When the blood pressure drug Bystolic hit the market in 2008, it faced a crowded field of cheap generics.
So its maker, Forest Laboratories, launched a promotional assault on the group in the best position to determine Bystolic's success: those in control of prescription pads. It flooded the offices of health professionals with drug reps, and it hired doctors to persuade their peers to choose Bystolic -- even though the drug hadn't proved more effective than competitors.
The strategy worked. In the 2012 fiscal year, sales of Bystolic reached $348 million, almost double its total from two years earlier, the company reported.
One doctor made more than $100,000 from 2009 to 2012.
Now, data obtained and analyzed by ProPublica suggest another factor in Bystolic's rapid success: Many of the drug's top prescribers have financial ties to Forest.
At least 17 of the top 20 Bystolic prescribers in Medicare's prescription drug program in 2010 have been paid by Forest to deliver promotional talks. In 2012, they together received $283,450 for speeches and more than $20,000 in meals.
Nearly all those doctors were again among the highest prescribers in 2011, the most recent year for which Medicare data are available. Forest began disclosing its payments only last year; the company didn't specify which drugs doctors spoke about.
Dr. Bernard Lo, who was chairman of a national panel examining conflicts of interest in medicine, said he doesn't believe the findings are coincidental.
When there's no evidence a drug is better, "You have to question: Why are doctors prescribing this?" said Lo, president of the Greenwall Foundation, a New York City nonprofit that funds bioethics research. "What your evidence suggests is that there is a financial incentive for doctors who receive payments from drug companies" for pitching their products.
Until now, doctors' prescribing habits have been secret from all but pharmaceutical companies, which pay millions of dollars for such information from other firms that collect it.
ProPublica's analysis marks the first time anyone has matched payment data made public by drug companies with physician prescribing records from the Medicare drug program, which covers about 1 out of every 4 prescriptions in the U.S.
Reporters identified the drugs that were most actively promoted to doctors in 2010 and 2011 using rankings from Cegedim Strategic Data, a company that tracks marketing expenses.
The top prescribers of some of these drugs, in addition to Bystolic, also received speaking payments from the companies that made them. As a group, these heavily marketed drugs were new or had new uses, were expensive, and often showed little benefit over existing medications or generics.
For example, nine of the top ten prescribers of the Alzheimer's drug Exelon received money from Novartis, the drug's maker. Eight of the top 10 for Johnson & Johnson painkiller Nucynta were paid speakers, as were 6 of the top 10 for Pfizer's antidepressant Pristiq.
Physicians with industry relationships said they were more likely to prescribe a brand-name drug when a generic was available.
The same was true for seven of the ten top-prescribers of the asthma drug Advair Diskus, made by GlaxoSmithKline. One doctor made more than $100,000 from 2009 to 2012.
Many of the physicians spoke for several drug companies.
If financial relationships influence physicians to choose pricier brand-name drugs that have little benefit over generics, everyone pays the cost -- particularly taxpayers, who spent $62 billion last year subsidizing Medicare Part D.
"I've never heard a doctor that said they were influenced, but obviously the companies are interested in doing it because the evidence overwhelmingly suggests that doctors are influenced," said Rita Redberg, a cardiologist at the University of California, San Francisco, and editor of the journal JAMA-Internal Medicine.
Companies are "not doing it for any reason except it improves their bottom line," she said.
A survey published in the Archives of Internal Medicine in 2010 found that physicians with industry relationships said they were more likely to prescribe a brand-name drug when a generic was available. And federal whistle-blower lawsuits against several pharmaceutical companies have alleged that payments are little more than thinly veiled kickbacks, which are illegal. Companies have paid billions of dollars to settle the cases.
Each of the top 20 prescribers of Bystolic wrote at least 530 prescriptions in Part D in 2010. ProPublica attempted to contact all those who also received money from Forest. Only a handful responded to phone calls, emails, and faxed letters requesting comment.
The No. 1 prescriber of Bystolic, Los Angeles cardiologist Gary Reznik, said that if patients have blood pressure under control with another beta blocker, he doesn't switch them. But he believes Bystolic is more effective at lowering blood pressure and doesn't cause the slower heart rate and erectile dysfunction of other drugs in the class.
"If you don't have to be on a beta blocker, I would not start you on a beta blocker," said Reznik, who was paid $3,750 to give talks by Forest in 2012. "If you have to have a beta blocker, Bystolic would be my choice." Reznik prescribed the drug more than 2,500 times in 2010 and more than 2,900 in 2011, including refills dispensed, Medicare records show.
"I have never felt that there were any expectations or pressure on the part of the company that I would prescribe it more or at all," he said.
Another top prescriber, internist Mark Barats, of West Hollywood, California, said he uses smaller doses of Bystolic to achieve the same effects as higher doses of generic medications. "It has much less side effects, particularly much less side effects on the respiratory system," he said.