Exploring the Psychiatrist-Industry Financial Relationship: Insight from the Open Payment Data of Centers for Medicare and Medicaid Services

Abstract

Objective:

The Physician Payments Sunshine Act (PPSA) requires reporting of financial payments by pharmaceutical and medical device companies to teaching hospitals and individual physicians in the US. Industry payments made to psychiatrists were quantified.

Methods:

Using the 2016–2017 Sunshine Act Open Payments database, general payments made to psychiatrists were descriptively analyzed. The number of psychiatrists who received payments, and median number, value (in US dollar), and nature of payments to psychiatrists were quantified. Top 10 manufacturers who paid the most to psychiatrists were also reported.

Results:

Over half of active psychiatrists (55.7%) received some form of payments from pharmaceutical manufacturers. Of these, top 2.8% of psychiatrists received 82.6% of the payments. Pharmaceutical manufacturers provided 812,877 payments worth $110,512,607.18 to 26,422 psychiatrists in the US. Compensation for services (e.g., speaker’s bureaus) and consulting fees altogether constituted 71.4% of the total payment, with a median value of $1,725.00 and $700, respectively. Among all psychiatrists who received payments, manufacturers that paid the most included Otsuka Pharmaceuticals, Alkermes, and Sunovion Pharmaceuticals.

Conclusions:

The PPSA was created to foster transparent disclosure of any financial relationship between physicians and industry. Findings highlight that many active psychiatrists receive payments from pharmaceutical industry and payment forms were varied (e.g., food/beverage, educational materials, and compensation for services).

INTRODUCTION

In the United States, Pharmaceutical and medical device companies spend billion dollars annually, marketing their products to physicians (Fleischman & Ross, 2017). While these payments are beneficial to support continuing medical education programs and research collaboration between academia and industry, such payments may also influence physician prescribing and potentially avoidable healthcare expenditures (e.g., prescribing brand-name products instead of available generic-name products) (Fleischman, Agrawal, et al., 2016; Fleischman & Ross, 2017; Fleischman, Ross, Melnick, Newman, & Venkatesh, 2016; Rhee & Ross, 2019; Rhee, Stanic, & Ross, 2020; Slentz, Nelson, & Lichter, 2019). Co-opting, particularly focused on key academic psychiatric leaders, has also been considered one of strategies to increase the size of pharmaceutical market (Moncrieff, 2007). Thus, transparency of any financial relationship between physicians and industry, and its public reporting has gained attention in the past two decades (Coyle, Ethics, & Human Rights Committee, 2002).

As part of the Affordable Care Act of 2010, the Physician Payments Sunshine Act (PPSA) was passed (Fleischman & Ross, 2017) and requires all pharmaceutical and medical device companies to report payments (greater than $10 per payment or $100 per calendar year) to physicians in categories such as consulting, gifts, speaking fees, and travel reimbursement. In addition, physicians are required to review their financial relationships with pharmaceutical and medical device companies; they can also submit a report to the Centers for Medicare and Medicaid Services (CMS) to correct their financial activities. Since 2013, these data have been publicly available, administrated by the CMS (Centers for Medicare and Medicaid Services, 2018a). To our knowledge, no study has yet published documenting the interaction between industry and physicians in the field of psychiatry. In this study, industry payments to psychiatrists by amount and payment type were explored.

METHODS

Using the Sunshine Act Open Payments database (Centers for Medicare and Medicaid Services, 2018a), an analysis of payments made from pharmaceutical and device manufacturers to psychiatrists from January 1, 2016 to December 31, 2017 was conducted (Centers for Medicare and Medicaid Services, 2018b). Notably, this dataset is representative of all physicians, including psychiatrists, who have financially interacted with pharmaceutical and medical device companies. A recent government report highlighted that the dataset is highly reliable and valid (US Department of Health and Human Services Office of Inspector General, 2018). The General Payments dataset reports all direct and indirect payments, except research-related activities (Centers for Medicare and Medicaid Services, 2018b). For this analysis, psychiatry specialists with MD or DO degrees, and excluded payments made outside the US (<0.01%) were included. Number and amount of payments to psychiatrists and compared payments types between psychiatrists receiving more than $20,000 and those receiving less than or equal to $20,000 were identified. Nature of payments (e.g., compensation for services, consulting fee, educational material, gift, food and beverage, travel and lodging, or other) was further stratified by psychiatrists who received more than $20,000 and those receiving less than or equal to $20,000. The pharmaceutical or medical device manufacturers that paid the most to psychiatrists were also reported. Our study was exempted from review by the Institutional Review Board at XXXX, as publicly available secondary data were used. Stata MP/6-Core 15.1 (College Station, TX) was used for all analyses (StataCorp., 2017).

