsible way to educate medical professionals about the latest medical treatments. A number of local doctors emphasized that the payments have no bearing on their prescribing habits and are simply fair compensation for performing an important education service.

Still, other physicians admitted they had some qualms about accepting the payments and a number of doctors on ProPublica's list said they are distancing themselves from the practice.


Prescription drug spending grew by 480 percent between 1990 and 2008, from $40.3 billion to $234.1 billion, according to data from the U.S. Centers for Medicare and Medicaid Services.

Under the federal health care reform law that passed in March, pharmaceutical companies will have to disclose payments to doctors to the federal government by 2013. ProPublica has compiled the disclosures from seven companies that already have made the payments public, sometimes as a result of court settlements.

Dozens of other companies have yet to reveal the data.

About 17,700 health professionals nationwide have collected $258 million from the seven companies in the last two years, including $6.6 million in Georgia, according to the database.

Ringgold, Ga.-based endrocrinologist Dr. Dianne Roland is listed as receiving more than $32,000 from drug companies in the last two years, the most of any other physician listed in the North Georgia region. She could not be reached for comment last week.

The data shows that Chattanooga's top earner is psychiatrist Timothy Jennings, who received $73,650 from Eli Lilly in 2009. The drug company described the payments as fees for educating colleagues or other advising.

Jennings also collected $44,870 from AstraZeneca for unspecified services in 2010, and $8,002 more from Eli Lilly in 2010 for health care professional education programs and travel expenses.

Jennings said in an interview that the payments have no bearing on his prescribing habits and can play an important role in educating medical professionals about new treatment options.

"In my case, I've never spoken for a product I didn't first have an experience withand come to have confidence in as an effective treatment option," he said.

But he added that he's stepping away from speaking on behalf of prescription drugs, alarmed by new restrictions on what he can say.

"Some companies would prefer us to read the [pre-approved] slides and never say more than is on the slides. They want us to simply use our credentials to be mouthpieces for the companies, rather than allow us to have the freedom to educate, as we used to be able to do," Jennings said. "It's really done a great disservice to the whole industry, in my opinion."

Tennessee by the numbersTotal drug company payments: $7.2 millionDoctors who took in more than $200,000: 5Percent of total payments nationwide: 2.8National ranking of Tennessee doctor who made the most money, $302,125: 2 (Only one other doctor earned more.)Source: ProPublicaWhat U.S. spends on drugs2008: $234.1 billion2003: $174.2 billion1998: $88.5 billion1993: $50.99 billionSource: National Health Expenditures data from the U.S. Centers for Medicare and Medicaid ServicesEarnings by stateTop five* California : $26.4 million* New York: $23.6 million* Texas: $18.1 million* Florida: $17.2 million* Pennsylvania: $13.9 million* Tennessee: $7.2 million* Georgia: $6.6 millionBottom five* Wyoming: $86,972* Alaska: $171,846* South Dakota: $284,911* Montana: $286,880* Vermont: $358,162Source: ProPublicaWho got paidChattanooga health professionals* Timothy Jennings, psychiatrist -- $126,522* Jay Sizemore, infectious diseases specialist -- $54,048* Lee Solomon, psychiatrist -- $29,825* Daniel Smith, pulmonologist, critical care specialist -- $21,500* David Huffman, endocrinologist -- $21,463* Robert Younger, asthma/allergy specialist -- $21,300* Mark Jennings, psychiatrist -- $18,734* Joseph Huffstutter, rheumatologist -- $17,018* Richard Pesce, intensivist -- $14,949* Marc Cromie, allergy specialist -- $12,575* Kenneth Patric, family medicine doctor -- $10,124* Brandy Biederman, RN -- $9,408* Kevin Ferguson, child/adolescent psychiatrist -- $7,834* David Chaffin, allergist -- $7,000* Todd Levin, allergist -- $6,750* Michael Geer, cardiologist -- $6,250* David Rankine, neurologist -- $6,250* Eugene Ryan, internal medicine -- $5,100* Vincent Viscomi, pulmonologist -- $4,500* Stephen Dreskin, anesthesiologist -- $4,529* Lane Griggs, OB-GYN -- $4,000* Amar Singh, urologist -- $4,000* Linda Melton, FNP -- $3,176* Susan Raschal, asthma specialist -- $3,125* Kymber Habenicht, urologist -- $2,000* Rhonda Campbell, nurse practitioner -- $1,500* Viviana Hargis, RN -- $1,200* Dustin Smith, pharmacist -- $1,000* Dr. Kirk Brody, OB-GYN -- $912North Georgia health professionals* Dianne Roland, endocrinologist -- $32,463* Robert Pendersen, neurologist -- $7,800* Erick Kimmerling, pulmonologist -- $5,950* Carlos Baleeiro, pulmonologist -- $5,887* Lisa Stevens, psychiatrist -- $1,850DRUG COMPANIES DISCLOSING PAYMENTSEli Lilly, Cephalon, AstraZeneca, GlaxoSmithKline, Johnson & Johnson, Merck & Co., PfizerSource: ProPublicaMORE Search ProPublica's "Dollars for Docs" database at dollars.

