TIMES WATCHDOG | An analysis by investigative journalists at ProPublica, with cooperation from The Seattle Times, finds that half of top doctors in Washington accept payments from the medical industry, and those who do are twice as likely to prescribe brand-name medications at high rates.
About half of doctors in top specialties in Washington state accept payments from pharmaceutical firms and medical-device makers, far less than their peers nationwide. But those who take the cash are nearly twice as likely as those who don’t to prescribe brand-name drugs at high rates.
That’s according to an analysis from the investigative journalism organization ProPublica, with cooperation from The Seattle Times, which provides evidence for the first time that doctors who accept payments prescribe drugs differently on average than those who don’t.
Doctors have long rejected the idea that the money they receive from pharmaceutical firms has any relationship to the way they prescribe drugs.
In Seattle, HIV expert Dr. Peter Shalit, 62, said there’s little link between the nearly $189,000 he received from the industry in 2014, mostly in consulting and speaking fees, and his very high rate of prescriptions for brand-name drugs.
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Yes, about 55 percent of his scripts were for name brands in 2014, more than twice that of his peers in internal medicine. But they’re mostly for his patients with HIV/AIDS, who have few generic alternatives, he said.
Shalit also lends his prescribing authority to chain stores such as Walgreens and Fred Meyer to allow them to dispense vaccines, adding thousands of doses of brand-name Tdap and shingles shots to his tally.
“It’s a very crude analysis because it doesn’t show the full picture,” he said. “I’m an outlier. I’ve been dropped from insurance plans for that.”
The examination by ProPublica, and a review by The Seattle Times, finds there is, overall, a relationship between payments to doctors and prescribing practices.
Doctors in the U.S. and in Washington state who received payments from the medical industry prescribed a higher percentage of drugs overall than those who didn’t. And the more money they received, the more name-brand medications they tended to prescribe, the analysis showed.
ProPublica matched records of payments from pharmaceutical firms and medical-device makers in 2014 with corresponding data on doctors’ medication claims in Medicare’s prescription-drug program. (Read their methodology here.)
They looked at doctors in the five top specialties — family medicine, internal medicine, cardiology, psychiatry and ophthalmology — who wrote more than 1,000 prescriptions for Medicare Part D patients in 2014.
Nationwide, about three-quarters of those doctors accepted payments, including speaking and consulting fees, travel, meals and gifts, ProPublica found.
And those who received the funds were two to three times as likely to have high or very high rates of brand-name prescribing as those who didn’t accept payments.
In Washington, 51 percent of the 3,286 doctors in the analysis received industry payments — and they were nearly twice as likely to prescribe brand-name drugs at high rates as those who did not receive payments.
Those 1,668 doctors accepted industry funds that totaled more than $2.1 million. Amounts ranged from as low as $4 to as much as $466,244, with an average payment of $1,296.
The doctor who received the most in payments, Dr. Robert M. Bersin, 61, an interventional cardiologist at Seattle’s Swedish Medical Center, did not prescribe high rates of brand-name drugs, the analysis found.
The payments Bersin receives — primarily from medical-device makers — are fees for consulting, speaking and training doctors in advanced techniques, such as cardiac stenting, that they require to stay current in their work, he said.
Industry payments do have the potential to influence prescribing habits, Bersin said.
“I can see that there could be an issue,” he said. “But it’s not really relevant to what I do.”
ProPublica’s analysis doesn’t prove that industry payments induce doctors to prescribe particular drugs, or even a particular company’s drugs. But it does show a larger pattern in which payments are associated with prescribing habits that bolster the drug companies’ bottom line.
Such a pattern makes it hard to know if the patients’ best interests are the doctors’ priority, said Dr. Howard Brody, a medical ethicist and professor at the Institute for Medical Humanities at the University of Texas Medical Branch at Galveston.
“If there’s a clear tie with the pharma industry, can we always assume it’s good for the patient?” said Brody, who has written extensively about the issue. “It’s going to be sometimes and not at other times.”
Best for the patient?
Of Washington doctors who accepted no payments, brand-name drugs accounted for 17.8 percent of their prescriptions.
Among those who accepted payments of any size, the percentage of name-brand drugs prescribed rose to 19.8 percent. And among those who received at least $5,000, that figure jumped to 27.2 percent.
Overall, among Washington doctors who received no payments, 2.5 percent were high or very high prescribers of brand-name drugs. For those who got money, the figure jumped to 4.7 percent — nearly double — the analysis showed.
That’s important information for consumers, said Dr. David Evans, a University of Washington professor of rural health who has studied the impact of industry payments on medical practice.
“Minimizing the unnecessary use of branded prescriptions is a worthy goal,” he said. “Brand-name drugs are more expensive than generics. Often, they’re less safe and usually not any better than the generics that are already out there.”
Concern about industry influence on prescribing has been a worry for years, even decades. The Washington State Medical Association (WSMA) first issued guidelines in 1993 cautioning members about accepting gifts and payments from industry representatives, said Tierney Edwards, the association’s director of legal and federal affairs.
“There has been growing concern in the medical industry that certain gifts and payments are not consistent with medical ethics,” she said.
It’s not clear why half of Washington doctors accept payments — and half don’t. Nationwide, there’s wide variation in the proportion of doctors who take money, from a high of 90 percent in Nevada to a low of 23 percent in Vermont, the data show.
Washington is in line with other states in the West. Only half of doctors in Oregon and Alaska accept payments, too, which could be one explanation, Brody said.
“If only 50 percent of my fellow doctors are accepting payments, I might not either. It does become a culture,” he said.
Many Washington doctors also work for hospitals and health systems that prohibit gifts, payments, samples and meals from industry vendors, noted Evans of the UW.
“I can’t imagine that doctors are any more virtuous or less virtuous here than anywhere else,” he said.
But the Washington doctors who received the highest payments and prescribed high or very high rates of brand-name drugs defended the practice — and their ethics.
Everett psychiatrist Dr. Larry Bornstein, 63, received 247 general payments totaling more than $142,000 in 2014, according to the government database known as Open Payments. It was formed under provisions of the Affordable Care Act to track such spending.
Bornstein is regarded as a high brand-name prescriber compared with his peers, but he said patient need, not money, drives his practice. For instance, some medications that keep patients with severe schizophrenia functional have no good generic equivalents, he said.
Like other doctors, Bornstein regularly accepts speaking fees of $2,400 to more than $4,000, plus travel expenses, to stay abreast of the latest treatments in his field — and to communicate those advances to others, he said.
“When industry is exploring new medicines, I think it’s valuable for me to be aware of that and to share what I know,” he said.
Dr. Gary Oppenheim, 60, a Bellevue interventional cardiologist, said the 30 payments totaling more than $12,000 he accepted in 2014 were from talks for three new drugs that accounted for his very high prescribing rates.
“They are more expensive, but I do not prescribe them because I have speakers’ fees from talks given for the companies that make them,” he said.
Rather, he approached the firms before the drugs he considered promising were approved, asking to learn about them so he could teach other doctors appropriate use.
Such arguments are often valid, said Evans, the UW professor. But new evidence of a link between payments and prescribing should inspire more doctors to consider industry influence — even if they believe they’re too smart to be affected.
“Time after time, when these things are looked at objectively, we’re not too smart for that,” Evans said. “I don’t think the drug companies would be pouring millions and millions of dollars into this if we were.”