Top Medicare Prescribers Rake In Speaking Fees From Drugmakers

This story was co-published
with NPR.

When the blood pressure drug Bystolic hit the market
in 2008, it faced a crowded field of cheap generics.

So its maker, Forest Laboratories, launched a
promotional assault on the group in the best position to determine Bystolic’s
success: those in control of prescription pads. It flooded the offices of
health professionals with drug reps, and it hired doctors to persuade their
peers to choose Bystolic — even though the drug hadn’t proved more
effective than competitors.

The strategy worked. In the 2012 fiscal year, sales of
Bystolic reached $348 million, almost double its total from two years earlier,
the company reported.

Now, data obtained and analyzed by ProPublica suggest
another factor in Bystolic’s rapid success: Many of the drug’s top prescribers
have financial ties to Forest.

At least 17 of the top 20 Bystolic prescribers in Medicare’s prescription drug program in 2010 have been paid by Forest to deliver
promotional talks. In 2012, they together received $283,450 for speeches and
more than $20,000 in meals.

Nearly all those doctors were again among the highest
prescribers in 2011, the most recent year for which Medicare data are
available. Forest began disclosing its payments only last year; the company didn’t
specify which drugs doctors spoke about.

Dr. Bernard Lo, who was chairman of a national
panel examining conflicts of interest in medicine, said he doesn’t believe the findings are
coincidental.

When there's no evidence a drug is better, "You
have to question: Why are doctors prescribing this?" said Lo, president of
the Greenwall Foundation, a New York City
nonprofit that funds bioethics research. "What your evidence suggests is
that there is a financial incentive for doctors who receive payments from drug
companies" for pitching their products.

Until now, doctors' prescribing habits have been
secret from all but pharmaceutical companies, which pay millions of dollars for
such information from other firms that collect it.

ProPublica's analysis marks the first time anyone has
matched payment data made public by drug companies with physician prescribing
records from the Medicare drug program, which covers about 1 out of every 4
prescriptions in the U.S.

(Readers can search for Medicare prescribers in our Prescriber
Checkup news app and for drug
company payments to doctors and other health professionals in Dollars
for Docs.)

Reporters identified the drugs that were most actively
promoted to doctors in 2010 and 2011 using rankings from Cegedim Strategic
Data, a company that tracks marketing expenses.

The top prescribers of some of these drugs, in addition
to Bystolic, also received speaking payments from the companies that made them.
As a group, these heavily marketed drugs were new or had new uses, were
expensive and often showed little benefit over existing medications or
generics.

For example, 9 of the top 10 prescribers of the Alzheimer's
drug Exelon received
money from Novartis, the drug's maker. Eight of the top 10 for Johnson &
Johnson painkiller Nucynta were paid speakers, as were 6 of the
top 10 for Pfizer's antidepressant Pristiq.

The same was true for 7 of the 10 top prescribers of
the asthma drug Advair Diskus,
made by GlaxoSmithKline. One doctor made more than $100,000 from 2009 to 2012.

Many of the physicians spoke for several drug
companies.

If financial relationships influence physicians to
choose pricier brand-name drugs that have little benefit over generics,
everyone pays the cost – particularly taxpayers, who spent $62 billion
last year subsidizing Medicare Part D.

"I've never heard a doctor that said they were
influenced, but obviously the companies are interested in doing it because the
evidence overwhelmingly suggests that doctors are influenced,"
said Rita Redberg, a cardiologist at the University of California, San
Francisco, and editor of the journal JAMA-Internal Medicine.

Companies are "not doing it for any reason except
it improves their bottom line," she said.

A survey published in
the Archives
of Internal Medicine in
2010 found that physicians with industry relationships said they were more
likely to prescribe a brand-name drug when a generic was available. And federal
whistle-blower lawsuits against several pharmaceutical companies have alleged
that payments are little more than thinly veiled kickbacks, which are illegal.
Companies have paid billions of dollars to settle the cases.

Each of the top 20 prescribers of Bystolic wrote at
least 530 prescriptions in Part D in 2010. ProPublica attempted to contact all
those who also received money from Forest. Only a handful responded to phone
calls, emails and faxed letters requesting comment.

The No. 1 prescriber of Bystolic, Los Angeles
cardiologist Gary Reznik, said that if patients have blood pressure under
control with another beta blocker, he doesn't switch them. But he believes
Bystolic is more effective at lowering blood pressure and doesn't cause the
slower heart rate and erectile dysfunction of other drugs in the class.

"If you don't have to be on a beta blocker, I
would not start you on a beta blocker," said Reznik, who was paid $3,750
to give talks by Forest in 2012. "If you have to have a beta blocker,
Bystolic would be my choice." Reznik prescribed the drug more than 2,500
times in 2010 and more than 2,900 in 2011, including refills dispensed,
Medicare records show.

"I have never felt that there were any
expectations or pressure on the part of the company that I would prescribe it
more or at all," he said.

