This story has been updated.
Few days went by last year when New Hampshire nephrologist Ana Stankovic didn't receive a payment from a drug company.
All told, 29 different pharmaceutical companies paid her $594,363 in 2014, mostly for promotional speaking and consulting, but also for travel expenses and meals, according to data released Tuesday detailing payments by drug and device companies to U.S. doctors and teaching hospitals. (You can search for your doctor on ProPublica's updated Dollars for Docs interactive database.)
Stankovic's earnings were certainly high, ranking her about 250th among 606,000 doctors who received payments nationwide last year. What was more remarkable, though, was that she received payments on 242 different days — nearly every workday of last year.
Reached by telephone Tuesday, Stankovic declined to comment. On her LinkedIn page, Stankovic lists herself as vice chief of staff at Parkland Medical Center HCA Inc. in Derry, New Hampshire, and as medical director of peritoneal dialysis at DaVita Inc., also in Derry.
That doctors receive big money from the pharmaceutical industry is no surprise. The new data released by the Centers for Medicare and Medicaid Services shows that such interactions are widespread, with not only doctors, but thousands of dentists, optometrists, podiatrists and chiropractors receiving at least one industry payment from August 2013 to December 2014.
What is being seen for the first time now is how ingrained pharmaceutical companies and their sales reps are in the lives of those who write prescriptions for their products. A ProPublica analysis found that 768 doctors received payments on more than half of the days in 2014. More than 14,600 doctors received payments on at least 100 days in 2014.
Take Juichih Hsu, a Maryland doctor whose specialty is family medicine. She received payments on 286 days of 365, more than anyone else. Sometimes, she received meals from several drug companies on the same day. Hsu's payments totaled $5,959 in 2014. She declined to comment when reached on Tuesday.
"There are physician practices which have very deep relationships with pharmaceutical representatives, where they are a very integral part of the practice," said Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School who has written about industry relationships with doctors. "Every day it's another drug company coming in for a lunch. Sometimes it may be some drug companies are bringing breakfast and some are bringing lunch and it's just part of the culture of the practice."
Sometimes there may be more at work than that.
A Packed Schedule
Maryland physician Juichih Hsu received payments — mostly food and beverages--from drug and device companies on 286 days in 2014, more than any other doctor in the country. Each box below represents a single day during the disclosure period. A gray box indicates no payments.
Source: Centers for Medicare and Medicaid Services
Graphic by: Cecilia Reyes/ProPublica
The doctor with the second-highest number of interactions with drug and device reps, John Fritz, of Jersey City, N.J., logged payments on 256 days last year. His payments totaled $232,003. Fritz was indicted in June for referring patients to a medical imaging company from 2006 to 2013 in exchange for about $500,000 in kickbacks. He was charged with fraud and bribery, according to a release from the state attorney general's office. A woman who answered the phone at his office on Tuesday said he declined to comment.
Kesselheim said that to have such extensive contact with industry reps can indicate that doctors are getting their information about the drugs they prescribe from the companies that make them, and not from impartial sources. "There's good evidence that that affects prescribing practices and physician behavior."
The drugs for which Stankovic received the most money to promote are costly. One, H.P. Acthar Gel, cost an average of nearly $39,000 a prescription, Medicare data from 2013 shows, and experts say there's little evidence it works better than less expensive drugs. Another drug, Soliris, for which Stankovic received promotional payments is among the most expensive drugs in the world but is considered highly effective in treating serious kidney disease.
ProPublica's analysis turned up big differences in the number of industry interactions among physicians in different specialties. On average, doctors who received payments interacted with drug and device companies on 14 days last year, receiving an average of $3,325 in total.
The nation's 3,900 rheumatologists in the data averaged 40 days of interactions with drug and device companies, more than doctors in any other large specialty. They were followed closely by endocrinologists, electrophysiologists and interventional cardiologists. On the other end of the spectrum, dentists, chiropractors, neonatologists and pathologists had among the fewest interactions with drug and device makers.
Some of the doctors who had the highest number of interactions were those ProPublica has previously identified as having high rates of brand-name prescribing in Medicare's prescription drug program, known as Part D. Others have been mentioned in previous ProPublica stories about doctors who have received large payments from the drug industry. A number of experts, including Kesselheim, note that payments from industry may influence physicians' choice of drugs.
