Doctors At Southern Hospitals Take The Most Payments From Drug, Device Companies

Jun 29, 2016
Originally published on February 14, 2018 3:28 pm

Where a hospital is located and who owns it make a big difference in how many of its doctors take meals, consulting and promotional payments from pharmaceutical and medical device companies, a ProPublica analysis shows.

A higher percentage of doctors affiliated with hospitals in the South have received such payments than doctors in other regions of the country, our analysis found. And a greater share of doctors at for-profit hospitals have taken them than at nonprofit and government facilities.

Doctors in New Jersey, home to many of the largest drug companies, led the country in industry interactions: Nearly 8 in 10 doctors working at New Jersey hospitals took payments in 2014, the most recent year for which data are available. Nationally, the rate was 66 percent. (Look up your hospital using ProPublica's new tool.)

For the past six years, ProPublica has tracked industry payments to doctors, finding that some earn hundreds of thousands of dollars or more each year working with drug and device companies. We've reported how the drugs most aggressively promoted to doctors typically aren't cures or even big medical breakthroughs.

And we recently found an association between payments and higher rates of brand-name prescribing, on average. Accepting even one inexpensive meal from a company was associated with a higher rate of prescribing the product to which the meal was linked, another study showed.

This analysis shows profound differences among hospitals, but it's uncertain why that is. It could be that hospitals play a role in shaping affiliated doctors' acceptance of payments or that like-minded physicians congregate at particular hospitals.

Those who support limits on such payments say patients may want to know how prevalent industry money is at a hospital before choosing it for care. "Maybe they're prescribing or treating you as a patient not based on evidence but rather based on markets or industry gain or personal gain," said Dr. Kelly Thibert, president of the American Medical Student Association, which grades medical schools and teaching hospitals on their conflict-of-interest policies. Patients, she said, "need to be aware that this could potentially be an issue and they need to speak up for themselves and their loved ones who may be in those hospitals."

ProPublica matched data on company payments to physicians in 2014 with data kept by Medicare on the hospitals with which physicians were affiliated at the time. We only looked at each doctor's primary hospital affiliation and only at doctors eligible to receive payments in the 100 most common medical specialties. The payments included speaking, consulting, meals, travel, gifts and royalties, but not research.

To be sure, the data aren't perfect. Companies must report their payments to the federal government, and some doctors have found errors in what's been attributed to them. Companies can face fines for errors, and doctors have a chance each year to contest information reported about them. Also, Medicare's physician data may not capture doctors who don't participate in the program and it may not accurately reflect the status of doctors who have moved. (Read more about how we conducted our analysis.)

As might be expected, hospitals with tougher rules, such as banning industry reps from walking their halls and bringing lunch, tended to have lower payments rates. For example, at Kaiser Permanente, a giant California-based health insurer that runs 38 hospitals, fewer than 3 in 10 doctors took a payment in 2014. Since 2004, the system has banned staff from taking anything of value from a vendor.

"Our intent was to disrupt the strategy of using what industry calls 'food, friendship and flattery' to develop relationships with prescribers and influence the choice of drugs, the choice of devices, implants, things like that," said Dr. Sharon Levine, an executive vice president of the Permanente Federation, which represents the doctor arm of Kaiser Permanente. "Passing a policy alone doesn't make anything happen. There's a fair amount of surround-sound in the organization around reminding people about this and reminding them why we took this step."

Levine said she believes many of the payments attributed to Kaiser doctors were for meals and snacks at professional meetings, even if they didn't eat them.

ProPublica's analysis found distinct regional differences in comparing where industry payments were most concentrated.

After New Jersey, the states with the highest rates of hospital-affiliated doctors taking payments were all in the South: Louisiana, Mississippi, Florida, South Carolina and Alabama had rates above 76 percent. At the other end of the spectrum, Vermont had the lowest rate of industry interactions (19 percent), followed by Minnesota (30 percent). Maine, Wisconsin and Massachusetts had rates below 46 percent. Some of these states had laws requiring public disclosure of payments to doctors that predated the federal government's.

