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The Food and Drug Administration said Tuesday that all fast-acting opioid pain medicines will be required to carry its strongest warning about risks, including the risks for abuse, addiction, overdose and death.

The decision to require instructions for the drugs to carry a so-called black box warning marks the latest in a series of steps by the FDA and other federal agencies to fight the epidemic of opioid addiction.

“This epidemic touches all corners of our nation and is devastating individual lives, communities and our nation,” said FDA Commissioner Robert Califf during a briefing for reporters. He called the epidemic the “most urgent and devastating public health crisis facing our nation.”

The warnings are aimed at more than 200 fast-acting versions of opioids, such as oxycodone, hydrocodone and morphine, which are intended for use every four to six hours for serious acute pain. Ninety percent of all opioid prescriptions are for these fast-acting, or immediate-release, formulations.

Black-box warnings are the most stringent the agency can require, and they have been found to get doctors’ attention and influence their prescribing decisions.

Califf said the FDA wants to warn doctors and patients about the dangers of the drugs while ensuring they remain available for patients who need them to alleviate pain. However, Califf stressed the drugs should be reserved for severe pain for which no alternatives are available.

In addition to the risks of addiction and overdose from opioids, the new labels will also warn that chronic use of the drugs by pregnant women could lead their newborns to suffer from neonatal opioid withdrawal syndrome.

When taken with antidepressants and migraine medications, opioids can also cause a potentially life-threatening central nervous system condition known as serotonin syndrome, which occurs when the body is overloaded with the brain chemical serotonin.

Opioids are also known to increase the risk for a “rare but serious” disorder of the adrenal glands known as adrenal insufficiency, and decrease levels of sex hormones, the FDA said.

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What’s more harmful to patients being treated for drug or alcohol use: Risking their health by keeping other medical providers in the dark about the care, or risking the patients’ jobs, homes and child custody arrangements by allowing potentially damaging details to be shared widely among providers?

Advocates have painted the possible patient outcomes in starkly different terms as they consider the federal government’s recently proposed update to guidelines that govern the release of patient records about treatment for alcohol and drug use.

What everyone can agree on is that protecting the privacy of people who are being treated for substance use is critical. If such information becomes public, it may have a devastating effect on their work and family lives. In some cases, it also may have legal repercussions, including arrest, prosecution and jail. The mere threat that treatment details might be disclosed can be enough to deter some people from seeking help.

The current privacy guidelines — often referred to as “Part 2” as an abbreviation for “42 CFR Part 2,” the section of the code of federal regulations where the rules are published — last got a meaningful update in 1987. Since then, electronic medical records have proliferated and become integrated.

Existing privacy rules are too cumbersome for today’s integrated world, say proponents who favor loosening the rules. Under current Part 2 rules, providers can’t disclose treatment information unless patients give their consent to release it to a specific health care provider.

Part 2 “is well intentioned, but it’s just not working,” said Matt Salo, executive director of the National Association of Medicaid Directors. “These special [treatment] silos are actually hurting people.” The Medicaid program for lower-income people is responsible for a significant and growing share of the money spent on treatment for substance use, Salo said.

In family medicine, it’s not unusual for patients to have 5 to 10 different diagnoses, one of them being substance abuse, said Dr. Wanda Filer, president of the American Academy of Family Physicians who practices at a federally qualified health center in York, Pa. Not having access to all the relevant medical information can be difficult or even dangerous. If someone is taking methadone to treat a heroin addiction, for example, the doctor may need to adjust his antidepressant or anxiety medications.

“Finding the right balance between getting access to information and protecting their privacy” is challenging, said Filer. The AAFP is still reviewing the potential changes.

The proposal from the Department of Health and Human Services would allow patients to give their consent to disclose their records not just to a specific provider but to the health care system or the accountable care organization with which the provider is affiliated, for example.

While the HHS proposal is an improvement over existing rules, it doesn’t go far enough, said Salo. His organization, along with others, would prefer that HHS align substance-use treatment disclosure rules with the federal Health Insurance Portability and Accountability Act of 1996, which governs other types of health care records disclosure.

Under HIPAA, health plans, providers and health care clearinghouses don’t have to get patients’ consent before disclosing their records to other similar groups and “business associates,” such as claims processing operations, if the disclosure is related to a patient’s treatment, payment or health care operations.

