Richard Radnovich is a pain doctor who runs an injury clinic in Boise. He treats 75 to 100 patients each week and has teaching appointments at the University of Washington and Ohio University.
He’s also paid by drug companies to talk about their pharmaceuticals up to three times a month. And he’s not apologetic. He’s proud.
“The fees that I collect for speaking engagements are the same fees that I collect if I have to go testify in court or give depositions,” Radnovich said. “Generally, these are in the hundred- to thousand-dollar range, not exorbitant.”
Radnovich accepted $15,433 in 2009 and 2010 from Cephalon and Johnson & Johnson. He was one of about 65 Idaho medical providers — almost all practicing physicians — who doubled as paid speakers, according to nationwide drug-company records
for those years. The drugmakers paid Idaho doctors $1.3 million to give talks in 2009 and 2010.
The companies disclosed the payments on their websites, and they were compiled in October by ProPublica, an investigative-journalism nonprofit.
ProPublica’s reporting suggested that pharma-funded work by doctors raises ethical concerns. One question is whether the money influences doctors’ prescription choices. ProPublica dug through lawsuits and found that multiple drug companies have been accused by whistleblowers and federal lawyers of using speaker fees to reward those who prescribe the companies’ drugs, and to pay speakers accused of misconduct.
At least three companies that hired Idaho doctors as speakers have spent billions to settle illegal-marketing charges over the past few years — including $1.4 billion from Eli Lilly, $2.3 billion from Pfizer and $520 million from AstraZeneca.
SPEAKERS: TEACHERS OR ADVERTISERS?
Taking a payment from a drug company to talk about its medications is not inherently bad. It doesn’t mean the doctor is doing something illegal or unethical. The American Medical Association’s ethics guidelines say doctors should not “place their own financial interests above the welfare of their patients.”
The AMA’s code of ethics specifies that, for educational meetings where the main incentive is to further attendees’ knowledge, an “appropriate disclosure of financial support or conflict of interest should be made.” The AMA says it is fair for faculty and consultants to accept “reasonable” payments and expense reimbursements.
Drug companies do not require the doctors to push their latest name-brand products. The opposite is true, paid doctors say. The companies send their own people to the speaking engagements to monitor what the doctors say. The doctors are reported if they break federal rules, like engaging in “off-label marketing,” or recommending a drug for a use that isn’t approved by the Food and Drug Administration.
The speaker’s job is to teach other health providers how the medication works, what its merits and downsides are, and what its effects are, based on the speaker’s own clinical experience.
A few Idaho doctors trumpet their roles as trusted experts. Two of the 384 top-paid speakers in the country are Idahoans who say their affiliations with drug companies not only are above-board but have helped them to become better doctors.
WHAT THE RECORDS SAY ABOUT IDAHO
This state is desperate for doctors, and not just in rural areas. Idaho is at the bottom of national rankings of medical providers per capita.
Yet some licensed medical providers are spending time outside their offices, touring the country on the pharmaceutical industry’s dime. Looking at the dollar amounts for the past two years, Radnovich is barely in the top third. Four doctors in Idaho each earned more than $60,000 in a year from a single company.
Psychiatrists stand out. Idaho’s list of paid doctor-speakers is filled with them, and the top three earners specialized in psychiatry, according to state records. Meanwhile, the U.S. Health Resources and Services Administration says the entire state of Idaho has a shortage of mental-health professionals.
Dr. Carol Bernstein, president of the American Psychiatric Association, said the number of psychiatrists who the disclosing companies paid to speak represent 0.2 percent of all psychiatrists in the country. In Idaho, it’s closer to 9 percent.
One of the Idaho psychiatrists is Linda Carter of Pocatello, the highest-paid pharmaceutical speaker in the state, according to the ProPublica database. As a national speaker for Eli Lilly, Carter has visited state hospitals and mental-health centers and done her share of dinner programs.
“I have nothing to hide,” Carter said. “I am being paid fair value. I take time off from work. It’s a trip, it’s long travel, and it’s hours of preparation.”
In return, she brings ideas from around the country back to Idaho. “This benefits patients, ultimately,” she said.
The slides she uses are FDA-approved and carefully worded. Every talk has to be balanced. The positive points must be followed by the side effects and warnings. Eli Lilly has trained her to speak in a way that meets strict FDA requirements, “and if we don’t, Lilly — the reps — will report us,” she said.
Carter talks exclusively about drugs that she has used on her own patients.
One of the popular medications she talks about is Zyprexa, a drug that earned Eli Lilly — Idaho’s top speaker-fee provider — about $2.2 billion in U.S. sales in 2008. Zyprexa has also cost Eli Lilly money; the company agreed in 2009 to pay Idaho $13 million to settle allegations that it marketed Zyprexa for off-label uses and did not adequately disclose side effects to health care providers.