There were also major differences between hospitals based upon who owned them. For-profit hospitals had the highest rate of payments to doctors, 75 percent, followed by nonprofit hospitals at 66 percent. Federally owned hospitals had the lowest rates at 29 percent, followed by other government hospitals at 61 percent. Hospitals operated by the U.S. Department of Veterans Affairs weren't included in our analysis.

Among hospitals with at least 50 affiliated doctors, the one with the highest proportion of doctors taking payments was St. Francis Hospital-Bartlett, a relatively small hospital outside Memphis that is owned by Tenet Healthcare Corp. Fifty-nine of the 62 doctors for which Medicare listed St. Francis as their primary affiliation took payments in 2014, a rate of 95 percent.

In a statement, the hospital said it supported disclosure and transparency: "Patients should have the ability to access information about any relationship that might exist between their doctor and the companies that make the products that might be recommended for their care, so that they can discuss that information directly with their physician." Spokesman Derek Venckus declined to answer other questions about the hospital's rate or its policies.

Overall, our analysis showed, the percentage of doctors taking payments at a given hospital wasn't correlated with the share of its doctors receiving larger payments, those totaling $5,000 or more. (In part that may be because so few doctors received more than $5,000.)

Some hospitals had a relatively low proportion of doctors taking payments but a relatively high share of doctors taking substantial amounts of money. In these cases, experts say, the hospitals are probably banning meals and gifts while permitting or encouraging deeper relationships, often with oversight.

At Karmanos Cancer Center in Detroit, more than a quarter of doctors took more than $5,000 from industry in 2014, the highest rate in the nation. Spokeswoman Patricia Ellis said in an email that the hospital has conflict-of-interest policies in place and is comfortable with its level of physician interactions.

"Our cancer experts are committed to providing exceptional care and work tirelessly to find/discover/advance innovative treatments that can help patients survive their cancer," she wrote. "I lost both my parents and several other loved ones to cancer. ... I know our experts at Karmanos Cancer Institute are doing everything they can to help other cancer patients have more time with their loved ones. And they're doing that with the highest integrity and commitment."

Many cancer hospitals and specialty hospitals, including heart and orthopedic facilities, had among the highest rates of doctors receiving high-dollar payments.

Researchers as well as officials at the Association of American Medical Colleges, a trade group for medical schools and teaching hospitals, said they hadn't analyzed the data the way ProPublica has. But officials said members do track payments made to doctors at their own institutions.

Across the country, hospital and medical school leaders are divided about what constitutes an appropriate payment. "There is a range of opinions between those people who believe that industry payments should be cut out vs. those who believe that there's a way to carefully monitor them," said Dr. Janis Orlowski, the association's chief health care officer.

ProPublica found differences in the payment rates at teaching hospitals based on the grades assigned to them by the American Medical Student Association, which reviewed their conflict-of-interest policies in 2014.

At the A hospitals we analyzed, 46 percent of doctors took a payment, compared to 48 percent at B hospitals, 58 percent at C hospitals and 63 percent at hospitals rated as incomplete because their policies were "insufficient for evaluation." By comparison, 69 percent of doctors at unrated hospitals took payments. Of the 204 hospitals graded, about 150 were in ProPublica's data (hospitals run by the U.S. Department of Veterans Affairs were not).

"I think that's significant," said Thibert, the group's president. "That's still a lot of docs receiving money unfortunately. That's something we're continuing to work on."

The University of Iowa Hospitals and Clinics received an A on the scorecard. Its rate of doctors taking payments, less than 27 percent, is among the lowest in the country. Less than 3 percent of its doctors took payments worth at least $5,000, also below average. Its policy, in place since 2009, bans drug companies from providing gifts and meals in almost all circumstances, bans doctors from giving promotional talks and requires consulting arrangements be signed off on by officials.

"We really have had great success in getting [physicians] to comply with it," said Denise Krutzfeldt, manager of the health system's conflict of interest office.

Other hospitals with below-average rates, including Massachusetts General Hospital and Stanford Hospital, limit interactions between doctors and pharmaceutical representatives and monitor doctor interactions with industry closely, officials said. Some post details of their doctors' commercial relationships on their websites.

In interviews, some said they double-checked their physicians' disclosures against the data reported by the companies.