Strong protections must remain in place to prevent information from being used for criminal charges or to conduct criminal investigations, said Lindsey Browning, senior policy analyst at the National Association of Medicaid Directors.

That’s not good enough, say some patient advocates. They argue that the HHS privacy rule changes are too broad.

Under the HHS proposal, “anybody throughout the system can get access” to patient substance use treatment records, said Jim Pyles, a principal at Powers Pyles Sutter & Verville who is an expert on patient privacy and has represented the American Psychoanalytic Association on this issue. “When the patient is at their most vulnerable time, it gets them to sign … this very general consent form.”

Patients can’t rely on health care systems to keep their information private, Pyles said, noting that in the past six years, more than 150 million Americans have been involved in health data breaches, according to an analysis of HHS data released by Melamedia, a healthcare research company.

In the midst of a privacy breach epidemic, “we’re substituting the interests of integrated delivery systems and accountable care organizations for patients’ interests, when what we should be doing is asking patients what they want,” Pyle said.

Comments on the proposed rules are due on April 11.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Email questions for future columns: KHNHelp@KFF.org. Michelle Andrews is on Twitter: @mandrews110.

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The battle over drug prices escalated Monday when health insurance giant Anthem Inc. sued Express Scripts, a manager of drug benefits, to get a bigger share of savings on prescription medicines.

Anthem is looking for a change in its contract with Express Scripts, which handles drug benefits for 80 million people. The insurer says it’s overpaying for pharmaceuticals and not benefiting from rebates the pharmacy benefit manager has negotiated with drugmakers.

Anthem’s CEO Joseph Swedish said in January that the company could save as much at $3 billion in drug costs by reworking the deal with the PBM, according to several news reports at the time. Anthem is now threatening to end its contract with the country’s largest pharmacy benefit manager if it doesn’t get the price breaks it wants.

Express Scripts contests Anthem’s assessment. “We do not believe they are entitled to $3 billion,” Express Scripts spokesman Brian Henry tells Shots via email.

Drug prices are among the most opaque aspects of the muddled health care industry. Almost nobody pays the retail price for prescription medications.

Here’s how it works.

Pharmacy benefit managers like Express Scripts contract with health insurers or directly with employers to administer the prescription portion of employees’ health care plans. The PBMs then negotiate prices with drug companies for medications.

When patients go to a drugstore, they usually pay a set copayment for their medicine and the PBM pays the remainder of the discounted price — which shows up on insurance records.

But those discounts are often supplemented with rebates from the pharmaceutical manufacturer to the PBM that are often invisible to patients and to insurers or employers.

Express Scripts boasts about the discounts that it has extracted from drug companies that it passes along, in part, to its clients, such as Anthem. In recent years, Express Scripts has been driving harder bargains, sometimes refusing to pay at all for popular brand-name medicines and steering patients to rival drugs from companies that offer the PBM better deals.

Prices of brand name prescription drugs have climbed 164 percent since 2008 while generic drug prices have fallen 70 percent over the same period, according to Express Scripts’ own report.

Anthem used to run its own PBM but sold it to Express Scripts in 2009. As part of the deal, Anthem agreed to use Express Scripts for 10 years. The contract, however, called for the companies to renegotiate prices last December.

In its lawsuit, filed in the U.S. District Court for the Southern District of new York, Anthem says Express Scripts has refused to negotiate in good faith. Anthem is asking for damages to compensate the insurer for overpaying for prescription drugs.

“We believe that Anthem’s lawsuit is without merit,” Express Scripts said in an emailed statement, adding that the company “has consistently acted in good faith and in accordance with the terms of its agreement with Anthem.”

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When Allison Fite was 16, she couldn’t stop falling asleep in class. Doctors told her it was from a severe sinus infection, but it never really went away. For the next decade she struggled with infection after infection, taking antibiotics and decongestants. “Having these sinus problems and not being able to breathe was debilitating,” she says.

Fite, now 27, couldn’t figure out why this kept happening. Neither could any of her doctors. They told her she had allergies, but “then the tests would come back and they’d be like, ‘Huh. You don’t have allergies,’ ” she says.

