This story used data from ProPublica’s Dollars for Docs database.

Over the course of five years, pharmaceutical and medical device companies paid 76 doctors in the Philadelphia region more than $500,000 each to consult on or promote their products, an analysis of federal data by The Inquirer and ProPublica has found.

Nearly two-dozen area doctors, among them some of the region’s most prominent health-care leaders, received more than $1 million in such industry payments. That group includes Julia Haller, the ophthalmologist-in-chief at Wills Eye Hospital and a board member for the biotechnology company Celgene, which paid her $2.1 million between 2014 and 2018. She also chairs the Department of Ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University, an institution that figures prominently on the payments list.

Stephen Klasko, the president of Thomas Jefferson University and CEO of Jefferson Health, was reported to have earned $1 million in industry payments over that five-year stretch, the bulk of which stemmed from his position on the board of Teleflex, a medical device company with headquarters in Wayne.

Serge Jabbour, director of endocrinology at Jefferson, received more than $1.6 million in connection with consulting and promotional speaking for several diabetes drugs. In 2018, he was paid more than almost any other doctor in the country to promote Bydureon, an AstraZeneca type 2 diabetes drug.

The highest-paid doctor in the region was Sharad Mansukani, an ophthalmologist from Moorestown and a former health administrator who served on the board of Par Pharmaceuticals for several years and was recently appointed to the board of Endo Pharmaceuticals. He earned $5.9 million in industry payments between 2014 and 2018, according to ProPublica’s database. (Endo representatives did not return a call for comment.)

While such financial relationships between doctors and drug companies have long been common practice, and are not illegal, until fairly recently the nature of the arrangements and the amount of money involved was kept secret.

Under the Affordable Care Act, drug companies and medical device makers must report to the federal government all payments and gifts to doctors. The Centers for Medicare and Medicaid Services annually publishes the information in a public database, which before 2014 was freely available only through ProPublica’s “Dollars for Doctors” project.

In the news organization’s most recent national report, it found that more than 2,500 U.S. physicians have received at least half a million dollars apiece from drugmakers and medical device companies in the last five years. These calculations do not include money for research or royalties from inventions.

Compensation can include meals, travel expenses, investment opportunities, and fees for consulting and speaking engagements, under federal law.

Academic medical centers also require researchers to disclose any industry payments they receive that could present conflicts of interest.

The ACA rules were a response to growing concern that payments from pharmaceutical payments may be compromising patient care.

But Arthur Caplan, a medical ethicist at New York University School of Medicine, is among those who question whether the well-intended push for transparency has had any meaningful effects.

“In a system that is awash with corporate ties and connections, transparency is nice, but I don’t think it is much of an antidote to the influence that the private sector has over medicine,” Caplan said.

Maintaining transparency

Fourteen doctors with Jefferson Health, and four at the Jefferson-affiliated Rothman Orthopaedic Institute, received more than $500,000, with four of the 18 making more than $1 million in the last five years. Eight doctors from Main Line Health reached the $500,000 threshold, as did seven current or former Penn Medicine doctors, with one receiving more than $1 million.

“Penn Medicine faculty physicians, like those at most academic medical centers, are entitled to do limited outside work with third parties such as pharmaceutical or medical device companies,” Patrick Norton, vice president for public affairs at the University of Pennsylvania Health System, said in a statement. Physicians have to disclose those contracts, Norton said, and the system is “committed to ensuring the transparency of all such activities."

The university is reviewing the payments database, which he said has mistakenly identified some industry-sponsored research at Penn as consulting fees for physicians.

Representatives at Main Line Health said in a statement that its physicians are also permitted to consult for pharmaceutical companies, but should do so “in accordance with all applicable laws, and [acting] with the utmost commitment to ethical principles.”

At Wills Eye, where Haller and another physician, neuro-ophthalmology chief Robert Sergott, received more than $1 million in five years, a spokesperson said that it was “no surprise" its doctors are “asked to lead or take part in conducting research to develop new medicines, surgical procedures, or medical devices to help patients and treat or cure disease."

The hospital said it supports “their right to be fairly compensated for their research and service," but also requires physicians to disclose their board service and consulting agreements.

Jefferson representatives said they “seek to optimize the benefits of principled relationships with industry to advance the mission of patient care, education and research" and that the institution has policies in place to identify and manage conflicts of interest.

“Both individually, as well as in conjunction with the industry, Rothman Orthopaedic has developed technology that benefits patients with musculoskeletal disorders and are compensated with consulting fees or royalty payments for these services,” said institute president Alexander R. Vaccaro, who also is a professor of neurosurgery at Jefferson. “Through the years, we have maintained our transparency in reporting income for the work we have done — and we will continue to do so.”

How patients perceive payments

Relationships between doctors and pharmaceutical companies can be difficult to interpret, said Sandro Galea, the dean of Boston University’s School of Public Health. There’s no public database that tracks how doctors prescribe drugs, and whether prescription patterns might have been influenced by consulting payments. (State prescription drug monitoring programs are confidential.)

A study by researchers at the University of Pennsylvania found that the CMS database made patients more aware of the issue. But it concluded that patients did not use the information to make decisions about their care.

“Although it did increase people’s awareness of the issue, it may have made them more cynical toward their own physician and the medical profession as a whole,” said Genevieve P. Kanter, an assistant professor of medicine, medical ethics and health policy at Penn’s Perelman School of Medicine, and the study’s lead author.

Kanter said the findings illustrate a common criticism of health care transparency initiatives: They improve access to information, but leave patients to apply it to their own lives.

And it may be hard for patients to understand the different kinds of relationships doctors have with private industry and discern whether payments pose a threat to their care.

Receiving a research grant to study a condition, drug or device is different from accepting a free meal or speaker fee from a company that wants you to prescribe its drug over a competitor’s. And increasingly, academic leaders are serving on boards of companies that financially support their institutions.

It’s straightforward for researchers who accept industry payments to disclose the relationship and detail steps they took to preserve the integrity of their findings. But “it’s a very different problem when you’re sitting on the boards,” Caplan said. “Board members are supposed to advance the corporate interest of the company.”

Alan Epstein, a Philadelphia rheumatologist who made more than $1 million consulting and speaking between 2014 and 2018, most recently for the Sanofi anti-arthritis drug Kevzara, said the lectures he gave for pharmaceutical companies are opportunities to educate his peers on new drugs and data on diseases. His compensation, he said, is standard, and “based on credentialing and other factors.”

“And, most important,” he added, “this has no relation at all to my prescribing habits. My patients’ welfare is always my primary concern.”

Antonino Secchi, a Devon orthodontist who made almost $1.8 million between 2014 and 2018, mostly through promotional speaking for Dentsply Sirona, a dental supply company, said his earnings came from speaking engagements and educational sessions on a technique he developed using Dentsply’s products. There’s less of a price differential among orthodontic products than among name-brand drugs, he said. “When you have braces, what you are paying for is the doctor’s time and the expertise,” he said.

But, he said, he thinks doctors should be transparent about who they’re consulting for. “When I go to my doctor, I want to make sure he’s using the best [products] available for me,” he said -- not just products from a pharmaceutical company they’re consulting for.

It’s imperative that doctors be up-front about who they’re taking money from, and why, said Galea.

“Just because something presents a potential conflict doesn’t mean it is going to become a conflict. It’s reasonable to ask your physician about the money they get from drug companies, and to what extent this influences their recommendation. And a reasonable, responsible physician should engage with that question."