Abstract
This study examines the distribution of payments within and across specialties and the medical products associated with the largest total payments.
Despite evidence that financial conflicts of interest may influence physician prescribing and may damage patients’ trust in medical professionals,1,2,3 such relationships remain pervasive.4 The Physician Payments Sunshine Act led to the creation of the Open Payments database in August 2013, a repository of industry payments to health care professionals.5 We examined the distribution of payments within and across specialties and the medical products associated with the largest total payments.
Methods
We used data from the Open Payments platform from 2013 to 2022.5 We included payments (cash and noncash equivalents) for consulting services, nonconsulting services (such as fees for serving as a speaker or faculty at a venue), food and beverages, travels and lodging, entertainment, education, gifts, grants, charitable contributions, and honoraria made to physicians (allopathic and osteopathic).
Open Payments data were linked to the National Plan and Provider Enumeration System (NPPES).6 Specialties for each physician are coded according to the Health Care Provider Taxonomy in the NPPES. We characterized between-specialty variation in industry payments to physicians by determining the total amount of payments from industry to physicians across 39 specialties (eMethods in Supplement 1), the amount received by the median physician (50th percentile of physicians), and the proportion of physicians receiving payments. We characterized within-specialty variation by comparing, within each specialty, the amount paid to the median physician and the mean amount paid to the top 0.1% of physicians. We also determined the 25 drugs and medical devices associated with the largest total payments. When a payment was made for several products, we assigned it to the primary product.
All analyses were performed using R, version 4.2.0 (R Project for Statistical Computing). The study was determined to be exempt by the Ain Shams University institutional review board because it used anonymized and deidentified data from a publicly available database.
Results
From 2013 to 2022, 85 087 744 payments with a total value of $12.13 billion were made by industry to 826 313 of 1 445 944 eligible physicians (% receiving payments, 57.1%; median payment, $48 per physician [IQR, $0-$1015]), and 79 774 940 (93.8%) of these payments were associated with 1 or more marketed medical products. Excluding the year 2013 (when data were only available for August onward), the total value of payments was highest in 2019 ($1.60 billion) and lowest in 2020 ($863.93 million). Additionally, the number of physicians receiving payments was highest in 2015 (468 164) and lowest in 2020 (359 509). The total value of payments changed from $1.34 billion (to 443 367 physicians) in 2014 to $1.28 billion (to 424 417 physicians) in 2022.
Orthopedic surgeons received the greatest sum of payments at $1.36 billion, followed by neurologists and psychiatrists at $1.32 billion, and then cardiologists at $1.29 billion (Table). Pediatric surgeons ($2.89 million) and trauma surgeons ($6.96 million) received the lowest sum of payments. Within each specialty, payment distributions were skewed, with payments to the median physician ranging from $0 to $2339, whereas the mean amount paid to the top 0.1% of physicians ranged from $194 933 for hospitalists to $4 826 944 for orthopedic surgeons.
Table. Industry Payments to Physicians, Overall and by Specialty, From August 2013 to December 2022.
