In 2018 Spain’s pharma industry group, Farmaindustria, will publish for the first time the names of all doctors who receive payments from the pharmaceutical industry, whether the payments are direct, such as honoraria, or indirect, such as conference cost reimbursements.

Until then, doctors must give permission for their names to appear on pharma payment lists. As it happens in Germany, Switzerland, Austria and the UK, pharma firms publish the remaining payments as a lump sum of all the doctors who refused to permit the use of their names. Data protection has been winning the battle against transparency in the medical sector.

So all these countries publish a declared portion – how much each doctor received from each firm – and an anonymous portion, published as an aggregate figure without names. It is partial transparency, at best.

Opacity level by country

In Spain, 8 of every 10 euros that pharma spends on doctors are opaque, according to a Civio analysis of 2016 data (story in Spanish). In Germany, the numbers are very similar: the recipients of 78% of the money are not public, according to Correctiv’s Euros for docs investigation.

In Switzerland and the United Kingdom, which also require doctor consent, the numbers are quite different. The hidden percentage in 2016 is much smaller. Swiss physicians who prefer to hide their name receive slightly more than 30% of the 2016 total. In the UK, doctors who chose to remain anonymous received just 40% of total payments, according to our analysis of the Association of the British Pharmaceutical Industry (ABPI) database.

The Telegraph reports that “Disclosure UK data showed that those clinicians who revealed the money and hospitality they had received tended to earn about 20 per cent less than their colleagues who refused.” Civio’s investigation showed similar results in Spain: the least transparent doctors received the most money (story in Spanish). The mean honoraria payments from each firm in 2016 was around 790 euro for doctors who gave consent for the use of their names. The mean for doctors who did not was over 1,000 euro.

Before publishing all the names, Farmaindustria queried the Spanish Data Protection Agency about whether it needed doctors’ consent. Last year the agency wrote that the “legitimate interest” of shining a light on these practices meant that the doctors’ consent is unnecessary for publishing the data (report in Spanish).

That said, according to the Spanish Data Protection Agency, firms should take measures to prevent the indexing of the names by search engines and include warnings prohibiting users from comparing the data across pharmaceutical firms. Users will be able to look at the data on each firm’s website, but not touch it. Projects such as Dollars for docs or Euros for docs, which publish how much each doctor received in total and per laboratory in the United States and Germany, respectively, would be illegal in Spain. The Federation of Spanish Medical Scientific Associations (FACME in Spanish) and the Spanish pharmaceutical industry group Farmaindustria are also against combining and publishing such data.

Barriers to data access

This is just one of several barriers that pharmaceutical firms around the world are building against data access. In many countries, as in Spain, Switzerland and Germany, each company publishes a difficult-to-analyze PDF document.

It does not have to be that way. In the UK, the Association of the British Pharmaceutical Industry (ABPI) publishes a central, downloadable database. And in other cases the government itself publishes the data in open, centralized form, eliminating those barriers. Transparency in the relationship between pharmaceutical firms and doctors has spread around the world since the passage of the pioneering Sunshine Act in the United States. The bill reached the U.S. Senate in 2009, became law in 2010, and the government issued regulations implementing it in 2013. The U.S. government began publishing the Open Payments website in 2014. The site allows anyone to download all the data, explore it, or filter it by medical specialty, pharmaceutical firm, or hospital, and see an individual doctor’s file, which shows the doctor’s total payments and compares them to the specialty and national average. In the event a payment is related to promoting a specific medicine, the name of the medicine appears, too. Most countries do not include that data, but it allows users to see how such payments relate to doctors’ prescribing practices.

That is what ProPublica did in an investigation that showed that physicians in five common medical specialties who accepted industry payments in 2014 were two to three times as likely to prescribe brand-name drugs compared with others in their specialty, who prescribed cheaper generic equivalents.

