Dr. Allan Collins may be the most influential kidney specialist in the country. He is president of the National Kidney Foundation and director of a government-financed research center on kidney disease.
In 2004, the year he was chosen as president-elect of the kidney foundation, the pharmaceutical company Amgen, which makes the most expensive drugs used in the treatment of kidney disease, underwrote more than $1.9 million worth of research and education programs led by Dr. Collins, according to records examined by The New York Times. In 2005, Amgen paid Dr. Collins at least $25,800, mostly in consulting and speaking fees, the records show.
The payments to Dr. Collins and the research center appear in an unusual set of records. They come from Minnesota, the first of a handful of states to pass a law requiring drug makers to disclose payments to doctors. The Minnesota records are a window on the widespread financial ties between pharmaceutical companies and the doctors who prescribe and recommend their products. Patient advocacy groups and many doctors themselves have long complained that drug companies exert undue influence on doctors, but the extent of such payments has been hard to quantify.
The Minnesota records begin in 1997. From then through 2005, drug makers paid more than 5,500 doctors, nurses and other health care workers in the state at least $57 million. Another $40 million went to clinics, research centers and other organizations. More than 20 percent of the state’s licensed physicians received money. The median payment per consultant was $1,000; more than 100 people received more than $100,000.
Doctors receive money typically in return for delivering lectures about drugs to other doctors. Some of the doctors receiving the most money sit on committees that prepare guidelines instructing doctors nationwide about when to use medicines. Dr. Collins, who received more money than anyone else in the state, is among a limited number whose payments financed research.
In dozens of interviews, most doctors said that these payments had no effect on their care of patients.
Dr. Collins said his sole focus was the health and well-being of patients. “Just because I might do consulting work doesn’t mean I don’t press the agenda of the public health,” he said.
Ken Johnson, senior vice president of Pharmaceutical Research and Manufacturers of America, said interactions between drug companies and doctors were beneficial. “In the end, patients are well-served when technically trained pharmaceutical research company representatives work with health care professionals to make sure medicines are used properly,” he said.
There is nothing illegal about doctors’ accepting money for marketing talks, and professional organizations have largely ignored the issue.
But research shows that doctors who have close relationships with drug makers tend to prescribe more, newer and pricier drugs — whether or not they are in the best interests of patients.
“When honest human beings have a vested stake in seeing the world in a particular way, they’re incapable of objectivity and independence,” said Max H. Bazerman, a professor at Harvard Business School. “A doctor who represents a pharmaceutical company will tend to see the data in a slightly more positive light and as a result will overprescribe that company’s drugs.”
In an e-mail message, Dr. Collins said he personally received in 2004 less than $10,000 from Amgen for educational presentations. “The contract amount of $1.9 million from Amgen was paid to the Minneapolis Medical Research Foundation (MMRF) for the research contract, on which I am the designated senior researcher,” Dr. Collins wrote. He wrote that he did not work for or serve on the board of directors of the foundation. Dr. Collins discloses on his Web site and research papers that he is a consultant to Amgen, among other companies.
Dan Whelan, an Amgen spokesman, said the company paid the Minneapolis Medical Research Foundation “to conduct sophisticated research and data analyses that have enhanced the understanding of health care delivery” for kidney patients.
But Dr. Daniel Coyne, a kidney specialist at Washington University, said he was troubled by the payments.
“Amgen’s funding for Dr. Collins’s MMRF is another huge financial connection to individuals at the National Kidney Foundation,” Dr. Coyne said. “The foundation’s recent pro-industry anemia guidelines — and the revisions due next month — have to be viewed with great skepticism.”
Dr. Coyne recently wrote an editorial in an influential journal decrying guidelines written last year by the kidney foundation that encourage doctors to use more of Amgen’s drugs to treat anemia in kidney patients despite studies showing that increased use led to more deaths.
Ellie Schlam, a spokeswoman for the National Kidney Foundation, said the foundation sought out the world’s foremost experts. “These are the same people that are wanted by government and industry,” she said. “We really work hard to separate the financing from the content.”
Drug makers listed Dr. Collins and the research group as the recipient of payments totaling more than $2 million between 1997 and 2005. Most doctors on the list are far less prominent than Dr. Collins.
Ten doctors and one dentist in Minnesota received more than $500,000. Because the records are incomplete, these sums likely underestimate the providers’ earnings. Device makers and Wall Street firms tracking medical research were not required to report, although consulting arrangements between such companies and doctors are common.
More than 250 Minnesota psychiatrists together earned $6.7 million in drug company money — more than any other specialty. Seven of the last eight presidents of the Minnesota Psychiatric Society have served as consultants to drug makers, according to the Times examination.
After psychiatrists, doctors who specialized in internal medicine garnered the most money, followed by cardiologists, endocrinologists and neurologists.
Unknown to Most Patients
Doctors in Minnesota said they generally did not tell their patients about these arrangements. Indeed, few patients are aware of the financial connections between those prescribing drugs and the companies making them.
A New York Times/CBS News poll last month found that 85 percent of respondents thought it “not acceptable” for doctors to be paid by drug companies to comment on prescription drugs. Eighty-five percent also said such payments would influence the decisions that doctors made about patient care.
In addition to Minnesota, legislators in Vermont, Maine, West Virginia, California and the District of Columbia have passed laws requiring some level of disclosure of drug company marketing efforts. In Vermont, the state has collected three years of data on payments to doctors, but drug makers are allowed to keep the records private by declaring them trade secrets.