But a few unusual symptoms helped Fite eventually figure out that she had a little-known disease shared by 1 to 1.5 million Americans. She has asthma, a loss of smell and taste, and a strong, adverse reaction to alcohol. “Before I could finish [a drink], I started to get these really bad headaches,” she says. “I really am allergic to fun.”

And she had nasal polyps, which are benign growths in the sinus cavities. When she was 20, she had them surgically removed for the first time. At age 25, she flew back from where she was living in Thailand to the U.S. for a second operation. But this time the polyps reappeared even faster, a mere eight weeks after the surgery.

“I was seeing a doctor in Bangkok at this point,” she says. “He was like, ‘This is not normal.’ ” But the doctor mentioned that aspirin can cause nasal polyps. This was Fite’s first real clue about her illness. It’s called aspirin-exacerbated respiratory disease, or AERD.

It was first described in the early 1900s, says Dr. Tanya Laidlaw, an immunologist at Brigham and Women’s Hospital in Boston who studies the disease. It’s seen in “patients who had this triad of asthma, nasal polyps and very idiosyncratic reactions to medications like aspirin,” Laidlaw says.

Things started clicking into place. Fite’s mother found one of Laidlaw’s presentations on the illness online and sent it to her daughter. Fite knew she had nasal polyps and asthma but she didn’t know if she had the third symptom — a potentially life-threatening reaction to painkillers like aspirin or ibuprofen. So her doctor in Thailand decided to test her. He gave her a fifth of a pill of aspirin, just to see what would happen.

“Forty-five minutes later,” Fite says, “I’m coughing, sweating, my heart is beating out of my body, and they’re like ‘OK, stop. She has the disease.’ “

After years of seeing doctor after doctor trying to understand why she was always sick, she finally knew the reason. “It felt so good to have the diagnosis. I started tearing up in the doctor’s office in Bangkok like mid-horrible reaction,” Fite says.

But there was one problem. Fite needed a treatment called aspirin desensitization. That’s when a doctor overloads a patient with a large dose of aspirin. And Fite’s doctor had never done it before.

“He was like, ‘I don’t feel comfortable doing it, and I don’t think you’ll find a doctor in Asia who is.’ ” Fite says.

So Fite left Thailand again and went to Tanya Laidlaw’s clinic in Boston to get the procedure. Laidlaw says nobody knows why the treatment works, but it desensitizes the patient to aspirin and helps alleviate the symptoms. Laidlaw says she’s frustrated by the lack of awareness of AERD. She estimates at least 20 percent of people who have it go undiagnosed. “It’s really frustrating,” she says.

It probably gets missed a lot by clinicians, particularly primary care providers who don’t specialize in immunology or ear, nose and throat medicine, says Dr. Ana Broyles, an immunologist at Boston Children’s Hospital.

And there’s a severe lack of science around the illness. When Laidlaw began studying it 10 years ago, she says barely any basic research had been done in the last century.

It’s not an allergy. There’s no geographic pattern to suggest an environmental link like a toxin. Family history doesn’t seem to factor either, so it doesn’t seem to be genetic. One theory suggests that AERD might begin with an infection, Laidlaw says. The body turns on an immune response to fight the illness, but then somehow never turns it back off. The person is left with an army of misplaced white blood cells that can inflame the airway and cut off smell receptors.

AERD patients also produce too much of inflammatory molecules called leukotrienes, and Laidlaw thinks that causes many of the symptoms. That has led to some useful advice for patients – like avoiding certain substances like alcohol that make the symptoms worse.

Fite’s been doing a lot better since her desensitization procedure. Over the last year, she’s only had one sinus infection. “It’s amazing,” she says. “Prior to that, I had one once a month.”

Fite still has her worries though. She has to be on aspirin for the rest of her life to maintain the desensitization. “Say I get in an accident, and I bleed too much because of the aspirin,” she says. The symptoms aren’t totally gone, and she still can’t drink alcohol without becoming really ill. Plus, she says, it’s just unnerving taking aspirin every day when she knows it should kill her.

But there aren’t many alternatives, so until there’s a better solution, she’ll stay on the aspirin.

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Medicare beneficiaries may get dinged with higher prescription drug bills this year because more than half of covered drugs in standalone plans require them to pay a percentage of the cost rather than a flat fee, an analysis from consulting group Avalere Health says.

