This article was originally published in The BMJ on November 5, 2014.
Orthopedic surgeons receive the biggest payments from industry in the US
according to the Open Payments database. The next step, writes
transparency pioneer Danny Carlat, is for researchers to compare payment data with disclosures of physicians’ prescribing patterns
After substantial delays, the Open Payments website was launched on 30 September.1
The website was mandated by the Physician Payments Sunshine Act of
2010, and it is a comprehensive registry of payments made to physicians
and teaching hospitals by drug and device companies.
This
first wave of reports must be interpreted in light of some data
limitations and technical problems. These reports cover only the last
five months of 2013, and roughly a quarter of industry payments were not
published because of disputed amounts and other factors. Of the
payments published, a third have been stripped of the doctors’ names
because there were problems ensuring that the payments were accurately
attributed to the right recipient. Therefore, only about half of all
payments are both published and attributed to identified recipients. The
Center for Medicare and Medicaid (CMS), the agency in charge of the
database, plans to roll out the missing payments in June of 2015, along
with all payments made in 2014.
Although the website is
not complete, it still provides unprecedented insight into the extent
and nature of financial relationships between physicians and industry.
In total, companies paid $3.5bn (£2.2bn; €2.8bn) to 546 000 physicians
(about 60% of all US doctors) and to 1360 teaching hospitals over the
five months. The largest payments, often in the millions of dollars,
went to orthopedic surgeons for royalty payments for inventing or
refining surgical products. However, most payments (84%) were small and
were for meals and beverages (table⇓).
| Breakdown of $3.5bn payments made to US doctors in last five months of 2013 | |
| Reason for payment | Amount ($) |
| Research | 1.5bn |
| Physician investors/owners | 1bn |
| General: | 1bn |
| Royalties and licences | 302m |
| Promotional speaking | 203m |
| Consulting | 158m |
| Food | 93m |
| Travel and lodging | 74m |
| Education | 36m |
| Gifts | 19m |
Interestingly,
over 90% of the 300 physicians who were most highly paid for speaking
or consulting were men, who comprise only 68% of US doctors. There is no
clear explanation for this gender disparity. Women are more likely to
work in lower paying specialties such as internal medicine and
pediatrics and are underrepresented in specialties that are often
recruited by industry for consulting. For example, only 4% of orthopedic
surgeons in the US are women.
Wider moves to change behaviour
The
Sunshine Act is only a transparency initiative and does not regulate
what doctors can or cannot receive. However, the new website has been
launched within a broader context of increasing pressure to reform
industry payments. Two states, Vermont and Massachusetts, have
instituted outright bans on gifts and meals, although the Massachusetts
law was repealed because of concerns that local restaurants were losing
income. The state’s original gift ban law of 2008 was controversial
because it prohibited companies from providing any meals of any value to
healthcare practitioners outside a healthcare setting.
For
several years, many of the larger companies have published their own
physician payment registries, most of which were required by settlements
of lawsuits alleging illegal marketing practices. As these payments
have been made public, several companies have decreased their spending
for promotional talks, and one company, GlaxoSmithKline, is eliminating
such payments altogether.
Like industry, the medical
profession is regulating itself. In 2008, the Association of American
Medical Colleges published strict conflict of interest recommendations
for academic medical centers, which have responded by strengthening
their policies. From 2008 to 2014, the percentage of medical schools
that ban their faculty from giving promotional talks has increased from
4% to 49%; the percentage of schools banning gifts and meals has also
risen sharply. Since 2007, the American Medical Students Association has
tracked such conflict of interest metrics in scorecards, which it
publishes annually (www.amsascorecard.org).
Disclosure
of payments to doctors is also becoming more common in Europe. The
French government, for example, is implementing a disclosure requirement
that is similar, though not quite as comprehensive, as the Sunshine
Act. In the UK, payment disclosure is based on a voluntary system run by
the Association of the British Pharmaceutical Industry, a drug company
trade group. Unlike the case in both France and the US, the UK system
allows physicians to opt out of disclosure. This opt out provision may
prevent meaningful disclosure, depending on the proportion of physicians
who use it. Patients may complain that they cannot look up their
doctors, and researchers and journalists may have difficulty comparing
an individual doctor’s payment with peer averages if the database is
incomplete.
Research possibilities
How
will the Open Payments database be helpful in the future? Although the
Sunshine Act was ostensibly passed to allow consumers to make more
informed healthcare choices, it is likely that the site will have even
more value to researchers and policy makers. The degree to which
industry payments actually influence medical care has not been resolved
because until now there were scant data with which to properly
investigate the issue. But researchers will now be able to compare a
trove of industry payment data with other databases recently released by
CMS, such as detailed disclosures of physicians’ prescribing patterns.
Even before Open Payments, one research group merged the prescribing
database with industry payment data aggregated by the investigative
journalism organization ProPublica. They found that payments were
strongly correlated with increased prescriptions of companies’ products.
Such results, if replicated on a larger scale, may well lead to
stricter government regulation of financial relations between companies
and physicians. Such regulations, in turn, would hopefully lead to more
evidence based healthcare and improved patient outcomes. If so, Open
Payments will turn out to be an enterprise well worth the effort.
Notes
Cite this as: BMJ 2014;349:g6651
Footnotes
- Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
- Provenance and peer review: Commissioned; not externally peer reviewed.
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