| Specialtya | Physicians, total No. | Physicians receiving payments, No. (%) | Total amount paid, $ | Amount paid to the median physician (IQR), $ | Mean amount paid to the top 0.1% of physicians, $ |
|---|---|---|---|---|---|
| Orthopedics | 48 665 | 31 620 (65.0) | 1 360 744 428 | 1187 (0-9004) | 4 826 944 |
| Neurology and psychiatry | 107 684 | 58 688 (54.5) | 1 322 668 751 | 32 (0-849) | 2 588 819 |
| Cardiology | 46 171 | 33 074 (71.6) | 1 293 613 594 | 1764 (0-10570) | 3 187 675 |
| Hematology/oncology | 22 937 | 17 025 (74.2) | 825 799 685 | 1153 (0-10134) | 3 164 180 |
| General internal medicine | 176 079 | 97 542 (55.4) | 588 249 423 | 30 (0-618) | 1 046 723 |
| Endocrinology | 11 612 | 8211 (70.7) | 546 513 674 | 616 (0-6492) | 3 298 092 |
| Family medicine | 202 768 | 110 692 (54.6) | 479 105 369 | 23 (0-571) | 789 896 |
| Rheumatology, allergy, and immunology | 16 903 | 11 181 (66.1) | 464 858 022 | 536 (0-6232) | 3 368 553 |
| Dermatology | 24 023 | 15 013 (62.5) | 462 809 832 | 297 (0-3225) | 3 106 183 |
| Gastroenterology | 24 269 | 17 576 (72.4) | 441 594 616 | 1008 (0-5540) | 1 918 545 |
| Ophthalmology | 34 892 | 21 804 (62.5) | 431 693 877 | 295 (0-2164) | 3 077 387 |
| Radiology | 68 718 | 34 385 (50.0) | 391 978 018 | 8 (0-299) | 1 939 695 |
| General surgery | 41 514 | 25 959 (62.5) | 360 474 915 | 194 (0-3332) | 1 357 423 |
| Obstetrics and gynecology | 71 584 | 45 002 (62.9) | 295 367 215 | 140 (0-1373) | 917 879 |
| Pediatrics | 118 244 | 64 692 (54.7) | 291 005 562 | 20 (0-333) | 944 561 |
| Pulmonology | 17 745 | 12 393 (69.8) | 286 121 375 | 533 (0-4488) | 1 923 776 |
| Urology | 18 639 | 12 693 (68.1) | 248 857 164 | 830 (0-5304) | 2 314 651 |
| Neurosurgery | 10 822 | 6899 (63.7) | 236 065 708 | 601 (0-6856) | 2 306 818 |
| Anesthesiology | 77 129 | 44 393 (57.6) | 217 675 440 | 35 (0-304) | 921 987 |
| Cardiothoracic surgery | 7432 | 5218 (70.2) | 183 646 912 | 2308 (0-12436) | 2 380 258 |
| Otherb | 23 554 | 11 113 (47.2) | 183 441 139 | 0 (0-979) | 1 478 426 |
| Infectious diseases | 11 940 | 7542 (63.2) | 170 694 009 | 119 (0-1376) | 2 446 113 |
| Plastic surgery | 12 651 | 7650 (60.5) | 159 538 869 | 491 (0-4602) | 1 730 056 |
| Nephrology | 15 905 | 11 005 (69.2) | 156 651 522 | 359 (0-2184) | 1 978 017 |
| Vascular surgery | 6740 | 4606 (68.3) | 133 653 084 | 2257 (0-9956) | 1 997 644 |
| Emergency medicine | 77 479 | 36 897 (47.6) | 102 889 555 | 0 (0-113) | 751 279 |
| Otorhinolaryngology | 18 122 | 11 924 (65.8) | 101 649 087 | 315 (0-1962) | 1 250 230 |
| Pathology | 25 590 | 11 894 (46.5) | 101 262 094 | 0 (0-122) | 1 283 312 |
| Physical and rehabilitation medicine | 25 243 | 10 199 (40.4) | 75 865 211 | 0 (0-264) | 810 448 |
| Gastrointestinal surgery | 2602 | 1926 (74.0) | 48 122 701 | 2339 (0-10091) | 1 275 288 |
| Critical care | 6071 | 4205 (69.3) | 44 090 927 | 167 (0-1185) | 1 294 478 |
| General practice | 25 953 | 9307 (35.9) | 35 592 151 | 0 (0-120) | 540 134 |
| Surgical oncology | 2039 | 1465 (71.8) | 22 500 511 | 604 (0-4385) | 1 114 954 |
| Hospitalist | 25 911 | 14 672 (56.6) | 17 309 602 | 28 (0-290) | 194 933 |
| Preventive medicine | 8195 | 2525 (30.8) | 16 345 150 | 0 (0-24) | 698 189 |
| Geriatrics | 5785 | 2676 (46.3) | 14 763 580 | 0 (0-251) | 874 219 |
| Nuclear medicine | 1396 | 706 (50.6) | 11 698 857 | 12 (0-432) | 1 716 973 |
| Trauma surgery | 1401 | 975 (69.6) | 6 955 629 | 340 (0-2108) | 645 428 |
| Pediatric surgery | 1537 | 966 (62.8) | 2 892 084 | 74 (0-506) | 338 183 |
| Overall | 1 445 944 | 826 313 (57.1) | 12 134 759 343 | 48 (0-1015) | 1 987 862 |
The 231 distinct categories identified in the Open Payments and National Plan and Provider Enumeration System databases were coalesced into 39 specialties to facilitate interpretation.
