October 22, 2010 — Psychiatrists dominate a list of physicians receiving the most in payments from pharmaceutical companies, according to a free, interactive database of such payments launched by investigative journalism group ProPublica, in partnership with other US media outlets

So far, the database includes payments made by 7 of the biggest pharmaceutical companies — some of which the US Department of Justice has required to disclose physician payments as part of settlement agreements over illegal drug marketing — which account for a boggling $258 million in payments to roughly 17,700 physicians. The plan is to add 70 more companies.

Any US physician is searchable by name in the database.

"Receiving payments isn't necessarily wrong," says the homepage for the Dollars for Docs, "but it does raise ethical issues."

The payments covered by the project include fees for such items as speaking, consulting, meals, and travel; the different types of payments from different companies have been compiled, streamlined, and tallied by ProPublica.

The 10 highest-paid physicians in 2009 to 2010 for each of the 7 companies are listed on the site, spanning all medical disciplines.

Endocrinologist Firhaad Ismail, MD, from Las Vegas, Nevada, ranked number one in pharmaceutical industry compensation, receiving $303,558 from GlaxoSmithKline, Eli Lilly, and Merck. Dr. Ismail did not return messages left with his office requesting an interview.

Top-Paid Psychiatrist Says Payments Do Not Cloud Clinical Judgment

ProPublica researchers also compiled a list of physicians who were paid more than $100,000 (typically from more than 1 company) during the past 18 months, turning up 384 names, including 41 who earned more than $200,000 through speaking or consulting arrangements and 2 who earned more than $300,000 from 1 or more of the 7 companies.

More psychiatrists are listed in the database than any other kind of specialist. Of the 384 physicians in the $100,000 group, 116 are psychiatrists. Leading all psychiatrists was Roueen Rafeyan, MD, in Chicago, Illinois, who received $203,936 from Eli Lilly, AstraZeneca, Johnson & Johnson, and Pfizer, mostly for professional education programs.

In an interview with Medscape Medical News, Dr. Rafeyan said that compensation from pharmaceutical companies does not cloud his clinical judgment at the expense of patients.

The day I'm influenced by that is the day I'm not fit to practice medicine.

"The day I'm influenced by that is the day I'm not fit to practice medicine," Dr. Rafeyan said.

He noted that the majority of the drugs he prescribed were generics. "If someone looked at my prescribing patterns, it would be the opposite of the [pharmaceutical] money I receive," said Dr. Rafeyan, an assistant clinical professor at Rush University Medical Center in Chicago.

Dr. Rafeyan said that although the extra income is always welcome, patient well-being was his prime motivation to talk to other physicians about brand-name psychiatric drugs. "When you educate other physicians, hopefully 1 patient will benefit from it."

When asked how he found the time to earn more than $200,000 as a pharmaceutical company educator over 18 months, Dr. Rafeyan said, "I work very hard, like many other physicians. None of us have 40-hour work weeks."

Dollar Value of Psychiatric Drugs Is Enormous

The preponderance of psychiatrists on the ProPublica list may reflect the proportion of prescription activity involving psychiatric drugs. In 2009, the dollar value of antipsychotic drugs came to $14.6 billion, topping all other therapeutic classes, according to research firm IMS Health. Antidepressants occupied the number 4 spot on the list, valued at $9.9 billion.

IMS Health put the total US prescription market in 2009 at $300.3 billion.

Carol Bernstein, MD, president of the American Psychiatric Association, told Medscape Medical News that the thorny issue of pharmaceutical industry compensation went beyond her specialty.

People with high-profile, high-visibility [positions] sometimes get carried away.

"Academic medicine needs a different relationship with the pharmaceutical industry," she said. Physicians must find new ways to facilitate the development of new drugs that do not compromise their ethics or patient care.

"People with high-profile, high-visibility [positions] sometimes get carried away," she said.

Research has shown, Dr. Bernstein added, that heavy pharmaceutical marketing indeed influences physician prescribing.

The Rest of the Compensation Leader Board

After psychiatry, the next largest specialty in the $100,000 group is internal medicine. However, this is an amorphous category, because many of the 114 physicians shown as board certified in internal medicine also are certified in fields such as endocrinology, neurology, cardiovascular disease, and medical oncology.

Table. 11 Most Compensated Specialties After Psychiatry and Internal Medicine

*Some physicians are listed with more than 1 board certification.

More to Come

By 2013, 70 additional companies will be required to disclose payments under federal healthcare reform legislation, a notion originally brought forward as the Physician Payments Sunshine Act.

ProPublica says it has launched a "rolling series" of stories generated by their research. The first addresses the high number of physicians paid to speak for drug companies who also have limited credentials or have faced disciplinary actions, criminal convictions, malpractice lawsuits, hospital sanctions, or US Food and Drug Administration warning letters.

Two of ProPublica's partners, the Chicago Tribune and the Boston Globe, have also used the database to research their own stories. The Globe's article focuses on payments to physicians at Harvard University and other Boston-area institutions, noting that "numerous doctors at Beth Israel Deaconess Medical Center and Boston Medical Center" also received payments, "despite hospital policies saying physicians cannot be paid speakers unless they control the content of the talks." The Tribune article zeroes in on payments being made to 4 Chicago-area practices: the psychiatry department at Rush University Medical Center, a headache clinic, a suburban urology practice, and a psychiatric hospital.

An editor's note on the ProPublica Web site urges interactivity and collaboration, inviting patients to search for their physicians and email the Web site with comments or stories. It also notes that stories of the kind being generated from this list would, in the past, have been "scoops" for single news organizations.

"We think we can achieve our primary mission at ProPublica — journalism that spurs change — by working in concert with other talented journalists and with the tens of thousands of people who will view, hear, and read stories by this partnership."

Copyright © 2012 H.E.Butler III M.D., F.A.C.S.