Carter said she considers it an honor to speak about medications she sees working for her patients. Another doctor said psychiatrists are popular on the speaking circuit because general-practice doctors are prescribing about half of all antidepressants now but don’t have the experience with them that a psychiatrist does.
Bernstein said it’s also about the money.
“One of the challenges we face in psychiatry is that reimbursement for services in the system is woefully inadequate,” Bernstein said. “Everybody needs to make a living. I’m not suggesting they shouldn’t be there taking care of patients,” but she says it is important to ask: “Are they really abandoning their patients?”
Another group that stands out is urologists. Idaho has 40 licensed urologists who deal with male urinary-system problems, including erectile dysfunction. Six of them, or 15 percent, are on the list of doctors paid by drug companies.
MORE TRANSPARENCY IS COMING
Disclosure by drug companies is spotty. Only eight — about one in 10 — have disclosed whom they have paid and how much.
That will change in a couple of years. The year-old federal health care reform law compels all drug companies to start disclosing what they pay doctors and teaching hospitals by the end of March 2013. Those records will go public Sept. 30, 2013, and on June 30 each year thereafter. The penalties for not sharing that information with the federal government will be stiff: up to$1 million per year.
Radnovich has his own set of guidelines that, he says, protect against being swayed by Big Pharma: “You do what’s best for the patient. You do the safest, easiest, cheapest stuff first. And if you always follow those rules, there is never a conflict.”
Bernstein said disclosure is one of the key ways that drug companies and those who take their money can show there is no conflict of interest.
“Look, I’m not going to condone this personally,” Bernstein said. “I don’t do any speaking engagements, and I think the wall ... is one that has to be managed very carefully. I certainly don’t want to suggest that every doctor speaking on a drug is biased, but I think the literature has shown (that industry ties are) demonstrated to affectprescribing practices.”
Bernstein said the payments “must be transparent.” She said it is appropriate for a patient to ask a doctor, “Do you speak for the pharmaceutical industry at any event? Can you tell me which drug?”
But Radnovich called the disclosures “irrelevant and distracting.” In a letter published in the Idaho Statesman in November, Radnovich said his speaking fees merely covered whatever money he lost from being out of the office, not seeing patients. Media reports about the disclosures, he wrote, are “a ridiculous, petty waste of time and resources.”
Health care industry critics should be looking elsewhere, he says. Speaking fees help him keep his office lights on, Radnovich said, but insurance practices have more influence on his prescribing choices. Insurers micromanage drug coverage, he said. For example, patients may have to try a series of medicines that don’t work because otherwise the insurer won’t pay for the medicine — maybe a more expensive, newer brand-name drug — that the doctor wanted to prescribe.
ARE CONFLICTS OF INTEREST UNAVOIDABLE?
“There is no human interaction or relationship where there is no conflict of interest,” says Dr. Scott P. Hoopes.
Hoopes, a Meridian psychiatrist, started speaking for the pharmaceutical industry about 13 years ago. He enjoyed teaching and giving presentations in rural areas where the town doctor didn’t have many opportunities to pick a psychiatrist’s brain. He chose which companies and drugs he would speak for, ones he found interesting and valuable. He spoke for drug companies because he prescribed their medications, not vice versa, he said.
Hoopes is proud that, five years ago, he was ahead of his time in teaching his peers how to manage the side effects of modern antipsychotics. As a drug speaker, he told other doctors that some of the drugs could, without proper monitoring and management, push people into type-2 diabetes. He urged the doctors to follow published guidelines for the drugs — to be careful, basically.
“As a consequence of that, possibly, I was dropped from two speakers’ bureaus” of drug companies “who didn’t want me to do that ... which was absolutely incorrect,” he said.
So not only did he operate with integrity, he said, but he gave valuable input to doctors who didn’t or couldn’t spend as much time following psychotropic drug trends.
Hoopes also loved talking shop with other doctors and being able to reach knowledge-hungry groups in places like Alaska.
Those who have pushed for a thicker wall between doctors and drug reps haven’t solved the problem, Hoopes argues. He blames news organizations and some politicians for killing the “bad old days,” when doctors understood that a drug company’s motive was to market its products but cultivated what he says were helpful relationships with them.
But he gave up his speaking after ProPublica created the searchable database of paid doctors.
“The reason for that is not that I came to conclude that it was any kind of nefarious activity, but because I anticipated that this phone call was going to happen, and I figured that as a nonspeaker, what I had to say would have more impact, more gravitas,” Hoopes told Business Insider. “Speakers are under fire by the FDA, many people in the media and the drug companies themselves.”
Audrey Dutton: 377-6448