Drug company funding of continuing medical education for doctors has become one of the most lucrative ways for pharmaceutical firms to promote and sell their products, adding to the enormous cost of health care in the United States, according to testimony Wednesday before a U.S. Senate hearing.

"CME (continuing medical education) has become an insidious vehicle for aggressive promotion of drugs and medical devices," said Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic. "CME has largely evolved into marketing, cleverly disguised as education."

Nissen was one of several experts to testify on conflicts of interest in doctor education activity before the Senate Special Committee on Aging, led by Sen. Herb Kohl (D-Wis.).

In questioning from Kohl, Nissen said the U.S. spends, on a per capita basis, $90 billion a year more than other industrialized countries, largely as a result of prescribing habits promoted by doctor education activities. If those costs were eliminated, it could fund a major portion of health care reform, he said.

Drug companies now spend more than $1 billion a year to fund doctor education, accounting for more than half of all such activity.

Influencing use

Critics contend that it leads to more use of expensive brand-name drugs and the use of those drugs for unproven therapies.

The Journal Sentinel has published a series of stories this year raising questions about the influence of pharmaceutical companies at the University of Wisconsin School of Medicine and Public Health, including several stories on drug company-funded doctor education. Drug companies spend about $13 million a year to fund UW medical education courses, and the university receives about $3 million of that.

In written statement to the committee, Robert Golden, dean of the UW medical school, said all of America's health care teaching institutions should abide by clear standards that eliminate or manage conflicts of interest.

"Transparency, however, must be a basic element of any approach to conflict of interest," Golden said.

However, Nissen noted that the flow of money is so enticing that large academic medical centers now compete with for-profit entities known as medical education companies for industry funding. Often those firms work with medical schools such as UW to produce doctor education material with funding from drug companies.

While the grants are supposed to be unrestricted, often there is a "wink and a nod" in which the private companies pick speakers and topics that will please the drug company, Nissen said.

Eye on the market

Drug companies can use their sponsorship of doctor education to increase market share and maximize their return on investment, said Lewis Morris, chief counsel for the Office of Inspector General in the Department of Health and Human Services.

He noted a study showing that every dollar spent by a drug company on doctor education activities generated $3.56 in increased revenue.

Sometimes continuing medical education can work as a cleverly disguised form of a kickback, he said. In such cases, a drug company might reward a doctor who prescribes large amounts of its drugs by directing a contractor to pay or overpay that doctor to be a CME faculty member, he said.

He noted that in 2006, Medtronic paid $40 million to settle allegations that it illegally paid doctors to promote and use its spinal devices. The payments included free travel and lodging for the surgeons and their families at lavish locations in Hawaii, Cancun and Malaysia for discussion groups of no or limited substance, he said.

Sometimes drug company-sponsored doctor education does not mention a specific drug, but rather a disease or condition that can be treated by the company's drug, said Adriane Fugh-Berman, a physician with Georgetown University Medical Center and director of PharmedOut, an organization that helps doctors resist inappropriate drug promotion.

Focus on disease

She said drug company-sponsored doctor education is used to sell drugs by selling diseases, often by emphasizing the severity or prevalence of a disease to expand a market.

"Manipulating physicians' understanding of the prevalence or severity of a medical condition can lead to over-treatment and expose patients to the adverse effects of drugs without significant benefit," she said.

In a statement, the Pharmaceutical Research and Manufacturers of America said there is no conclusive evidence that drug company funding of doctor education creates bias.

"Eliminating commercial funding of CME would not benefit patients or doctors," the group said.

Nevertheless, the group said its revised code calls for drug companies to separate doctor education grant-making decisions from the sales and marketing departments.

In an interview after the hearing, Kohl said continuing medical education for doctors is important and also expensive. While drug companies expect the money they spend will help promote their products, he did not think those financial relationships were rife with corruption.

"We need a firewall to separate science from commerce," he said. "Hopefully, the industry will become more self-policing. (But) we may need some legislation on that."