Jon W. Draud, the medical director of
psychiatric and addiction medicine at two Tennessee hospitals, pursues
some eclectic passions. He’s bred sleek Basenji hunting dogs for show.
And last summer, the Tennessee State Museum featured “African Art: The
Collection of Jon Draud.”
But the Nashville psychiatrist is also notable
for a professional pursuit: During the last four years, the 47-year-old
Draud has earned more than $1 million for delivering promotional talks
and consulting for seven drug companies.
By a wide margin, Draud’s earnings make him the
best-paid speaker in ProPublica’s Dollars for Docs database, which has
been updated to include more than $2 billion in payments from 15
drugmakers for promotional speaking, research, consulting, travel, meals
and related expenses from 2009 to 2012.
Payouts to hundreds of thousands physicians are now included.
Draud is not the only high earner: 21 other
doctors have made more than $500,000 since 2009 giving talks and
consulting for drugmakers, the database shows. And half of the top
earners are from a single specialty: psychiatry.
“It boggles my mind,” said Dr. James H. Scully
Jr., chief executive of the American Psychiatric Association, referring
to the big money paid to some psychiatrists for what are billed as
educational talks.
Paid speaking “is perfectly legal, and if
people want to work for drug companies, this is America,” said Scully,
whose specialty has often been criticized for its over-reliance on
medications. “But everybody needs to be clear — this is marketing.”
When Dollars for Docs launched in 2010, it gave
the first comprehensive look at the money that drug companies spend to
enlist doctors as a sales force. The new data show how payouts to
psychiatrists like Draud and other doctors have added up over time. And
they underscore the key role physicians play for drugmaker profits even
as scrutiny and criticism of such payments grows.
The companies say physician speakers are the
best messengers to teach their peers about new and effective treatments.
But critics counter that the speakers are little more than highly
credentialed pitchmen who typically use the drug companies’ slides and
talking points to sell rather than educate.
Attention to the issue has prompted prominent
medical schools to tighten rules on faculty acceptance of drug company
money for such talks. Questions about undue industry influence also have
bedeviled medical journals and professional groups representing
physician specialists.
Susan Chimonas, a research scholar at the
Center on Medicine as a Profession at Columbia University, said many
medical centers that regulate interactions between drug companies and
their doctors would be “alarmed” by the high tallies in the updated
Dollars for Docs.
“How do these folks have time to do their real
jobs if they’re speaking so much?” Chimonas said. Hospital
administrators, she predicted, would be “concerned not only about the
conflict of interest, but also the conflict of commitment.”
Draud’s $1 million in drug company earnings is
probably a minimum figure. Some of the seven companies he represented
have reported their payouts for only a short time. And Draud has
separately disclosed ties with at least four additional companies that
haven’t revealed how much they pay speakers.
Draud has friends among the other highest-paid
doctors in the database. He teaches continuing medical education courses
with fellow psychiatrists Rakesh Jain and Vladimir Maletic. Jain, of
Lake Jackson, Texas, has earned $582,049. Maletic, of Greer, S.C., made
$527,850, according to Dollars for Docs. Both also speak for other
companies that keep their payments private.
Draud and Maletic did not return several
messages seeking comment. But in an interview, Jain said he loves
teaching and delivers the same lectures about drugs and medical
conditions regardless of whether a drug company is paying him.
“I am not a marketer, I am an educator,” Jain said.
In a later email, Jain said he is proud of his
collaboration with Draud. “He’s been fair, balanced and is wickedly
smart. And I like smart people who serve community needs.”
Jain and many top earners also have active clinical or research practices.
Next year, every drug and medical device maker
that pays physicians will have to report such spending to a federal
database as part of the Affordable Care Act health reform law. The first
disclosure, scheduled for public release in September 2014, will
include payments from August to December of this year.
The companies in Dollars for Docs accounted for
about 47 percent of U.S. prescription drug sales in 2011. It’s unclear
what percentage of total industry spending on doctors they represent,
because dozens of companies do not publicize what they pay individual
doctors. Most companies in Dollars for Docs are required to report under
legal settlements with the federal government.
Even the $2 billion total underrepresents
spending by these companies. Some in the database have begun reporting
only in the past year, and others report spending in only a few
categories. In addition, two companies reported some payments in ranges,
so that spending was excluded from the total.
Overall, roughly half the payments were for
research. A third went to speakers and the rest was for consulting,
educational materials, meals and travel.
For Some Docs, An Earnings Drop
The push for transparency on physician payments started years ago.
Studies began showing that even trinkets doled
out by drug sales reps could affect physician attitudes. At the same
time, drugmakers were settling federal lawsuits alleging that they paid
kickbacks and encouraged doctors to push drugs for unapproved uses. Two
U.S. senators began calling out prominent physicians for not properly
disclosing financial ties to the companies.
Dollars for Docs took transparency a step
further by putting the available payment disclosures in one place and
making them easy to search.
