This article is part of an ongoing investigation conducted by Civio into the relationship between pharmaceutical companies, doctors, medical associations and public bodies.
In 2017, pharmaceutical companies spent €182.5 million on payments to doctors for their services or to cover conference fees and travel expenses, in a sum which was similar to the previous year’s. This is what the industry passes off under the euphemism of transfers of value. But not everyone who received payments or invites to conferences was on an equal footing. 18 doctors deposited some €50,000 to their accounts from a single lab in a single year. They make up only a tiny part of the 253,796 registered doctors in the country as a whole.
Direct payments and indirect payments
Doctors can receive direct transfers (payments for services such as consultancy, lectures, etc) or indirect transfers (the pharmaceutical company covers travel costs, conferences admission fees, or expenses related to the services they are hired for).
If we analyse these special lab-doctor relationships, we find that the numbers range from those barely exceeding this €50,000 cut, to those that reach almost €100,000, as in the case of the €98,000 that Bayer paid to doctor Jordi Bruix. And that’s without factoring in what the doctors received from other labs, which saw specialists such as María Victoria Mateos amass almost €170,000, or Luis Puig, who pocketed over €150,000.
Doctors who received over €50,000 from a single pharmaceutical company in 2017
jordi bruix tudó
Hepatic Oncology - Hospital Clínic+ More information
maría victoria mateos manteca
Haematology - Salamanca Hospital+ More information
antonio martorell calatayud
Dermatology - Manises Hospital+ More information
enrique grande pulido
Oncology - MD Anderson Madrid + More information
anna sureda balari
Clinical Haematology – Catalan Institute of Oncology+ More information
maría elisa reig monzón
Hepatic oncology - Hospital Clínic+ More information
emiliano calvo aller
START Madrid - Clara Campal Comprehensive Oncology Centre+ More information
jerzy aleksander krupinski bielecki
Neurology - Hospital Mutua in Terrassa+ More information
marc miravitlles fernández
Pulmonology - Vall d'Hebrón Hospital+ More information
eduard montanya mías
Endocrinology and Nutrition – Bellvitge Hospital+ More information
luis puig sanz
Dermatology - Sant Pau Hospital+ More information
ana lluch hernández
Oncology – Valencia University Clinical Hospital+ More information
javier puente vázquez
Oncology - San Carlos Clinical Hospital+ More information
antonio salar silvestre
Haematology - Hospital del Mar, Barcelona+ More information
miguel cordero coma
Ophtalmology - León Hospital+ More information
jesús garcía foncillas
Oncology - Jiménez Díaz Foundation Hospital+ More information
francisco javier nistal rodríguez
Traumatology - Río Hortega Hospital, Valladolid+ More information
marcos meseguer escrivá
Embryology - IVI Valencia+ More information
The data reveal unidirectional relationships, such as that of the aforementioned Bruix Tudó with Bayer (the pharmaceutical company accounts for 98% of his total transfers of value) or that of Emiliano Cabo with Novartis (90%), as well as other more varied relationships. Thus, 15 laboratories make payments—directly or indirectly—to Javier Puente, although Pfizer accounts for 66% of these gains, while the almost €60,000 paid to Luis Puig by Lilly, in spite of the hefty sum, only amounts to 40% of his total transfers.
“There could be a potential problem if you are not an expert in a certain field and receive transfers of value from just one company.”
María Victoria Mateos receives transfers from four pharmaceutical companies. She is, in fact, the person who receives the largest sum when taking all of the transfers into account and not only the largest. For her, if several laboratories make contributions then the situation can be seen as more transparent and less risky. “There could be a potential problem if you are not an expert in a certain field and you receive transfers of value from just one company,” she argues.
14 of these 18 are men, and only 4 are women. Moreover, the majority of them (14) work in public health facilities, although two of them combine this with private practice. 3 of the group are members of the network of experts of the Spanish Agency for Medical and Healthcare Products (AEMPS), the public body responsible for evaluating, authorising and monitoring medicines.
“When it comes to advising [these agencies] I have my limits. I’m the first one to admit that. Often, I’m not 100% impartial with my decisions, but who is”, admits Miguel Cordero, one of the doctors who appears on the list. The important thing, in his opinion, is that the agencies know about these relationships (both the AEMPS as well as its European counterpart request that healthcare professionals disclose their possible conflicts of interest) and that this potential bias is taken into account when it comes to evaluating their recommendations.
In more than half of the cases, the research and/ or practice of these 18 professionals is within the field of cancer—a disease that regularly benefits from new and expensive medicines, and into which the pharmaceuticals industry has poured a large part of their research efforts. 7 of them are oncologists, while another three are haematologists, a speciality related to certain forms of the disease (such as leukaemia, lymphoma, or melanoma). For Cordero, the explanation is obvious: “The industry works in the fields where most money is moved”.
For some doctors, the reason is that cancer is one of the diseases that affects the largest number of people. According to the National Institute for Statistics, tumours are the second highest cause of death in Spain, only beaten by diseases of the circulatory system. There are no cardiologists on the list.
Continuous education, paid for by the industry
For yet another year, publication of these sums has reopened the debate on who should bear the costs of training for healthcare professionals. Medical societies and professional bodies remind them of the need to continuously learn to be able to offer the best treatment possible to their patients. When it comes to public healthcare, this ongoing education is not covered, they claim, by public funds.