Another top prescriber, internist Mark Barats, of West
Hollywood, Calif., said he uses smaller doses of Bystolic to achieve the same
effects as higher doses of generic medications. "It has much less side
effects, particularly much less side effects on the respiratory system,"
he said.

"I've never seen anything that contradicts what
Forest said about Bystolic," said Barats, who was paid $3,750 to speak for
Forest in 2012.

Dr. Henry Yee, who was paid $5,000 by Forest, said he
chooses the drug for many of the same reasons as Reznik and Barats. The
cardiologist, whose office is in the Los Angeles suburb of Alhambra, said he
learned about the drug from company sales reps and from reading studies. He
started prescribing it "even before I started speaking for the
company," he added.

Yee said he believes drug companies ask him to speak
for their products because is an influential specialist in his community.
"I think it is most likely because a lot of doctors listen to me," he
said.

Among the 17 top prescribers with Forest ties,
speaking payments ranged from $1,250 to $85,750. Seven doctors also received at
least $1,000 in Forest-paid meals.

But several prominent cardiologists say no studies
have proved that the benefits cited by Bystolic's top prescribers are real. Dr.
Steve Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, said
he understands why doctors would like to believe that the beta blocker has
additional benefits. "Wishing it to happen isn't the same as proving it,"
he said.

In 2008, the U.S. Food and Drug Administration rebuked Forest for an ad claiming the drug was "novel" and superior
to other products. The FDA said the claim wasn't factual.

"I don't see any purpose for Bystolic whatsoever,"
said Eric Topol, a cardiologist and chief academic officer of Scripps Health, a
San Diego-based health system. Topol said he doesn't use the drug because it is
expensive with no added benefit. "I have no idea how you could come up
with a storyline for use of that drug."

Bystolic costs about $80 per month, compared with less
than $10 for a generic cousin, according to Costco's pharmacy website. (Patient
copays vary by drug plan.)

In an email, a Forest representative called Bystolic "an
important treatment option" because it is effective and well-tolerated but
didn't assert that the drug was superior.

Forest also defended its spending on physician
speakers. The company "believes that patients benefit" from paid
talks and other initiatives that "enable health care professionals to stay
abreast of the latest treatment options available," a representative
wrote.

Three years ago, Forest paid the government $313 million to settle civil and criminal allegations about its
marketing of drugs, among other things. In its lawsuit, the government alleged that Forest made "cash payments disguised as
grants or consulting fees, expensive meals and lavish entertainment, and other
valuable goods and services" to doctors.

Forest denied those allegations despite settling the
case.

More recently, in a lawsuit unsealed in April against the drug company Novartis, the U.S. government alleged the company's "own
internal analyses showed that speaker programs had a high return on investment
in terms of the additional prescriptions for its drugs written by the doctors
who participated in the programs, both as speakers and attendees, with the
highest return arising from payments to doctors as 'honoraria' for speaking."

Novartis disputed the allegations. In 2010, the firm pleaded guilty to a misdemeanor and paid $422.5 million to settle allegations that it
illegally promoted Trileptal, an antiseizure drug, and paid kickbacks for
prescribing it and other drugs. Trileptal isn't frequently used in the Medicare
population.

Forest, Novartis and other drugmakers said they choose
speakers based on their expertise and credentials.

Pfizer "explicitly prohibits the selection of
speakers based on their prescribing behavior ... any inference to the contrary
is misleading," a spokesman wrote in an email. Glaxo and Johnson &
Johnson also said they don't choose speakers based on prescribing.

The spending by pharmaceutical companies on speaking
and consulting fluctuates based on whether they have new drugs or are marketing
older ones for new uses.

To date, only 16 companies have publicly reported
their payments to physicians. All companies will be required to report such
payments next year under the Physician Payment Sunshine Act, a part of the broader 2010 health overhaul law.

Boehringer Ingelheim Pharmaceuticals, the maker of the
blood thinner Pradaxa, began reporting its payments just last month. Pradaxa, introduced in 2010, accounted for more spending on local promotional events than any other drug in 2011, according to Cegedim Strategic Data. Of the
top 20 prescribers in 2011, six received speaking fees in the first quarter of
this year.

Boehringer said it doesn't pay speakers based on
prescribing.

The physician prescription tallies in this story are
from Medicare Part D records in 2010. Recently obtained data for 2011 show
similar patterns, however. The prescription counts don't include drugs paid for
by other parts of Medicare or for patients with private insurance, on Medicaid
or in the Veterans Health Administration system.

Some doctors say the drug company money can undermine patients'
trust.

Nissen of the Cleveland Clinic said: "I don't
want the patient sitting opposite to me in the exam room to have to worry about
whether I am prescribing a drug because I am being paid by the company that
makes the drug."

Correction, July 3: The original version of this story incorrectly said the blood thinner Pradaxa accounted for more spending on promotional speakers than any other drug in 2011 and attributed that to Cegedim Strategic Data. Pradaxa actually ranked first for spending on local promotional events, including meeting venue, speakers fees and catering, according to the company, which doesn’t track spending on speakers alone.