Fancy steak dinners, junkets at lush resorts, and cushy speaking gigs to promote new drugs have been on the wane since lawmakers forced drug companies to disclose most of the ways they steered lucrative perks and consulting fees to doctors.
But critics say the stream of drug money to top physicians has flourished on a route that remains largely hidden: the continuing education programs that doctors must attend to keep their licenses.
Federal law allows pharmaceutical and medical device companies to funnel millions of dollars a year, without disclosure, to doctors who teach continuing education programs. The conduits for the money are independent companies that sponsor medical lectures for doctors. Since 2011, drug industry payments to these outside companies have risen 25 percent, to $311 million in 2014, according to a Boston Globe analysis.
Doctors who deliver the lectures typically receive between $2,000 and $3,000 per appearance.
The biggest lobbying organization for doctors is fighting in Congress to keep those payments out of public view, backing a bill to derail an Obama administration push for more transparency. The lobbying group, the American Medical Association, says disclosure would unfairly stigmatize doctors who are leaders in their fields and deliver lectures on breakthroughs in medicine.
But some physicians say payments to provide medical education have been transformed into a bigger channel to conceal drug company cash.
“To be blunt, this is just government-sanctioned money laundering," said Dr. Paul Lichter, a University of Michigan ophthalmologist who heads the medical school's conflict of interest committee. “Companies are making it appear charitable, but it's clearly to influence physicians to prescribe expensive drugs and order expensive tests."
Continuing education for doctors has long been underwritten by drug manufacturers who have a direct financial stake in medical decision-making. Industry subsidies help pay speaking stipends for top doctors in their specialties while also keeping costs low for rank-and-file doctors who attend the lectures to maintain professional certification.
Defenders of the system say medical education companies have already pledged, when they get accreditation, that their lectures and classes “were made free of the control of a commercial interest."
“Investment by industry is safe, and commercial bias is minimized to as close to zero as we can possibly get it," said Dr. Graham McMahon, former associate dean for continuing education at Harvard Medical School who in April became president and chief executive of the Accreditation Council for Continuing Medical Education. “The intended purpose of accreditation is to give attendees the reassurance that they are not being subjected to promotion and marketing."
More than 40 percent of the country's 1,908 accredited continuing education providers — including medical schools, hospitals, professional medical societies, and for-profit companies in Massachusetts — rely on drug company money to defray the cost of their courses, according to the accreditation council.
One of the country's top recipients of pharmaceutical money is Pri-Med, a for-profit company based in Boston's Back Bay that offers both live and online continuing education for doctors, according to a 2013 paper published in the Journal of the American Medical Association.
Pri-Med is scheduled to host a medical education conference at the Boston Convention and Exhibition Center in September. The conference, a typical example of industry practice, is sponsored by more than half a dozen pharmaceutical companies, including AstraZeneca, which has a research hub in Waltham, and Novartis, whose biomedical research headquarters is in Cambridge.
The conference features Dr. Peter Libby, a prominent cardiologist at the Harvard-affiliated Brigham and Women's Hospital, as a keynote speaker.
Libby would not reveal his payment to give educational talks when contacted by the Globe. He said in an e-mail that the content of his talks is “independent of influence by outside organizations, as assured by several layers of review and compliance."
Separate from his educational lectures, Libby also serves as a consultant for more than a dozen pharmaceutical companies, including AstraZeneca, according to Pri-Med's website.
As leaders in their fields, doctors who give educational lectures commonly accept separate drug industry payments — which are required to be disclosed — for things like consulting and serving on advisory boards.
For his part, Libby said he does all his outside consulting work for free, because he wants to avoid perceptions of bias. But the federal Open Payments database, created in 2014 to disclose the financial relationships between industry and physicians, shows that Libby received more than $12,600 from pharmaceutical companies last year, mostly for travel and lodging. Libby said the majority of the travel reimbursements pertain to his industry-sponsored research, not for consulting.
Another accredited Pri-Med education event, a webcast on pulmonary fibrosis, is sponsored by Genentech and Boehringer Ingelheim Pharmaceuticals. All three of the doctors teaching the webcast, including Dr. Ivan Rosas, a lung disease program director at Brigham and Women's, also serve as consultants or speakers for either Genentech or Boehringer Ingelheim, according to Pri-Med's website.