Jennings said he will maintain a contract with Eli Lilly, which allows doctors to speak at events that educate about diseases broadly, rather than specific drugs.

He said those events are free of drug salespeople and advertisements and are orchestrated by a third-party vendor, though funded by the drug company.


Jennings is one of 384 U.S. doctors whom ProPublica identified as collecting more than $100,000 in payments in 2009 and 2010.

Nationwide, 43 doctors made more than $200,000 and two made more than $300,000, according to ProPublica's database, published online in October.

In Tennessee, five physicians -- none from Chattanooga -- took in more than $200,000, the database shows. No other state had as many doctors receiving that much money.

Tennessee also ranked No. 2 in the nation for prescription drug use in 2008, according to the Novartis Pharmacy Benefit Report.

Tennessee averaged 16.9 prescriptions per capita in 2008, compared with 11.8 nationwide, the report found.

Drug companies argue that paying physicians to educate others on their products benefits patients by keeping doctors up to date on medical advances.

"Patients ultimately benefit when physicians are well informed and knowledgeable about our medicines, treatment options and standards of care," according to an e-mail from AstraZeneca spokeswoman Katie Lubenow. "We are working to ensure that there is full transparency surrounding payments to physicians and in other areas where patients and other interested stakeholders have voiced concern over manufacturer influence."

AstraZeneca also is complying with new industry-sponsored restrictions on distributing promotional items, such as pens and paper pads, to doctors' offices, and with prohibitions on treating doctors to meals in restaurants.

In a 2007 article, the New England Journal of Medicine reported that the pharmaceutical industry spends the bulk of its $30 billion annual marketing budget on direct marketing and free samples to physicians.


Doctors also argue that they are asked to speak on behalf of drug companies because of their clinical expertise, and there is no reason they shouldn't be compensated for their time.

"We're considered experts in our field. I guess we're supposed to spend hours and hours of time educating other doctors for free," said local pulmonologist Daniel Smith.

The database lists Smith as receiving $21,500 from GlaxoSmithKline for speaking about treatments for chronic obstructive pulmonary disease.

Smith chafed at what he said were accusations that seem to underlie the ProPublica database.

He emphasized that his use of GlaxoSmithKline's Advair inhaler began long before he started speaking for the company.

"The assumption is if the doctor didn't have the relationship, he wouldn't prescribe the medication," he said. "It basically is a way to impugn my reputation, in a sense, by implying that there's some nefarious payments under the table."

While some local doctors resent the implication that such payments could represent a conflict of interest, local psychiatrist Dr. Lee Soloman said he welcomes the disclosures.

Soloman has received $29,825 in drug company payments in the past two years, typically in exchange for educating primary-care physicians on psychiatric medications such as antidepressants.

Though he has wrestled with whether such payments could influence his prescribing, the need to educate others outweighs the drawbacks, he said.

Because of a shortage of psychiatrists in Chattanooga, most of the psychiatric care provided locally comes from primary care doctors, he said.

"Primary care desperately needs this information in psychiatry," Soloman said. "They need their questions answered. ... But I wish there were better ways of getting this information out that [were] not so much tied to the drug companies."


Dr. Vince Viscomi, a Chattanooga sleep medicine specialist and past-president of the Chattanooga and Hamilton County Medical Society, said drug companies have pulled back from paying doctors to spread the word about their products. Now they get more bang for their advertising buck by marketing directly to consumers on TV, he said.

"Everyone is going away from this [doctor payment] model because, with all the generics out there now, unless patients ask for something, a lot of them have generic equivalents," he said. Drug companies are now "spending their money on television ads, rather than pharmaceutical reps and educating physicians on their products."

Still, a recent survey found that patients are concerned about ties between their doctors and for-profit drug manufacturers.

According to an October Consumer Reports survey, 77 percent of 1,250 people surveyed said they would be somewhat or very concerned about the quality of advice they would get from a doctor who took drug company payments. The survey was conducted in collaboration with ProPublica.

Another survey found that some doctors are severing ties to drug companies. The number of doctors who accepted payments for attending medical meetings, including money for travel, dropped from 35 percent in 2004 to 18 percent in 2009, according to the survey led by a researcher at Massachusetts General Hospital and Harvard Medical School.

Local obstetrics and gynecology physician Dr. Kirk Brody also has qualms about doctors' financial ties to drug companies. He is listed as having received $912 from Pfizer for meals and travel to attend medical conferences.

But Brody said he hasn't actually spoken on behalf of a drug company for eight years or so. He quit after one year when he realized the drugs he lectured about ended up popping into his head when it came time to prescribe, he said.

"I felt like it was probably influencing my prescription habits," he said. "If you're out there singing the praises of something, you tend to believe it. It was just an ethical problem."

On the other hand, Jennings said his overall prescribing levels have actually decreased since he began devoting more of his time to public speaking in 1998.

"I'm out of my office and I actually see less patients. My actual prescribing went down for these products as I spoke more," he said.

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