Reports continue to pour in that US doctors tend to prescribe unwanted, even possibly harmful medicines in return for payments from drug makers in the name of lecture assignments.
Lawmakers are stepping in to see whether they could require drug makers to disclose payments made to doctors and also keep within certain limits such payments.
US psychiatrists, for instance, earn more money from drug makers than doctors in any other specialty.
Not coincidentally prescription of atypical antipsychotics to children is also shooting up, like never before, when such drugs considered risky for children and not approved by the Food and Drug Administration (FDA).
The term antipsychotic is applied to a group of drugs used to treat psychosis. Common conditions with which antipsychotics might be used include schizophrenia, mania and delusional disorder, although antipsychotics might be used to counter psychosis associated with a wide range of other diagnoses.
Atypical antipsychotics are second-generation medicines designed to cause fewer neurological complications than conventional antipsychotics. They include aripiprazole (sold as Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon). Each is approved by the Food and Drug Administration to treat schizophrenia and bipolar disorder, and risperidone is also approved to treat irritability in children ages 5 to 16 who have autism.
Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state's Medicaid program.
Over all last year, drug makers spent $2.25 million on marketing payments, fees and travel expenses to Vermont doctors, hospitals and universities, a 2.3 percent increase over the prior year, the state said.
The number most likely represents a small fraction of drug makers' total marketing expenditures to doctors since it does not include the costs of free drug samples or the salaries of sales representatives and their staff members. According to their income statements, drug makers generally spend twice as much to market drugs as they do to research them.
"For the fourth year in a row, our analysis shows that there is a great deal of money being spent in our small state on marketing pharmaceutical products," said William H. Sorrell, the Vermont attorney general.
Endocrinologists received the second largest amount, according to the Vermont analysis, earning an average of $33,730. Since the state identified the specialties of only the top 100 earners, these averages represent the money earned by only some of the state's specialists. There were 11 psychiatrists and 5 endocrinologists in that top group of 100.
Still, a similar pattern was evident in a Minnesota database that was the subject of a series of articles in The New York Times this year. As in Vermont, psychiatrists earned on aggregate the most in Minnesota, with payments ranging from $51 to $689,000.
The Times found that psychiatrists who took the most money from makers of antipsychotic drugs tended to prescribe the drugs to children the most often.
These and other stories have helped to fuel a growing interest among state and federal officials to document and restrict payments to doctors from drug makers.
And the Senate Special Committee on Aging, which is led by Senator Herb Kohl, Democrat of Wisconsin, on Wednesday held the first of a series of hearings on the issue, which could lead to legislative proposals to restrict and require disclosure of payments and gifts to doctors from drug companies nationwide.
Several lawmakers on Capitol Hill have expressed interest in such legislation, including Senator Charles E. Grassley, Republican of Iowa. "A federal law requiring public disclosure of payments to doctors could be very effective if it was carefully monitored and consistently applied," Mr. Grassley said.
Efforts to require disclosure of payments to doctors began almost by happenstance in 1993, when The Minnesota Legislature passed a law that restricts drug companies from giving doctors gifts valued at more than $100 in any given year. The legislation also required companies to report and make public any consulting fees paid to doctors.
Lee Greenfield, a former state representative in Minnesota and one of the law's authors, said it passed with little fanfare or debate after legislators heard stories about doctors accepting gifts of great value from drug makers.
"Why do we want them bribing doctors to use what may not be the best or most cost-effective drug for the patient purely to get some hand-held TV, we all asked," Mr. Greenfield said.
Still, compliance with the law has been relatively indifferent. And governments don't crack down. Now tightening up could be on the cards.
Besides Vermont and Maine, more than a dozen other states have or are now considering similar legislation, said Sharon Anglin Treat, executive director of the National Legislative Association on Prescription Drug Prices.