Artificial Joints, Real Money

The hips and knees are synthetic, but it's real money changing hands.

Five makers of artificial joints have paid more than $200 million this year to doctors and hospitals, often the same ones who are deciding which company's joints to buy, according to an Associated Press calculation of disclosures required this week by a settlement with federal prosecutors.

The five companies were scrutinized by the U.S. attorney's office in New Jersey over allegations they gave money and trips to surgeons who used their products. Four of them - Biomet Inc., DePuy Orthopaedics Inc., Smith & Nephew Inc. and Zimmer Holdings Inc. - had their charges dropped when they paid a total of $310 million in fines and agreed to monitoring in a settlement announced in September. The fifth company, Stryker Corp., was never charged and paid no fines but agreed to disclose its payments.

The payments to doctors and hospitals ranged from a few dollars to individual doctors to about $3.9 million to Mayo Clinic. And the AP's calculation is conservative, because the companies were required to disclose payments within a $25,000 range, and the AP used the low end in its calculation.

The money includes items like royalties for inventions and payments for teaching classes. Prosecutors alleged that from at least 2002 through 2006, the companies paid exorbitant amounts for doctors to be consultants and to use their products exclusively.

They did not allege that all the money was illegitimate.

"Certainly it was not a majority of doctors who had contracts that were operating illegally," said Mike Drewniak, a spokesman for the U.S. attorney's office in New Jersey. Drewniak said the investigation into the five companies in the settlement has wrapped up, but that prosecutors are still looking into payments by smaller medical device companies.

The settlement required the companies to disclose who it paid during 2007, and to update the information quarterly. Later this year, it will also require them to disclose non-monetary payments, such as trips.

Mayo took in money from all the companies except Biomet, including almost $2.1 million from DePuy, which is a unit of Johnson & Johnson. Mayo spokesman Lee Aase said nearly all of the money it received was for royalties, as well as sponsored research. Doctors who invent medical devices get paid some of the royalty money through the clinic, he said.

"By lumping all this stuff together, you have some places like Mayo look like one of the bigger recipients of this, but it's because they're inventing things," Aase said.

Zimmer Holdings, the biggest maker of artificial hips and knees, paid the most to doctors - $85.8 million, according to the disclosure made on its Web site on Wednesday. DePuy paid $48.8 million, Stryker paid $27.8 million, Biomet paid $19.6 million, and Smith & Nephew paid $19.3 million.

DePuy said in a statement that it had begun to change its interactions with doctors before the Justice Department investigation was announced. It said that the payments are "critical to advancing patient care and keeping the orthopaedic community appropriately educated and trained on new products and surgical techniques."

Spokesmen for Zimmer, Stryker, and Smith & Nephew all declined to comment. Stryker posted its information in a way that made it difficult to sort the data and declined a request to make it available in a more usable format. A Biomet spokeswoman did not return a phone message seeking comment.

Cincinnati orthopedist Dr. Edward Lim has written about the relationship between doctors and the implant industry. He also was listed as receiving $14,794 from Zimmer.

He said the money was for teaching classes that demonstrate joint replacements, such as a new shoulder he put into a cadaver last week.

"By and large I think the industry is fairly up front in terms of, you provide a service and you expect to get paid for a service," he said. "What you're not expected to do is, say, get a kickback for doing a certain number of joints."

"I'm paid for my time and my expertise. I'm not paid for being their mouthpiece," he said.

The settlements with the companies include a limit of $500 per hour for consulting services. Companies that want to pay more must get a third-party evaluation of a fair price for the consulting.

Rosamond Rhodes, who is director of bioethics at Mount Sinai School of Medicine in New York, said the relationship between doctors and companies is more necessary with medical devices than in other areas, such as pharmaceuticals. Doctors need to learn how to implant an artificial joint, and that probably needs to happen at an event the company paid for, she said.

But even though those relationships may be necessary, she also believes they influence doctors to buy the product made by the company paying the bills.

"The amazing thing is each doctor who is involved believes with a totally pure heart that they are immune. So the influence is silent," she said. "But we know that it affects their judgment."