Fifty-eight percent of covered drugs in Part D drug plans in 2016 are subject to this so-called coinsurance, the Avalere analysis found. That means patients are on the hook for a percentage of the costs, which can be much higher than a traditional copay, which is flat. If a drug costs $200, instead of making a $20 copayment, they may owe 20 percent of the cost, or $40.

The percentage of drugs requiring coinsurance has climbed steadily, increasing from 35 percent in 2014 to 45 percent last year. That percentage is approaching two-thirds of all covered drugs.

More coinsurance makes beneficiaries’ drug costs less predictable, said Caroline Pearson, a senior vice president at Avalere. It may also result in fewer affordable options if patients can’t achieve any savings by substituting drugs in the same therapeutic class, she said. The shift toward coinsurance also means that Medicare beneficiaries will have to rely to a greater extent on cost-estimating tools like the Medicare plan finder to figure out how much they may owe out of pocket.

Medicare Part D plans typically divide drugs into five tiers with different levels of cost sharing. In the past, coinsurance may have been limited to high-cost specialty drugs, but that’s changing. Last year, about two-thirds of people in drug plans faced coinsurance in more than one drug tier; this year the figure is 96 percent, according to Avalere.

Medicare Advantage managed care plans aren’t shifting to coinsurance to the same degree as the standalone drugs plans that accompany traditional Medicare coverage, the analysis found. In 2016, 26 percent of covered drugs in Medicare Advantage plans required coinsurance.

“On the Medicare Advantage side, the premium includes both medical and drug benefits, and the drug piece is smaller,” so the incentive to tightly manage drug costs may be lower in Medicare Advantage plans, Pearson said.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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California’s insurance exchange is threatening to cut hospitals from its networks for poor performance or high costs, a novel proposal that is drawing heavy fire from medical providers and insurers.

The goal is to boost the overall quality of patient care and make coverage more affordable, said Peter Lee, executive director of the Covered California exchange.

“The first few years were about getting people in the door for coverage,” said Lee, a key figure in the rollout of the federal health law. “We are now shifting our attention to changing the underlying delivery system to make it more cost effective and higher quality. We don’t want to throw anyone out, but we don’t want to pay for bad quality care either.”

It appears to be the first proposal of its kind in the country. The exchange’s five-member board is slated to vote on it next month. If approved, insurers would need to identify hospital “outliers” on cost and quality starting in 2018. Medical groups and doctors would be rated after that.

Providers who don’t measure up stand to lose insured patients and suffer a black eye that could sully their reputations with employers and other big customers.

By 2019, health plans would be expected to expel poor performers from their exchange networks.

The idea has already sparked fierce opposition. Doctors and hospitals accuse the exchange of overstepping its authority and failing to spell out the specific measures they would be judged on.

Health insurers, normally at odds with providers, have joined them in the fight. The insurers are balking at the prospect of disclosing their negotiated rates with providers. Health plans have long resisted efforts that would let competitors or the public see the deals they make with doctors and hospitals.

But scrutinizing the negotiated rates would help the exchange identify high-cost providers and allow policyholders with high deductibles to see the differences in price before undergoing a surgery or imaging test.

Lee said it’s time for the exchange to move beyond enrollment and flex its market power on behalf of its 1.5 million members. He said insurers haven’t been tough enough on hospitals and doctors.

Other public exchanges or large employers could try to replicate the idea, putting more pressure on providers and insurers. Lee has shared his proposal with other state marketplaces, government officials and employer groups to promote similar efforts.

Still, there are limits to this strategy. Exceptions would be granted if excluding a hospital or doctor from a network meant an area wouldn’t have a sufficient number of providers. Insurers could appeal and offer other reasons for keeping a provider in the network.

“California is definitely ahead of the pack when it comes to taking an active purchasing role, and exclusion is a pretty big threat,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. “There may be a dominant hospital system that’s charging through the nose, but without them you don’t have an adequate network. It will be interesting to see how Covered California threads that needle.”

The composition of networks has typically been left up to insurers. Until now, most of the discussion has centered on the proliferation of narrow networks, with a limited range of providers, sold under the Affordable Care Act as a way to hold down rates. A study in 2015 found that 75 percent of Covered California plans had narrow physician networks, with more restricted choices than all but three other states.