In 2010, many universities and teaching
hospitals were surprised to find that their faculty members were engaged
in promotional speaking. ProPublica compared the faculty lists of
institutions with conflict-of-interest policies barring such speaking
with the database and found a number of physicians in violation.
Drug firms, too, learned of problems with their
chosen speakers. ProPublica found their rosters peppered with some
physicians who had serious disciplinary actions against their medical
licenses.
Both the drug companies and academia tightened their policies.
Only a handful of doctors who were among the 20
highest-paid in 2010 have maintained their level of income from
speaking, the new data show.
Ten of the doctors dropped from making about
$100,000 a year to less than $20,000 in 2012. Some doctors whose
payments declined spoke about drugs the companies are no longer pushing.
Others, like prominent cancer expert David Rizzieri at Duke University
School of Medicine, faced new restrictions from their employers.
Rizzieri had been a speaker for Cephalon,
GlaxoSmithKline and Novartis in 2010 and 2011. But after Duke restricted
participation in speakers’ bureaus, his speaking pay dropped markedly
in 2012, the new data show. All told, Rizzieri has received at least
$567,300 in speaking and consulting payments since 2009.
Dr. Ross McKinney Jr., director of the Trent
Center for Bioethics, Humanities and History of Medicine at Duke, said
university officials “had multiple discussions” with Rizzieri, who “is
getting more restrained.”
McKinney said Duke physicians can deliver paid
talks about diseases, but only if they use their own slides and
presentation materials. “The general tone is a little bit more distant
and less cozy than it used to be,” he said.
In an email, Rizzieri said he still did some
paid speaking that is allowable within Duke’s new guidelines, but has
focused his attention on a series of educational talks developed by the
Division of Cellular Therapy at Duke.
New Drugs, New Dollars
Drug companies say their spending often
reflects market realities — not a changing opinion on the use of
physician speakers. Should a top-selling drug lose its patent, allowing
cheaper generics to compete, there’s no impetus to push sales. A new
drug or a new approved use for an existing drug, conversely, may prompt a
burst of speakers.
New York’s Forest Laboratories, for example, is a fraction the size of its Big Pharma brethren Pfizer, AstraZeneca and Merck.
But when it comes to paying doctors to promote its products, the drugmaker has recently dwarfed its rivals.
During the first three quarters of 2012, Forest
spent $31 million on doctors who touted the virtues of such drugs as
Bystolic for high blood pressure, the antidepressant Viibryd, and
Daliresp for chronic obstructive pulmonary disease. Nine doctors each
made nearly $100,000 from Forest in that time alone, the data show.
Pfizer — whose U.S. sales are five times
greater than Forest’s — spent a fifth of Forest’s total, paying out $6.2
million to promotional speakers during the same period. AstraZeneca,
second to Pfizer in sales, spent $12.2 million.
Forest spokesman Frank Murdolo said in an email
that the company spends more on speakers because it doesn’t use pricey
direct-to-consumer TV marketing. It also has more new drugs than its
competitors, Murdolo said.
In contrast, GlaxoSmithKline spent $52.8
million on speakers in 2010. That fell to $24.1 million in 2011 and $7.6
million in the first three quarters of last year.
Glaxo spokeswoman Mary Anne Rhyne wrote in an
email that the company’s spending tracks with new drugs or new uses for
existing products. “That activity has been relatively low in the past
year, so spending for speaker programs has been lower, too,” she said.
The top recent speaking programs for Glaxo
involved Advair, a drug for asthma and chronic obstructive pulmonary
disease, and Jalyn, which treats problems with urination for men with
enlarged prostates, Rhyne said.
Glaxo and other top pharmaceutical companies
have laid off thousands of workers in the past couple of years as their
top drugs have lost patent protections, the pipeline of new drug
approvals has slowed, and cost pressures arose.
Other companies contacted by ProPublica about their spending would not reveal which products they paid speakers to extol or why.
“We don’t disclose how we allocate our speaker
program budget,” Tony Jewell, a spokesman for AstraZeneca, said in an
email. AstraZeneca’s spending on promotional speakers decreased from
$31.6 million in 2010 to $17.6 million the following year and $12.2
million in the first three quarters of 2012.
“The decrease in spending is based on a variety
of factors, including where our medicines are in their life cycles and
brand budgets and strategies,” Jewell wrote.
The company’s blockbuster antipsychotic drug
Seroquel went off patent last year. Another top drug, Nexium, which
treats acid reflux, goes off patent in 2014.
Because each company is in a different stage
with its blockbuster drugs, it’s difficult to compare their outlay on
speakers and consultants head to head.
It may be too soon to tell whether continued
publicity over the spending will cause companies to cut back further,
said Chimonas, of the Center on Medicine as a Profession. But
transparency might be having some effect.
At a recent conference, Chimonas said she heard
that pharmaceutical companies themselves are using the disclosures
about payments to “push back on doctors who are greedy.”
