Hawaii doctors received $4.29 million in total payments from drug companies for promotional talks or consulting work in 2018.

That’s according to research by ProPublica, an independent, nonprofit news organization in New York, which recently published five years of data on payments to doctors by pharmaceutical companies and medical device makers.

The payments raise concerns that drug companies could be encouraging doctors to prescribe pharmaceuticals from a particular company even when another drug may be more beneficial to the patient.

“There’s always a concern about conflict of interest when somebody gains financially or professionally from any relationship,” said Dr. Eileen Hilton, CEO of Crown Care, a Hawaii patient advocacy company. “If they’re giving a lecture and they are pushing a particular drug because the drug company supplied the money for the lecture and paid them, that would be a major conflict of interest. It doesn’t benefit patients particularly unless it’s the best drug there is for that indication, but ofttimes that is not the case.”

Over the past five years, the highest-paid doctor, Maui dermatologist George Martin, received $1.3 million. Three others were paid more than half a million: Honolulu neurologist Leo Maher, $916,919; Kailua gastroenterologist Naoky Tsai, $855,892; and Philip Suh, a family medicine physician, $750,540. This does not include payments for research or royalties from inventions.

Bethany Dilley, a practice management consultant for Martin, who was traveling to India for a dermatology world conference, said most of the money the doctor receives pays for costly medical conferences each year. He runs three dermatology conferences and two nondermatology events annually as owner and director of Advances in Medical and Cosmetic Dermatology, she said.

“That’s where doctors come to learn all the new cutting-edge ways to treat all the different issues and diseases that are part of the dermatology world,” Dilley said. “Sometimes he will sit on the advisory board as a medical advisor for research purposes as they’re developing a new medication or … new treatments for medications currently on the market.”

The earnings from drugmakers do not affect treatment decisions for patients “whatsoever at all,” she said.

“He treats his patients based on who they are, what their needs are and what the best treatment is going to be for that individual. It’s not based on any particular medication or company unless he feels that is the best medication for the diagnoses they have been given,” she said. “The drug companies, they are very good about making sure they’re not influencing (doctors). They just want to make sure they are able to have the resources for patients as well as the best information for both patients and doctors. Very rarely do you find a doctor who is not working for the best results for each patient. Yes, there are some out there, but those are very few and far between.”

Tsai said that there is no conflict of interest or influence on his prescription decisions, as the compensation he receives is “based on a clear scope of work” that is educational in nature.

“The discussions are on the indications, safety and efficacy of their products. (The U.S. Food and Drug Administration) has set very strict guidelines on what is being presented,” he said. “I am invited to serve as speaker and adviser based on my experience and my knowledge on the disease and treatment.”

All the drugs Tsai has spoken about on behalf of pharmaceutical companies are also “dictated by the health insurers,” meaning health plans need to approve the prescriptions, “therefore, I would not have any say in which drug the patient is to receive.”

“The health providers who come to listen to my presentations can also make their mind, and they are able to report me if there is any misrepresentation from my discussion,” Tsai added. “To me it is an educational and interactive discussion on the scientific evidence and significant safety issues concerning the medication in discussion. I know there is always a perceived conflict of interest of things we do even in our daily life, and I am always mindful to stick to the science and provide the evidence-based information to my audience.”

Working with physicians, including researchers and scientists, can improve patient care and help “nurture the discovery of new medicines,” according to the Pharmaceutical Research and Manufacturers of America, representing U.S. biopharmaceutical research firms.

“Companies engage with physicians to keep them current on new indications for approved medicines, potential side effects of medicines, and both emerging benefits and risks of medicines,” said a PhRMA spokeswoman, adding that drug companies compensate physicians for time spent on clinical research and educating peers about new medicines and treatments. “Physicians provide real-world insights and valuable feedback and advice to inform companies about their medicines to improve patient care.”

Dr. Lee Buenconsejo-Lum, interim associate dean for academic affairs at the University of Hawaii John A. Burns School of Medicine, said drug company payments in Hawaii “appear modest by comparison” with other states.

“Some of these physicians and hospitals are involved in approved clinical research, which are supported in part by pharmaceutical or device companies,” Buenconsejo-Lum said. “These relationships and materials are fully disclosed and part of the approved research protocols.”

Conducting research and developing new medical devices are allowed among physicians at Hawaii Pacific Health, many of whom also are on the faculty of universities or research organizations and often share their expertise with other medical providers, said Kristen Bonilla, a spokeswoman for HPH, parent company of Kapiolani Medical Center for Women &Children, Pali Momi Medical Center, Straub Medical Center and Wilcox Health on Kauai.

Hospitals also received drug company payments. Last year The Queen’s Medical Center was the highest- earning teaching hospital, earning $235,000 from drug companies, significantly more than any other local facility. By contrast, the second-highest paid was Kaiser Permanente Hawaii at $14,824, followed by Straub at $12,805.

“These payments are generally in support of training … for equipment that The Queen’s Medical Center has purchased. That training may include physicians, nurses, technicians and others,” said Dr. Todd Seto, director of academic affairs and research at Queen’s. “These are also institutional grants for research and education that QMC develops and that the industry supports, which is common in academic settings. Given our size, complexity of patients and academic focus, it would make sense that industry partners collaborate with us more than other sites, since we have more complex equipment, more staff to train and more research being done.”