In France, a scandal involving benfluorex, an antidiabetic drug sold off-label for weight loss, eventually implicated the French drug agency and forced the country to follow the American example and pass its own doctor payments law. The French government website has data, including hospitality and meals, back to 2012. Portugal has had a law since 2013 that requires reporting doctor payments. Its website, which contains data from 2013 to 2017, allows searches by recipient, event, quantity, and firm. Denmark has a similar law and its medicines agency publishes all the data in one place.

In Spain, article 76 of the Law on guarantees and rational use of medicines and health products, approved in 2006, established that “offers of prizes, grants, contributions and subsidies for meetings, conferences, study trips and similar acts by people or legal entities related to the design, production, distribution and prescription of medicines and health products will be published as regulated.” Although it only referred to one category (conference costs, not honoraria), the government never wrote the regulation necessary to implement the law.

In the legal vacuum in countries such as Spain, Germany, Austria, and Switzerland, among many others, and in the absence of European directives on doctor payments, the pharmaceutical industry regulates itself. In 2013, the European Federation of Pharmaceutical Industry Associations (EFPIA), which includes Farmaindustria, approved a code of conduct that obliges members to publish once a year what they call transfers of value. In 2016, Farmaindustria members published the first set of data, from 2015.

Health Action International published in March a study about the transparency of financial relationships in the healthcare sector. It reports that self-regulation is an “intrinsic conflict of interest” and that the European Union and member states should pass their own laws rather than leave transparency rule-making in the hands of the pharmaceutical industry.

Spanish pharma firms pay doctors more than German and British pharma put together

Germany’s population is greater than that of the United Kingdom’s, which, in turn, is greater than that of Spain. Germany’s pharmaceutical industry has a greater market value, at 30 billion euro, than Britain’s, at just over 22 billion euro, which is still more than Spain’s 15.6 billion euro pharmaceutical industry. But a look at pharma’s total payments to doctors flips that ranking. Spain leads both countries despite its smaller population and pharmaceutical industry.

Expenditure on ‘value transfers’ during 2016 by country

In 2016 Spanish pharmaceutical firms spent 181 million euros on “transfers of value,” an industry-coined euphemism to describe the financial relationship between pharma and doctors. Their German counterparts spent less: 109 million euro, and British pharma spent much less, at 58 million euro. The payments in Spain are greater than that in Germany and the United Kingdom put together. Swiss companies, for their part, spent more than 15 million euros.

These figures are the total that firms allocated exclusively to doctors, across four categories: honoraria, service-related expenses, conference fees, and conference travel. This last category includes train or plane tickets and hotel stays, for example. It is the largest category in Spain, at 71 million euro. Spending in this category is far lower in Germany, at 33 million euro, and in the UK, at 12 million euro.

In addition to these payments to doctors, pharmaceutical firms pay medical associations for services, to sponsor events, and make direct donations. Apart from direct spending on doctors and medical associations, there is a third category: what they label research. Spending labeled as research goes to both doctors and medical associations. The problem is that it is not broken down: each firm reports a total research spending figure. So we cannot know what fraction goes to individual doctors, nor which doctors are collecting. Spanish pharma firms report spending 209 million euro on research, which is less than the 324 million euro reported by British pharma and 356 million euro reported by Germany pharma. If we add this to the 181 million euro in payments to doctors, not accounting for the fact that it includes payments to organizations, total spending in Spain would be 390 million euro, lagging Germany (465 million euro) but leading the UK (382 million euro).

Methodological note

The Spanish data comes from Civio’s analysis of transfers of value as reported by the 189 firms and associations that follow Farmaindustria’s self-regulation system. Further details are available at the end of this article in Spanish.

To obtain the British data, we downloaded and analyzed the database published by ABPI.

Swiss data provided by the investigation of Otto Hostettler and Sylke Grunhwald, who collaborated in the data gathering.

In Germany, our source is data available thanks to the contribution of Correctiv, which has been conducting its Euros for docs investigation on these matters for two years.

The source for the market value of each country’s pharmaceutical industry is this European Federation of Pharmaceutical Industry Associations (EFPIA) report.

For the conversion of Swiss francs and British Pounds to euros we used the average 2016 exchange rate, as specified by the American Internal Revenue Service.