In the 2005 fiscal year, the most recent year for which figures are available, drug makers declared 73 percent of payments to doctors in Vermont as trade secrets. The Journal of the American Medical Association today is publishing data summarizing physician payments from drug makers in Minnesota and Vermont. The study concludes that many payments exceeding $100 were made but that the records were difficult to decipher and all but impossible for individuals in either state to interpret.
Dr. David Blumenthal, director of the Institute for Health Policy at Massachusetts General Hospital, said, “We have given physicians a lot of freedom and self-governance because of their professional reputation and a sense that they know how to help their patients.”
Doctors said their lectures about drugs to other doctors in return for the payments were gentle marketing pitches that adhered strictly to messages approved by drug makers and federal drug regulators.
Drug companies “want somebody who can manipulate in a very subtle way,” said Dr. Frederick R. Taylor, a headache specialist in Minneapolis who earned more than $710,000 between 1997 and 2005, much of that from GlaxoSmithKline, the maker of the migraine drug Imitrex.
Dr. George Realmuto, a psychiatrist from the University of Minnesota, said most of the marketing associated with his lectures was packaged around his talks.
“It’s at a wonderful restaurant, the atmosphere is very conducive to a positive attitude toward the drug, and everyone is having a good time,” said Dr. Realmuto, who compared the experience to that of buying a car in a glitzy showroom. He earned at least $20,000 between 2002 and 2004 from drug makers.
Doctors said that lectures were highly educational, and that drug makers hired them for their medical expertise and speaking skills. But former drug company sales representatives said they hired doctors as speakers mostly in hope of influencing that doctor’s prescribing habits.
“The vast majority of the time that we did any sort of paid relationship with a physician, they increased the use of our drug,” said Kathleen Slattery-Moschkau, a former sales representative for Bristol-Myers Squibb and Johnson & Johnson who left the industry in 2002. “I hate to say it out loud, but it all comes down to ways to manipulate the doctors.”
Jamie Reidy, a drug sales representative for Pfizer Inc. and Eli Lilly & Company who was fired in 2005 after writing a humorous book about his experiences, said drug makers seduced doctors with escalating financial inducements that often start with paid trips to learn about a drug.
“If a doctor says that he got flown to Maui, stayed at the Four Seasons — and it didn’t influence him a bit? Please,” Mr. Reidy said.
‘A Silent Quid Pro Quo’
The lectures earn doctors more than cash.
“You’re making him money in several ways,” said Gene Carbona, who left Merck as a regional sales manager in 2001. “You’re paying him for the talk. You’re increasing his referral base so he’s getting more patients. And you’re helping to develop his name. The hope in all this is that a silent quid quo pro is created. I’ve done so much for you, the only thing I need from you is that you write more of my products.”
For many doctors, marketing lectures are also a welcome diversion.
“It beats talking to little old ladies about their bowels,” said Dr. Eric Storvick of Mankato, Minn., who made more than $174,000 between 1998 and 2005 from drug makers.
The number of drug marketing presentations delivered by doctors across the United States rose nearly threefold between 1998 and 2006, according to Verispan, a company that tracks drug marketing efforts.
In some cases, consulting doctors are so well recognized that they offer drug makers far more than the chance to influence their own prescriptions. For drug makers, among the most prized consultants are those who write guidelines instructing their peers about how to use drugs.
Drug Companies’ Nature
This list of top doctors in Minnesota includes Dr. Richard Grimm of the Berman Center for Outcomes and Clinical Research in Minneapolis, who has twice served on government-sponsored hypertension panels that create guidelines about when to prescribe blood pressure pills. Last year, he served on a National Kidney Foundation panel that wrote guidelines about when kidney patients should be given cholesterol pills.
Between 1997 and 2005, Dr. Grimm earned more than $798,000 from drug companies, according to records. In 2003 alone, Pfizer paid Dr. Grimm more than $231,000. Pfizer markets Lipitor, a cholesterol drug that last year had $12.9 billion in sales, more than any other drug in the world. It also markets Norvasc, a hypertension drug that last year had $4.9 billion in sales. Guidelines that suggest greater use of these drugs would be a huge boon to Pfizer.
“Drug companies are like lions,” Dr. Grimm said of his sponsored talks. “For lions, it’s their nature to kill zebras and eat them. For drug companies, it’s their nature to make money. They’re not really trying to improve anybody’s health except if it makes them money.
“On your side, you’re making a bit of money, but you’re also trying to educate the doctors. And in my view, the doctors need a lot of educating.”
Dr. Grimm said that he contributed more than $50,000 between 1997 and 2005 to the Minneapolis Medical Research Foundation, and that his lectures were not biased.
Dr. Donald Hunninghake served on a government-sponsored advisory panel that wrote guidelines for when people should get cholesterol-lowering pills. The panel’s 2004 recommendations that far more people get the drugs became controversial when it was revealed that eight of nine members had financial ties to drug makers. The full extent of those ties have never been revealed.
In 1998 alone, Pfizer paid Dr. Hunninghake $147,000, and he earned at least $420,800 from drug makers between 1997 and 2003. He left the University of Minnesota in 2004 to become a full-time industry consultant. He is now retired.
“Most of my talks did not relate to drugs but the guidelines for treatment,” Dr. Hunninghake said. He said his consulting practice included a variety of activities, including lectures.
A 2002 survey found that more than 80 percent of the doctors on panels that write clinical practice guidelines had financial ties to drug makers.
“It is critical that the experts who write clinical guidelines be prohibited from having any conflicts of interest,” said Dr. Marcia Angell, a former editor of The New England Journal of Medicine. “Since they have no data themselves but are just making judgments based on their expertise, they absolutely must be impartial or it undermines the whole enterprise.”