“I don’t know of anyone even close to trying this,” said Dan Polsky, the study’s author and executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. “I applaud Covered California for being bold to improve quality and reduce costs, but I worry about the implementation.”

Polsky said measuring quality can be complicated, and steps must be taken to ensure hospitals and doctors aren’t penalized for treating sicker patients or serving lower-income areas. Most quality-boosting efforts use financial bonuses and penalties rather than exclusion.

Under the Covered California plan, hospitals would be judged on a wide range of performance and safety measures, from rates of readmission and hospital-acquired infections to adverse drug events. The exchange said it will draw on existing measures already tracked by Medicare and other groups, and it will work with hospitals, consumer advocates and other experts over the next 18 months to finalize the details.

The California Hospital Association said the exchange is moving too fast and acting too much like a regulator.

“The devil is in the details, and the rapidity of this concerns us,” said Dr. David Perrott, chief medical officer at the state hospital trade group. “We understand value-based purchasing is here in some form and we do not oppose that. But Covered California is charging ahead with this assessment and trying to figure out the answers when it hasn’t been worked out.”

California physicians warn that the exchange’s proposal could further reduce networks that are already too thin for patients.

“Right now, one of the biggest problems in healthcare is limited access to specialty care. This allows more narrowing of the networks under spurious guidelines,” said Dr. Ted Mazer, a board member of the California Medical Association and a head and neck surgeon in San Diego.

Charles Bacchi, chief executive of the California Association of Health Plans, predicted that Covered California’s idea will backfire, discouraging hospitals and doctors from participating in the exchange and driving up premiums as a result.

“It’s the right goal but the wrong approach,” Bacchi said. “Covered California is proposing a top-down, arbitrary measurement system that carries a big stick. This can make it difficult for health plans and providers to work together constructively.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California HealthCare Foundation. Follow Chad Terhune on Twitter: @chadterhune.

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At 85 years old, Alpha Edwards did not expect to be out of savings or to have $3,000 of credit card debt.

“I don’t do anything that costs money,” Edwards says. “I can’t.”

The problem started four years ago, when Edwards moved to Miami Springs with her little brown dog. Her husband had recently died and Edwards wanted to be closer to her daughter.

Edwards regularly sees doctors for her chronic lung disease and her pacemaker. And not long after she moved, she needed a cardiac procedure.

That’s when the bills started rolling in — thousands of dollars in medical bills.

“I remember crying all day, every day,” she says.

Edwards learned that one of the specialists she was seeing didn’t take her insurance.

At first, while she still had a few thousand dollars in savings, she made some payments. But when the money ran out, she stopped.

Edwards is not alone. Health insurance is no guarantee against financial hardship, according to a national poll by NPR, the Robert Wood Johnson Foundation and the Harvard T. H. Chan School of Public Health.

“People are financially overwhelmed in lives that are working OK — they have financing for everything else in their life but they can’t deal with this large medical bill,” says Robert Blendon, a professor of health policy and political analysis at the Harvard Chan School.

Blendon says the poll found that among Floridians who have experienced serious financial problems in the past two years (problems like spending down savings, not being able to afford necessities and racking up credit card debt), 76 percent had health insurance.

Consider the case of Wilson Gamboa — one of the Floridians polled.

Gamboa has a black Suzuki C50 motorcycle in his garage. But he hasn’t driven it in two years since his health insurance premiums went up by $50 a month.

“It’s been a while,” says Gamboa. “I start her up regularly — you know, just to make sure the wheels keep going and the engine stays lubed — but she’s sitting there now.”

Gamboa is a U.S. Army reservist and owner of a pressure-washing company in Miami. His business lost money last year — which means Gamboa is leaning on his wife’s nursing salary and her employer-sponsored health benefits. It bothers him that they haven’t been able to buy the property they were hoping to invest in.

He considers himself lucky.

“If my wife wasn’t working and had the job that she had, then we probably couldn’t even stay afloat,” he says. “We’re luckier than a lot of people. But we’re trying to live the American dream.”

For many people, these pressures are compounded when rising copayments, coinsurance and deductibles lead to missed payments or collection agencies.

Roughly 1 in 5 Americans have medical debt on their credit reports, according the Consumer Financial Protection Bureau.

“We also know that this estimate of the number of consumers with medical debt is probably an underestimate,” says the bureau’s Ken Brevoort, who has studied the problem. “And that residual expense wound up being reported on the credit records of these consumers and they ultimately wound up paying a price for it.”