A spokeswoman for the pharmaceutical industry said in a statement that company interactions with doctors are important.
"Collaboration between physicians and biopharmaceutical professionals is critical to improving the health and quality of life of patients," the statement from the Pharmaceutical Research and Manufacturers of America said. "Clinical trials sponsored by biopharmaceutical companies have led to life-saving breakthroughs for people suffering from cancer and other life-threatening diseases. Physicians also provide real-world insights and valuable feedback to companies about their medicines to improve patient care. Educating the public about the nature of these collaborations helps patients understand in which ways these interactions can improve both their health and medical innovation."
ProPublica has been tracking industry payments to doctors since 2010. Our Dollars for Docs interactive database allowed people to search payments made by 17 companies between 2009 and 2013. Most of those companies were required to report their payments as a condition of legal settlements with the federal government.
The data released Tuesday radically expands the amount of data available to patients — and ProPublica has overhauled Dollars for Docs to include these payments. The Physician Payment Sunshine Act, a part of the 2010 Affordable Care Act, mandated that all drug and device companies publicly report payments to doctors. The transparency effort is called Open Payments.
The government initially released some data last fall, covering the period of August to December 2013, but it was significantly redacted because of data inconsistencies. The data released Tuesday covers the period of August 2013 to December 2014. The data inconsistencies have been resolved.
All told, 1,617 companies reported 15.7 million payments valued at $9.9 billion. Nearly all of those payments — 14.9 million — were classified as "general payments," covering promotional speaking, consulting, meals, travel and royalties. They totaled $3.5 billion over the 17-month period.
Where Did the Payments Go in 2014?
A breakdown of general payments by category, not including research or payments to physician owners of a company.
Source: Centers for Medicare and Medicaid Services
Graphic by: Cecilia Reyes/ProPublica
Correction, July 2, 2015: This graphic included incorrect numbers for “Gift" and "Nonaccredited Training.” They have been corrected.
There were far fewer research payments, 826,000, but they were valued at $4.8 billion. The remaining payments related to ownership or investment interests that doctors had in companies. Research and ownership payments are currently not shown in Dollars for Docs.
Open Payments does not include money spent on drug samples left at doctors’ offices and doesn’t include the bulk of the money companies spend on independently administered continuing medical education, which they support with unrestricted grants. The government has tightened the rules for reporting such continuing education in the future.
From August 2013 to December 2014, Genentech Inc. spent the most on general payments, $387.7 million, mostly royalties for its drugs Rituxan, Avastin and Herceptin to City of Hope National Medical Center in Duarte, California. That was four times more than the second-ranked company, DePuy Synthes Products LLC, which spent $94.7 million, nearly all on royalties. Topera Inc., a small medical device company, came in third, with $93.1 million, almost exclusively acquisition payments to its physician founders from device maker Abbott Laboratories.
Among other pharmaceutical companies, AstraZeneca spent the most on general payments ($90.9 million), followed by Pfizer ($82.1 million) and Allergan ($70.7 million). In a statement, AstraZeneca said that it believes "it is important to be open about the way we conduct our business and how we help people through our medicines and programs. We are committed to the highest standards of conduct in all of our operations, including how we partner with physicians and medical institutions."
Royalty fees, though few in number, accounted for $803.5 million in general payment spending in 2014, more than any other category. They were followed by promotional speaking ($632.4 million) and consulting ($369.4 million). Food and beverages accounted for the highest number of payments by far, 9.4 million, but these had a relatively low value of $224.5 million.
ProPublica news application developers Mike Tigas and Lena Groeger and senior reporting fellow Annie Waldman contributed to this report.
Update, July 8, 2015: Although Stankovic declined to comment for the initial story, she has now provided the following statement: "I am very passionate about clinical research and up to date medical information; and truly enjoy educating medical professionals on various complicated disease states. There is so much new information to be learned every day in medicine, but simply there is no enough time during the day, especially if provider has a busy medical practice. Many of the interactions that doctors have with pharmaceutical industry are needed in order to stay current with newer FDA approved therapies that may cure illnesses or slow progression of the complicated diseases. Patients should be able to appreciate those medical professionals who can thoroughly discuss all available treatment options on the market and warn them about possible side effects and contraindications."