Rosas said that his involvement in continuing education courses has been approved by his hospital. “I'm committed to continual learning and sharing my expertise with other physicians to ensure high-quality care for patients," he wrote in an e-mail.
Pri-Med defends the use of industry money to pay doctors for continuing education lectures. Rick Watson, Pri-Med's chief marketing officer, says the company often reviews speakers' financial ties to drug companies and what they plan to say to ensure talks are “accurate and balanced."
Hospitals and medical schools also sponsor industry-funded education with undisclosed payments to physicians. At the Harvard-affiliated Joslin Diabetes Center, a nonprofit institution and the world's largest diabetes research center, an online course on combatting Type 2 diabetes is sponsored by, among other pharmaceutical companies, GlaxoSmithKline LLC. The company last year received FDA approval for an injectable drug to treat Type 2 diabetes.
Dr. Richard Beaser, a Harvard Medical School professor and former chief of Joslin's medical education program, called corporate sponsorship of medical education “a good thing" because diet and exercise alone are not enough to control diabetes.
Critics say secrecy around payments to physicians for educational lectures means the public is not getting a full picture of how doctors may be influenced.
“It's just hard to believe drug manufacturers would keep contributing the massive amounts they are contributing unless they have some pretty realistic expectations that they are going to make some money off of it," said Timothy Jost, a professor emeritus at Washington and Lee University School of Law in Virginia who served on an Institute of Medicine Panel that recommended greater disclosure. “They certainly have influence over the subjects and particular medical conditions that are going to be covered."
It's also a great opportunity to advertise, Jost said. Doctors attending educational conferences will often be greeted by a poster, handout, or slide identifying the sponsoring drug companies before the program begins.
Dr. Daniel Carlat, a Newburyport psychiatrist and Tufts Medical School professor, publishes his own medical education newsletter but does not accept industry money. “My concern is that industry funding subtly distorts medical education in the direction of the newly marketed medications," Carlat said. Increased prescription of new drugs may not only raise health care costs, but expose patients to poorly understood risks of side effects, he said.
Holly Campbell, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, said companies underwrite medical education because they “seek to improve patient health." The association's own code says continuing education sponsored by industry is intended to cover a “full range of treatment options and not to promote a particular medicine."
The current law requiring industry to disclose noneducation payments — such as consulting fees — was enacted in 2010 as part of President Obama's sweeping health care overhaul. It followed years of congressional criticism and media reports on conflicts of interests and companies illegally paying doctors to promote unapproved uses of their drugs.
Senator Chuck Grassley, the Iowa Republican who introduced the initial bill, said Congress should have included continuing education payments in the disclosure law.
“Greater reporting of continuing medical education is something that needs to happen," Grassley said in a written statement to the Globe.
Now, the Obama administration's Centers for Medicare and Medicaid Services, which sets the rules, wants to target this stream of industry money by requiring some disclosure of medical education payments in 2017. But the AMA, pharmaceutical companies, and dozens of physician specialty groups are fighting back in Congress. They've partially won in a section of a bill called the 21st Century Cures Act, which passed the House with broad, bipartisan support in July.
Critics say that 362-page bill, which would increase federal research funding and speed the development of new drugs, has become a grab-bag of industry provisions. A small section, one and a half pages, explicitly exempts from disclosure industry money that is used for educational purposes — including speaking fees, tuition, and medical literature.
Consumer watchdogs, the American Medical Student Association, and the National Physicians Alliance say the bill would widen the door for secret industry influence.
But those who want to keep the payments secret say Congress must guard against confusion created by the Obama administration's proposed rules.
“This should be codified in statute and no longer subject to interpretation," said Dr. Steven Stack, president of the AMA, in a written statement.
Proponents of keeping the payments out of public view said doctors do not want their names and fees reported, because the public will equate industry payment with industry influence.
“Physicians involved are afraid they will be viewed by the public as having done something inappropriate, that they are on the take," said Christopher Clark, director of the Office for Interactions with Industry at Partners HealthCare, the umbrella organization that includes large Boston teaching hospitals.