Beyond the money they earn for treating patients in their care, top doctors in South Carolina have another lucrative income source.
More than 30 S.C. doctors have received at least $500,000 from pharmaceutical companies and medical device makers in consulting and promotional speaking arrangements that are under scrutiny from medical ethics groups and researchers.
Such payments have fueled a years-long debate about the ethics of doctors accepting money from pharmaceutical and device companies that want doctors to prescribe their medicine and use their equipment.
Some studies have found that physicians who receive more money from drug companies tend to prescribe higher rates of their expensive, name-brand drugs than their peers. Scrutiny over those payments has heightened since the federal government began gathering and publicly reporting drug company payments to physicians under the 2010 Affordable Care Act.
“The problem is, if you’re getting money for using someone’s equipment and implanting their devices or using their medication, that’s a kickback,” said Charles Rosen, a California spine surgeon and co-founder of the Association for Medical Ethics. “Sometimes it gets disguised as payment for being a ‘key opinion leader,’ and it became evident that this is just a way of getting money to somebody.”
But doctors, hospitals and drug companies alike deny they have that kind of arrangement. They say their work relationships ultimately improve patient care by helping to advance medical innovation and inform doctors across the country of new medications and treatment options.
The state’s largest hospital system, Prisma Health, and the Medical University of South Carolina have conflict of interest policies that require disclosure of physicians’ industry ties and compliance officers to monitor the arrangements.
“It’s a misperception that these companies are paying us off to write prescriptions,” said Fort Mill dermatologist Rebecca Smith, who has made $1.72 million from pharmaceutical companies over the past five years, most of it tied to promotional speaking for specific medications. “That’s insulting to think that a pharmaceutical company can buy me.”
‘Knowledge is power’
The lion’s share of the money appears to be flowing to doctors with impressive resumes.
Most of the highest earning doctors in South Carolina are renowned experts in their fields. They are neurosurgeons, pathologists, endocrinologists and psychiatrists who get high marks from their patients in online reviews and are considered “thought leaders” by their peers.
Naturally, they are sought out by pharmaceutical companies that want a credible voice to promote their newest drugs to gatherings of doctors at lectures and seminars.
But there are limitations placed on physicians who accept payments for promotional speaking, according to some S.C. physicians interviewed by The State.
Doctors who are paid to speak about a drug must stick to a slideshow provided by the pharmaceutical company and approved by the U.S. Food and Drug Administration.
Still, physicians who give those talks don’t see them as a conflict of interest.
Smith, the owner of Fort Mill Dermatology, has three decades of medical experience and has been on the speaking circuit for 24 years. She spends two days a week on the road and has traveled to 47 states, including Maine last week to speak with a group of dermatologists.
Smith said she enjoys teaching and speaking about diseases like eczema and psoriasis and the treatments for them. Working in the lucrative field of dermatology, she said she would make more money if she gave up speaking entirely and focused solely on her practice.
Smith was paid $117,000 in 2018 by Pfizer for promotional speaking and consulting — plus travel and meals — related to Euchrisa, a drug that treats eczema. She also was paid $115,000 last year by the maker of Otezla, a drug that treats psoriasis.
Smith and other doctors say they would not speak in support of a drug they don’t trust and regularly prescribe. Instead, she said, the speaking engagements give her a platform to share her experiences and require her to do her research before she gets on stage.
“I do this because I love it,” said Smith. “I love my patients, and I do this to make myself a better physician.”
Vonda Calcutt, an endocrinologist in Walterboro who has earned $891,000 from pharmaceutical companies over the past five years, agrees.
Calcutt said she loves sharing knowledge about new drugs to other doctors who are “in the trenches” with her in the fight against diabetes.
“Knowledge is power,” Calcutt said. “I try to learn something every time I go, too.”
‘Me and Momma test’
Some S.C. doctors are among the highest-paid speakers in America for certain drugs.
Just one doctor in the United States made more money last year promoting Rexulti, an antipsychotic drug, than Greer psychiatrist Vladimir Maletic, who made $111,000 promoting the drug, ProPublica’s analysis shows.
Just two doctors made more than Maletic — who made $164,000 — in 2018 for work related to Vraylar, an antipsychotic that was approved by the FDA in 2016.