“They can say, ‘No. We see you’re taking this
amount of money from our competitor. Why should we give you more than
that?’” she said.
A Harder Sell For Antipsychotics
Once a reliable profit machine for drug
companies, psychiatric drugs are now a challenge. And drugmakers are
fighting hard to stanch the losses.
Starting in the 1990s, when the second
generation of antipsychotics hit the market, drugmakers enjoyed a period
of wild profitability. Doctors embraced these new drugs, such as
Risperdal, Seroquel and Zyprexa, as safer and causing fewer of the
troubling side effects of older psychiatric drugs. Domestic sales of
Seroquel hit $4.7 billion in 2011, the year before it went off patent.
But as the drugs lost their patent protection,
their makers have tried to shift the market to newer drugs in their
stables. Critics say these new drugs are not appreciably different, but
the drug companies claim they are easier to take or have fewer side
effects.
Johnson & Johnson, for example, lost its
Risperdal patent in 2008 but now markets Risperdal Consta, a long-acting
injection, and Invega, another antipsychotic. AstraZeneca lost Seroquel
but is now marketing Seroquel XR, which works for an extended period.
The pressure to reclaim sales is great.
Overall, the market for antipsychotics dropped from $18.5 billion in
2011 to $13.7 billion last year, according to IMS Health, which closely
tracks the industry’s ups and downs.
The newer drugs, like their predecessors, need someone to explain their benefits, several doctors said.
“I actually enjoy the aspect of educating my
counterparts about developments in the field,” said Dr. Gustavo Alva, a
California psychiatrist.
Alva has received $663,751 for speaking and
consulting since 2009 for the companies in Dollars for Docs. He
separately discloses speaking for other companies as well.
Tighter restrictions on speaking and consulting
mean doctors will be less up to date on new treatments, according to
several current physician speakers.
Psychiatrists aren’t always among the
highest-paid. In 2010, when Dollars for Docs first launched,
endocrinologists represented 11 of the 43 top money-making speakers.
From year to year, the in-demand specialists are largely a function of
the market.
But critics say psychiatrists are a particular
concern because of their controversial role when the first waves of new
antipsychotics hit the market.
AstraZeneca, Johnson & Johnson and Eli
Lilly have paid billions in settlements to the federal government over
allegations that they paid doctors to push these drugs for unapproved
uses from children to seniors with dementia. One lawsuit alleged that a
Florida psychiatrist switched patients from drug to drug based on his
relationships with companies.
Texas psychiatrist Jain acknowledges the
excesses of the past and said he does not excuse them. But he said he
sees real value in the new brands because they give psychiatrists
options if their patients are not responding to older drugs.
He said he has recently spoken on behalf of
Forest’s antidepressant Viibryd, Merck’s antipsychotic Saphris, Lilly’s
ADHD drug Strattera, Pfizer’s antipsychotic Geodon and its
antidepressant Pristiq.
Having the financial support of drug companies does not lessen the value of this teaching, he said.
Jain’s tally in Dollars for Docs does not reflect his work with another group that is heavily sponsored by drugmakers.
Jain, top-paid speaker Draud and Maletic all
serve on the advisory board and steering committee of the U.S.
Psychiatric and Mental Health Congress, which will hold its annual
convention in Las Vegas in September and October. Maletic is the 2013
program chairman.
The convention receives financial support from
several drug companies, and some of its presentations are sponsored by
the firms, according to information on its website. Much like
professional medical societies, the congress also collects fees for drug
company ads on things attendees see at their conventions, from tote
bags to hotel room keys.
The congress is owned by North American Center
for Continuing Medical Education, LLC, a for-profit New Jersey company
that provides continuing medical education courses. Health professionals
must take such classes periodically to retain their licenses. Draud,
Jain and Maletic also teach classes for the company.
In response to written questions, Randy P.
Robbin, president of the company, said members of the steering committee
have “demonstrated experience and expertise in mental health and
commitment to providing the highest quality education possible.”
The trio are paid for their work for the
congress, but the money does not come from pharmaceutical sponsors,
Robbin said. In continuing medical education courses, he said, drug
companies don’t have a say in the educational content or speaker
selection.
Jain said in an interview that his talks for
the company are reviewed for bias before and after he speaks. “I cannot
present anything at the Psych Congress that hasn’t been vetted
repeatedly,” he said. “Pharma is not able to influence anything that I
do at the Psych Congress.”
Scully, of the American Psychiatric
Association, said he hopes all the drug company money doesn’t taint
relationships between patients and their doctors.
“The public trust,” he said, “is too important.”
—
Utah doctors paid $25.8 million by drug companies
Drug companies have made $25.8 million in
payments to Utah doctors since 2009 for research, consulting, travel
and entertainment — a common practice, the scope of which is only now
becoming clear and causing uneasiness in medicine.