A secondary price: worse credit scores and a harder time financing things like a home.

In Miami Springs, Alpha Edwards gets by with help from her family. But she feels the financial strain every day.

“I lived in a three-bedroom, two-bath, two-car garage home, Edwards says. “I went out to lunch every day during the week — and I was very social, had a lot of friends. And here I have no social life whatsoever, except with my children.”

Edwards may be lonely, but she is far from alone in her financial struggles. Many Floridians are feeling that same pinch.

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Doctors have long disputed the accusation that the payments they receive from pharmaceutical companies have any relationship to how they prescribe drugs.

There’s been little evidence to settle the matter, until now.

A new ProPublica analysis has found that doctors who receive payments from the medical industry do indeed prescribe drugs differently on average than their colleagues who don’t. And the more money they receive, the more brand-name medications they tend to prescribe.

We matched records on payments from pharmaceutical and medical device makers in 2014 with corresponding data on doctors’ medication choices in Medicare’s prescription drug program.

Doctors who got money from drug and device makers prescribed a higher percentage of brand-name drugs overall than doctors who didn’t, our analysis showed. Even those who simply got meals from companies prescribed more brand-name drugs, on average.

Moreover, as payments increased, brand-name prescribing rates tended to as well.

Doctors who received more than $5,000 from companies in 2014 typically had the highest brand-name prescribing percentages. Among internists who received no payments, for example, the average brand-name prescribing rate was about 20 percent, compared to about 30 percent for those who received more than $5,000.

ProPublica’s analysis doesn’t prove industry payments sway doctors to prescribe particular drugs, or even a particular company’s drugs. Rather, it shows that payments are associated with an approach to prescribing that, writ large, benefits drug companies’ bottom line.

“It again confirms the prevailing wisdom … that there is a relationship between payments and brand-name prescribing,” said Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School who provided guidance on early versions of ProPublica’s analysis. “This feeds into the ongoing conversation about the propriety of these sorts of relationships. Hopefully we’re getting past the point where people will say, ‘Oh, there’s no evidence that these relationships change physicians’ prescribing practices.’ “

Numerous studies show that generics, which must meet rigid Food and Drug Administration standards, work as well as name brands for most patients. Brand-name drugs typically cost more than generics and are more heavily advertised. Although some medications do not have exact generic versions, there usually is a similar one in the same category. In addition, when it comes to patient satisfaction, there isn’t much difference between brands and generics, according to data collected by the website Iodine, which is building a repository of user reviews on drugs.

There’s wide variation from state to state when it comes to what proportion of prescribers take industry money, our analysis found. The share of doctors taking payments in Nevada, Alabama, Kentucky and South Carolina was at least twice as high as in Vermont, Minnesota, Wisconsin and Maine.

But overall, payments are widespread. Nationwide, nearly 9 in 10 cardiologists who wrote at least 1,000 prescriptions for Medicare patients received payments from a drug or device company in 2014, while 7 in 10 internists and family practitioners did.

Doctors nowadays almost have to go out of their way to avoid taking payments from companies, according to Dr. Richard Baron, president and chief executive of the American Board of Internal Medicine. And those who do probably have greater skepticism about the value of brand-name medications. Conversely, doctors have to work to cultivate deep ties with companies—those worth more than $5,000 a year—and such doctors probably have a greater receptiveness to brand-name drugs, he said.

“You have the people who are going out of their way to avoid this and you’ve got people who are, I’ll say, pretty committed and engaged to creating relationships with pharma,” Baron said. “If you are out there advocating for something, you are more likely to believe in it yourself and not to disbelieve it.”

Physicians consider many factors when choosing which medications to prescribe. Some treat patients for whom few generics are available. A case in point is doctors who care for patients with HIV/AIDS. Others specialize in patients with complicated conditions who have tried generic drugs without success.

Holly Campbell, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, the industry trade group, said in a statement that many factors affect doctors’ prescribing decisions. A 2011 survey commissioned by the industry found that more than nine in 10 physicians felt that a “great deal of their prescribing was influenced by their clinical knowledge and experience,” Campbell said in a written statement.