Maletic, who was paid just over $2 million by the industry over the past five years — mostly for promotional speaking engagements and travel and meal expenses — did not return a request for comment. A staffer for his office said he was traveling in Canada for a series of product theaters, which are informative sessions that focus on a particular product.
Medical device companies also seek out S.C. doctors — especially surgeons — for feedback on their latest prototypes.
Ross said he helps test new products — like surgical balloons and stents — and offers advice. Some device makers don’t realize that the equipment they are developing already exists or is outdated, Ross said.
Ross said he doesn’t see an ethical conflict with that kind of work because he doesn’t purchase or use equipment unless he thinks it is superior.
“I work for the patients. I don’t work for the device companies,” Ross told The State. “I have what I call the ‘Me and Momma’ test. If I wouldn’t want it used on me and Momma, I don’t want to use it.”
An industry trade group said companies’ work with physicians “can improve patient care and help nurture the discovery of new medicines.”
“Companies engage with physicians to keep them current on new indications for approved medicines, potential side effects of medicines, and both emerging benefits and risks of medicines,” Tiffany Haverly, public affairs director for Pharmaceutical Research and Manufacturers of America, wrote in a statement to The State. “Physicians provide real-world insights and valuable feedback and advice to inform companies about their medicines to improve patient care.”
‘Ruin it for everybody else’
Rosen, the Association for Medical Ethics co-founder, said “95% of doctors are trying to do the right thing.”
“There are 5% (or less) that are doing these illegal things that ruin it for everybody else.”
But, Rosen added, physicians who accept even small gifts — a cup or a pen — from a drug or device company feel “an inherent subconscious need to reciprocate.” Consciously or not, those relationships can affect prescribing behavior or decisions about which equipment to use, he said.
Rosen’s group has pushed Congress for greater transparency of business dealings between industry groups and physicians, including the 2010 federal law that now requires drug companies and device makers to disclose their payments to doctors.
Rosen said he also has worked with the FBI as it investigates fraudulent kickback schemes in medicine.
Improper arrangements can take many forms, he said. Companies can put a doctor on monthly retainer as a consultant or pay the doctor to be part of an advisory board. Or a company might give a doctor a patent for a device or technology the doctor didn’t invent — anything to get the physician on the company’s payroll.
Those kind of improper arrangements aren’t much different from special interests’ efforts to cozy up to state and federal lawmakers, he said.
“They’re bribes, basically,” he said.
Rosen said he would urge hospitals to be transparent about their physicians’ dealings with the industry and encouraged patients not to be afraid to ask their doctors if they have been paid to promote the medication they are prescribing.
“If the doctor is offended by that, then to hell with him or her,” he said.
South Carolina’s largest hospitals encourage their doctors to be involved in the pharmaceutical and device industries but are aware of potential conflicts.
Six Prisma Health doctors — all in Greenville — have been paid at least $500,000 from the industries over the past five years. Two MUSC doctors and a professor emeritus made the list.
Both health systems have conflict of interest policies in place and say their compliance departments monitor possible conflicts.
While Prisma Health physicians are paid by drug companies to speak on behalf of their products, those doctors only speak about drugs they are already prescribing, Prisma Health Upstate Compliance Officer Scott Pietras said.
“We’re either consulting with them or speaking on behalf of a product or device we believe to be superior,” Pietras said. “They would not actively engage in a relationship with a company that they didn’t believe their product was scientifically superior … and in the best interest of the patient.”
Not all the money from those speaking engagements flows directly to the doctor, Pietras said. Instead, he said, the money is sent to Prisma Health, and the speaker and department head decide how the money is divided up, he said.
Pietras said he didn’t know how much of the money typically goes back to the speaker.
Still, Pietras ceded, Prisma Health doctors are free to prescribe whatever medications they deem best for each patient.
Asked if Prisma Health’s compliance department checks whether doctors paid by a drug company are prescribing more-than-usual amounts of those drugs, Pietras replied, “We have found no reason why we need to do that.”
In a statement, MUSC said two of its physicians and one professor emeritus who each have accepted more than $500,000 in industry money “have properly executed and up-to-date conflict of interest documents on file with our organization.”
“It is in keeping with health care industry operations for leaders in their fields to engage in consulting arrangements to share knowledge and best practices in their areas of specialty,” MUSC chief spokeswoman Sheila Champlin wrote in a statement. “These physicians are in full compliance with MUSC conflict of interest standards and policies.”