"It's like stop signs. Everybody knows they're supposed to stop at stop signs but as you and I both know, people seem to cruise through them from time to time," said Dr. Harry Greenberg, senior associate dean for research at Stanford University School of Medicine. "That's just human nature. We have a system we try to pick it up and do corrective action."

Deputy data editor Olga Pierce contributed to this report.

Copyright 2018 ProPublica. To see more, visit ProPublica.

ROBERT SIEGEL, HOST:

Some doctors take payments from drug and medical device companies, and the nonprofit newsroom ProPublica has been investigating those payments for years. Its latest analysis looks at hospitals and what types of hospitals are most likely to have doctors who take payments. And here to discuss their findings is Charles Ornstein of ProPublica. Welcome to the program once again.

CHARLES ORNSTEIN: Thanks, Robert.

SIEGEL: And tell us mainly what were your findings?

ORNSTEIN: Well, there's actually really big differences between hospitals when it comes to the doctors that take payments from drug companies or medical device companies. Doctors who work at for-profit hospitals - so those are hospitals that are owned by corporations or individuals - are more likely to take these payments than the doctors who work at not-for-profit hospitals or government hospitals.

But also there's big differences based on parts of the country. So doctors in the South, southern United States, are more likely to take these payments than doctors pretty much anywhere else.

SIEGEL: Now, you mentioned that at for-profit hospitals, the rate of doctors receiving payments is higher. But what about the medical or surgical specialties of the hospitals?

ORNSTEIN: So it's interesting because cancer centers across the United States and also specialty hospitals, like surgical hospitals, orthopedic hospitals, heart hospitals, you find a higher percentage of doctors who are taking big money payments. So those are payments that are greater than $5,000.

SIEGEL: The implication here is that payments might lead a doctor to make a decision to use a drug that the doctor might not otherwise have made. If that's true, what could be done about that?

ORNSTEIN: Well, there is definitely a concern that there's some type of a link between money that's provided by a company and the decisions that a doctor makes whether that's in the operating room or with their prescription pad.

And what the key thing that experts have told us is that patients just need to be aware and not be afraid to ask the question of their doctor. Is there a less expensive drug you can get for me? Is there a surgical intervention that perhaps doesn't use a device that you're getting a royalty on? So those are the types of questions that - while they're uncomfortable - having this information may make us a little more willing to ask.

SIEGEL: That would be patient behavior. What would be an example of, say, a hospital policy that might curb some bad behavior?

ORNSTEIN: Well, that's interesting, I mean, because this behavior isn't illegal, and some people don't even view it as bad. But a number of hospitals have put in place policies that restrict their physicians' ability to interact with a drug and device industry. So they don't let them take free meals, and they don't allow drug representatives to walk the halls of the hospital or to access physicians as easily as they did in the past.

And what we found in looking at this data is that a lower percentage of doctors at those hospitals have relationships and in some cases a much lower percentage of doctors.

SIEGEL: Let me play doctor's advocate here for a moment. Let's say that there are drugs that issue new drugs that are actually especially effective and better than the old drugs. If drug companies weren't out there selling and flogging and giving lunches and making payments to doctors, who would be telling them about the new drugs? That is - is there another system for telling doctors about what the best medications might be other than the drug companies?

ORNSTEIN: So it's an excellent question. And I think the new drugs that are game changers, like hepatitis C cures, for example, they sell themselves. You don't have to see as much in terms of advertising and promotion.

What we've seen as we've looked at the data in the past is that the drugs for which companies spend the most money on are the ones where there's, you know, less benefit where it's more marginal and where there are cheaper drugs, generic drugs that are available on the market. And so that's where the companies really need to spend the money to differentiate their product and have doctors choose it.

SIEGEL: I mean, where there might be a real consumer choice by the doctor that's where they would try to influence that choice more.

ORNSTEIN: Where the patient could save some money and while the drug may have an incremental benefit, the question is - is it a benefit that's worth the cost associated with that drug?

SIEGEL: Charles Ornstein of ProPublica, thanks for talking with us.

ORNSTEIN: Thanks, Robert. Transcript provided by NPR, Copyright NPR.