Includes those classified by Open Payments as internal medicine physicians with a subspecialty of sports medicine, obesity medicine, integrative medicine, sleep medicine, electrodiagnostic medicine, addiction medicine, adolescent medicine, hospice and palliative medicine, hypertension, and magnetic resonance imaging. It also includes those practicing legal medicine, neuromusculoskeletal medicine, and phlebology; independent medical examiners; clinical pharmacists; geneticists; and those practicing pain medicine (not specified under another specialty, such as anesthesia or physical and rehabilitative medicine). Additionally, it also includes surgeons with subspecialties in oral and maxillofacial surgery, hospice and palliative medicine, hand surgery, surgical critical care, and transplant surgery. These specialties generally had a low number of physicians in each category and could not readily be grouped alongside any of the other 38 specialties herein.
The 3 drugs associated with the most payments were Xarelto ($176.34 million), Eliquis ($102.62 million), and Humira ($100.17 million) (Figure, A). The 3 medical devices associated with the most payments were the da Vinci Surgical System ($307.52 million), Mako SmartRobotics ($50.13 million), and CoreValve Evolut ($44.79 million) (Figure, B).
Figure. Top 25 Drugs and Top 25 Medical Devices Related to Industry Payments in the US From August 2013 to December 2022.
The numbers do not include payments made for acquisitions, loans, royalty or licensing fees, or debt forgiveness payments.
Discussion
From 2013 to 2022, US physicians received $12.1 billion from industry. More than half of physicians received at least 1 payment. Payments varied widely between specialties and between physicians within the same specialty. A small number of physicians received the largest amounts, often exceeding $1 million, while the median physician received much less, typically less than a hundred dollars.
Study limitations included not recording payments made to other health care professionals (nurses, nurse practitioners, and physician assistants) because these payments only began to be recorded in 2021; the reliance on industry reporting; the absence of data on certain types of payments (like free drug samples), which may underestimate financial transactions; and the different durations of time over which products were marketed because the analysis focused on cumulative totals rather than annualized amounts.
Section Editors: Kristin Walter, MD, and Jody W. Zylke, MD, Deputy Editors; Karen Lasser, MD, Senior Editor.
eMethods.
Data Sharing Statement
References
- 1.Annapureddy AR, Henien S, Wang Y, et al. Association between industry payments to physicians and device selection in ICD implantation. JAMA. 2020;324(17):1755-1764. doi: 10.1001/jama.2020.17436 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hwong AR, Sah S, Lehmann LS. The effects of public disclosure of industry payments to physicians on patient trust: a randomized experiment. J Gen Intern Med. 2017;32(11):1186-1192. doi: 10.1007/s11606-017-4122-y [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mitchell AP, Trivedi NU, Gennarelli RL, et al. Are financial payments from the pharmaceutical industry associated with physician prescribing?: a systematic review. Ann Intern Med. 2021;174(3):353-361. doi: 10.7326/M20-5665 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Marshall DC, Tarras ES, Rosenzweig K, Korenstein D, Chimonas S. Trends in industry payments to physicians in the United States from 2014 to 2018. JAMA. 2020;324(17):1785-1788. doi: 10.1001/jama.2020.11413 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.OpenPaymentsData.gov. Centers for Medicare & Medicaid Services. Accessed July 21, 2023. https://openpaymentsdata.cms.gov/
- 6.NPI files. Centers for Medicare & Medicaid Services. Accessed January 7, 2024. https://download.cms.gov/nppes/NPI_Files.html
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods.
Data Sharing Statement