A federal transparency program designed to lower healthcare costs had relatively little impact on total and annual payments to physicians from drugmakers and device makers between 2014 and 2018, according to a new study published in the The Journal of the American Medical Association (JAMA).
Since 2013, the Centers for Medicare & Medicaid Services has publicly posted the amounts that physicians receive from industry, along with related information. The initiative, known as Open Payments, "was established out of concern for undue industry influence on health care decision-making and costs," say the study's authors, who hail from the Icahn School of Medicine at Mount Sinai and Memorial Sloan Kettering Cancer Center, both in New York City.
The percentage of all physicians who received at least one industry payment dropped from 52.2%, or 458,269 physicians, in 2014 to 45%, or 394,991 doctors, in 2018, the authors say. That change represented a decrease of 13.8% from 2014 to 2018 and an annual drop of 3.5%.
The decline in the portion of doctors accepting industry payments varied by specialty. For primary care specialties, it was 16.4%; for medical specialties, 10.8%; for surgical specialties, 9.5%; for ob/gyns, 12%; and for hospital-based specialties, 15.2%.
During the study period, physicians who got any payments received 49.8 million payments totaling $9.3 billion, the study found. The total payment value was highest in medical and surgical specialties ($3.4 billion and $3.9 billion, respectively).
Payment Values Stable
Total and annual payment values remained stable across specialties except for primary care, for which the total value of industry payments decreased.
The value of gifts to primary care physicians who accepted them declined 28.6% over the 4 years. The per-physician average payment declined by 14.6% during that period.
For medical specialties, total payment value dropped 8% during the study period, but the average per-doctor payment rose 3.1%.
Surgeons, in contrast, saw a 6.5% increase in total payment value, and average per-doctor gifts jumped a whopping 17.7% during the 4 years.
Ninety percent of physicians who accepted industry payments received less than $10,000 each annually. Those who received more than $50,000 accounted for only 3.4% of physicians accepting payments but 82% of the total payment value, the study reported. For those doctors, annual payment values increased or remained stable over time.
Observers said the high-dollar payments to relatively few physicians were associated with the large amounts that surgeons often receive from device manufacturers.
In a separate study published in the same issue of JAMA, investigators found that nearly all of the 4435 surgeons who placed implantable cardioverter-defibrillators (ICDs) in patients had received personal payments from one or more of four manufacturers.
"Patients were more likely to receive devices made by the manufacturer that provided the highest total payment to the physician who performed the implant procedure," according to an accompanying editorial.
"No Apparent Change"
In an interview with Medscape Medical News, Deborah Marshall, MD, a research fellow at the Icahn School of Medicine who was lead author of the study, avoided attributing the decrease in the percentage of physicians accepting industry gifts to the transparency program, noting only that there was a correlation between the two.
"My general interpretation of the data is that we haven't seen a big change in how physicians are being marketed to," she said, "and the dollar amounts are still exceptionally high. So if we think transparency would have had a major impact on the dollars being directed toward physicians, we don't see that big a drop."
Gregory Curfman, MD, deputy editor of JAMA, who cowrote the editorial on the Open Payment and ICD studies, told Medscape Medical News, "The transparency of Open Payments seemed to have some effect on physicians receiving smaller payments. Some of them discontinued receiving payments altogether, and some of those payments became smaller. But among the physicians who really got big money, there was no apparent change."
The payments to surgeons, of course, aren't represented as "pay for play" in the Open Payments database. The device companies often avoid liability under the AntiKickback Statute, the editorialists say, by claiming the payments are intended to cover speakers' fees or travel costs.
In some cases, Marshall said, surgeons are being reimbursed for coming up with ideas for new devices. Although some physicians may be entitled to royalties or licensing fees for their intellectual property, other surgeons may be paid for consulting or for nonaccredited medical education activities, she said.
Transparency and Gifts
Most of the smaller amounts paid to doctors come from pharmaceutical companies, which have long marketed directly to physicians by providing them with lunches, trinkets, travel expenses, and more. Some institutions have cracked down on these financial interactions, noted Marshall. Those restrictions may account for some of the decrease in payments to doctors at the lower end of the scale, she added.
Transparency may have also discouraged some physicians from accepting industry gifts, Curfman suggested. "My own feeling is that doctors don't like having themselves identified on the database. And there's a lot of detail up there [on the Open Payments site]. It can be very revealing. So especially for physicians who weren't receiving very much money, they figured this wasn't worth it."
However, both Curfman and Marshall said they doubt that many patients have gone on the website to see how much money their physician has taken from industry.
"I try to get people to go to the site all the time," said John Abramson, MD, a family physician and a lecturer in the Department of Health Care Policy, Harvard Medical School, told Medscape Medical News. "My experience is that consumers don't want to go there and don't know what to do with the information on the site."
Abramson, who also wrote the book Overdosed America, said it was good that the percentage of doctors accepting industry payments has declined in recent years. "On the other hand, that leaves almost half of physicians receiving gifts from industry," he said. "From my point of view, that's a problem."
Although most of the gifts are fairly small, he noted, "accepting just a single inexpensive meal can change a physician's prescribing behavior toward the brand-name drug they're being educated about. It makes physicians more susceptible to accepting information that they make patient care decisions on."
The information provided by drug company reps is slanted, he emphasized, and most practicing physicians are not in a position to distinguish good evidence from bad. Therefore, "doctors shouldn't see drug reps at all," he said. "The drug reps have only one mission, which is to get doctors to prescribe their brand-name drugs."
JAMA. Published online November 3, 2020. Abstract, Editorial
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