So to train, they are forced to accept pharmaceutical companies covering the costs of conferences and travel. Costs which, furthermore, are exempt from income tax thanks to the income tax reform passed by ex-minister Cristóbal Montoro at the end of 2017.
The debate surrounding this lifelong learning centres on these indirect payments that cover the expenses of attending conferences (admission, travel, hotels, etc). However, the bulk of the transfers received by these 18 doctors comes in fact from another strand: fees (accounting for over 1 million of the 1.6m in total), whether participating in lectures, in sessions as speakers or moderators, as consultants or as members of advisory councils, for example.
The code that regulates the publication of pharmaceutical payments to health professionals is an exercise in industry self-regulation and not a rule issued by public administrations.
So what do these 18 doctors think about this relationship being made public? Having conferred with each of them, we unveiled a wide range of opinions (out of those who chose to respond, of course). Thus, Marcos Meseguer states that it is “unfair” and that he feels “mistreated”. He mentions the possible jealousies that may arise and claims that the publication of such data is damaging to him. “Why do people here have to gossip about what I’m paid or not paid, when I work in a private centre and have no say in procurement decisions?” he complains. He is the only person from the list who isn’t a doctor, but rather a biologist.
In contrast, Emiliano Calvo lauded the measure. After admitting that his first reaction, “from the gut”, was against the publication of such information, he now believes that it is a good thing because it creates a “self-censoring” effect—when you know that everything will be made public, you tend to avoid the path of malpractice. He is even calling for further transparency: “It has to be done properly, not just a declaration of such income but also what it was paid for”, something which is not currently included in these lists because, he continues, “sometimes disclosure is no better than creating misinformation”.
The code regulating the publication of such data is an exercise in industry self-regulation and not a rule issued by public administrations. Article 76 of the Law on Medicines and Healthcare Products (Guarantees and Rational Use), passed in 2006, had already established that “offers of prizes, grants, contributions and allowances for conferences, study trips and similar functions, by any natural or legal person involved in the manufacturing, production, supply, prescription or dispensing of medicines and healthcare products shall be made public in the manner determined as per the regulations”. Although only referring to one of the four categories (admission to conferences and trips, but not fees), a policy that would have set out how this information was to be published has never been developed.
Payments to doctors, medical societies and the catch-all that is R&D
Expenditure on healthcare professionals is not the only cost covered by these labs. Besides such payments, they sponsor conferences and make donations to medical societies too. Meanwhile they also allocate €251.5 million to research and development, the area the industry most widely publicises when it comes to disclosing these payments. However the truth is that R&D is a catch-all where any transfer linked to research can be written off, without disclosing or specifying what it has been spent on, or who—associations or professionals—are its beneficiaries.
|millions of €|
When a doctor is a leader in their field, it’s only logical that lots of pharmaceutical companies want them to participate in conferences or count on their services. But what about those cases where only a single laboratory is interested in their work? The debate becomes more significant when these healthcare professionals are linked to medicines they regularly prescribe, or recommend in articles or to colleagues.
For Antonio Salar, the biggest risk comes not from those who receive the largest sums, as in the case of the 18 on our list, but from those receiving smaller amounts. And while he admits that “it’s possible that in the context of data transfer between companies, promoting their products may prompt these to be prescribed” he affirms that this only happens when there is a “lack of awareness” from the doctor prescribing the medicine, and that it doesn’t happen in large teaching hospitals, where there are “clear protocols”.
Using data from doctors in the USA, ProPublica revealed that those who do receive transfers from the industry tend to prescribe more brand medicines than generic drugs. Within the scope of this investigation, various studies highlight that professionals who have a conflict of interest are more likely to present more favourable results to private companies.
For Cordero, the risk is also clear: “Of course the industry is looking to have influence”. In his opinion, however, it is hampered because the most important decisions are not made by a single person, but taken at the heart of scientific societies. “This means any bias is ironed out,” he states. The problem is that the large societies depend in part on the pharmaceuticals industry.
The following people assisted in the analysis and data cleansing required for this investigation: María Álvarez del Vayo; Miguel Ángel Gavilanes; David Cabo; Javier de Vega; Amir Campos; and Raúl Díaz Poblete, who was also responsible for visuals.
We have analysed transfer documents from 145 pharmaceutical companies associated with the Farmaindustria Code of Good Practice. Extraction and analysis of the data was performed between the end of August and the start of September 2018. As some of these companies belong to business groups, the data are published over 85 documents.
To create the ranking, we have focused not on the total payments (data for which isprovided for these 18 doctors) but on those healthcare professionals who receive more than €50,000 from a single lab. In other words, those cases where the economic relationship between the pharmaceutical company and the healthcare professional stands out.
If any cases struck us as suspicious, such as vast sums paid for admission to conferences for a single doctor, we checked the facts with the relevant parties and the pharmaceutical companies, and in the event of an error, we have modified the assigned sums.
For the sake of simplicity, we sometimes use the word doctors instead of healthcare professionals, although one of the 18 is not a doctor but rather a biologist.
We have contacted the 18 professionals from the list on several occasions. 10 of them responded to our questions and 8 chose not to. We have also contacted the Collegiate Medical Organisation without receiving any response.