“Working together, biopharmaceutical companies and physicians can improve patient care, make better use of today’s medicines and foster the development of tomorrow’s cures,” she wrote. “Physicians provide real-world insights and valuable feedback and advice to inform companies about their medicines to improve patient care.”

Individual doctors who received large payments from industry and had above-average prescribing rates of brand-name drugs said they are acting in patients’ best interest.

“I do prefer certain drugs over the others based on the quality of the medication and also the benefits that the patients are going to get,” said Dr. Amer Syed of Jersey City, N.J., who received more than $66,800 from companies in 2014 and whose brand-name prescribing rate was more than twice the mean of his peers in internal medicine. “My whole vision of practice is to keep the patients out of the hospital.”

Dr. Felix Tarm, of Wichita, Kansas, likewise prescribed more than twice the rate of brand-name drugs than internal medicine doctors nationally. Tarm, who is in his 70s, said he’s on the verge of retiring and doesn’t draw a salary from his medical practice, instead subsidizing it with the money he receives from drug companies. He said he doesn’t own a pharmacy, a laboratory or an X-ray machine, all of which other doctors use to increase their incomes.

“I generally prescribe on the basis of what I think is the best drug,” said Tarm, who received $11,700 in payments in 2014. “If the doctor is susceptible to being bought out by a pharmaceutical company, he can just as easily be bought out by other factors.”

A third doctor, psychiatrist Alexander Pinkusovich of Brooklyn, N.Y., also prescribed a much higher proportion of brand-name drugs than his peers in 2014 while receiving more than $53,400 from drug companies. He threatened to call the district attorney if a reporter called again. “Why are you doing a fishing expedition?” he asked. “You know that I didn’t do anything illegal, so good luck.”

ProPublica has been tracking drug company payments to doctors since 2010 through a project known as Dollars for Docs. Our first lookup tool included only seven companies, most of which were required to report their payments publicly as a condition of legal settlements. The tool now covers every drug and device company, thanks to the Physician Payment Sunshine Act, a part of the 2010 Affordable Care Act. The law required all drug and device companies to publicly report their payments. The first reports became public in 2014, covering the last five months of 2013; 2014 payments were released last year.

The payments in our analysis include promotional speaking, consulting, business travel, meals, royalties and gifts, among others. We did not include research payments, although those are reported in the government’s database of industry spending, which it calls Open Payments.

Separately, ProPublica has tracked patterns in Medicare’s prescription drug program, known as Part D, which covers more than 39 million people. Medicare pays for at least one in four prescriptions dispensed in the country.

This new analysis matches the two datasets, looking at doctors in five large medical specialties: family medicine, internal medicine, cardiology, psychiatry and ophthalmology. We only looked at doctors who wrote at least 1,000 prescriptions in Medicare Part D.

Dr. David W. Parke II, chief executive of the American Academy of Ophthalmology, suggested that many payments made to ophthalmologists don’t relate to drugs they prescribe in Medicare Part D, and instead may be related to drugs administered in doctors’ offices or devices and implants used in eye surgery. As a result, he said, it may be unfair to presume that industry payments are associated with prescribing in Part D.

Still, he said, ProPublica’s analysis points to areas that specialty societies may want to look at. “In some cases, there are very appropriate and clinically valid reasons” for doctors who are outliers in their prescribing, he said. “For others, education may very easily result in prescribing change leading to substantive savings for patients, employers and society.”

Dr. Kim Allan Williams Sr., president of the American College of Cardiology, said he believes relationships between companies and doctors are circular. The more physicians learn about a new drug’s “differentiating characteristics,” he said, the more likely they are to prescribe it. And the more they prescribe it, the more likely they are to be selected as speakers and consultants for the company.

“That dovetails with improving your practice, and yes, you are getting paid to do it,” he said.

Williams said new drugs are, at least in part, responsible for a significant decrease in cardiovascular mortality in the past three decades.

“If you’re not making strides in this highly competitive area, if you don’t have a product that’s better, it’s not going to fly,” he said. “So the fact that there’s this high relationship in cardiology [between doctors and companies] may in fact be driving the progress that we’re making.”

ProPublica deputy data editor Olga Pierce contributed to this report, which was produced as part of a partnership between ProPublica and NPR.

Does your doctor accept payments from pharmaceutical and medical device companies? Find out using Dollars for Docs.

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