Thursday, November 6, 2014

Exploring the link between industry payments to doctors and prescribing habits

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 ( 

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.


Cite this as: BMJ 2014;349:g6651


  • 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.