RESULTS

In 2016–2017, pharmaceutical manufacturers provided 812,877 payments worth $110,512,607.18 to 26,422 psychiatrists in the US. The median number of payments per psychiatrist was 6 (inter-quartile range [IQR], 2–26), and the median payment per psychiatrist was $194 (IQR, $59–$751). The data were highly skewed, with the top 2.8% of psychiatrists earning 82.6% of the payments from pharmaceutical companies (Table 1). Compensation for services (e.g., speaker’s bureaus) and consulting fees altogether constituted 71.4% of the total payment, with a median value of $1,725.00 and $700.00, respectively. The majority of payment to psychiatrists receiving ≤$20,000 were in the form of food and beverages, totaling $12.6 million (65.2%). The majority of payment to psychiatrists receiving >$20,000 were for compensation for services ($61.7 million, 67.7%) or consulting fees ($12.1 million, 13.2%).

Table 1.

Payment characteristics of psychiatrists who received payments of from pharmaceutical companies, 2016–2017 CMS Open Payments Data

	Psychiatrists who received ≤ $20,000			Psychiatrists who received > $20,000			All psychiatrists
Number of psychiatrists (%)	25,681 (97.2)			741 (2.8)			26,422 (100.0)
Total value of payment (%)	$19,251,929 (17.4)			$91,260,679 (82.6)			$110,512,608 (100.0)
Median payment per psychiatrist (IQR)	$180 (56 – 657)			$60,726 (32,845 – 136,384)			$194 (59 – 751)
Median number of payments per psychiatrist (IQR)	2 (6 – 25)			398 (244 – 632)			2 (6 – 26)
Nature of payments	Value of payment (%)	*No. of psychiatrists (%)	Median payment (IQR)	Value of payment (%)	*No. of psychiatrists (%)	Median payment (IQR)	Value of payment (%)	*No. of psychiatrists (%)	Median payment (IQR)
Compensation for servicesa)	$3,315,866 (17.2)	1,011 (3.9)	$750 (150 – 5,500)	$61,746,388 (67.7)	680 (91.8)	$44,987 (21,752 – 102,585)	$65,062,254 (58.9)	1,691 (6.4)	$6,790 (150 – 32,188)
Consulting fee	$1,735,246 (9.0)	1,280 (5.0)	$175 (150 – 986)	$12,082,578 (13.2)	492 (66.4)	$5,500 (900 – 23,286)	$13,817,824 (12.5)	1,772 (6.7)	$300 (150 – 3,813)
Educational materials	$183,292 (1.0)	5,445 (21.2)	$10 (4 – 33)	$496,116 (0.5)	513 (69.2)	$25 (9 – 82)	$679,408 (0.6)	5,958 (22.5)	$11 (4 – 38)
Food and beverage	$12,554,439 (65.2)	24,945 (97.1)	$170 (53 – 578)	$3,357,470 (3.7)	730 (98.5)	$3,422 (1,749 – 6,016)	$15,911,909 (14.4)	25,675 (97.2)	$182 (56 – 642)
Gift	$72,183 (0.4)	871 (3.4)	$36 (8 – 106)	$29,851 (<0.0)	155 (20.9)	$94 (16 – 174)	$102,034 (0.1)	1,026 (3.9)	$47 (9 – 112)
Honoraria	$242,005 (1.3)	98 (0.4)	$2,258 (464 – 3,240)	1,793,217 (2.0)	116 (15.7)	$5,150 (2,400 – 13,034)	$2,035,222 (1.8)	214 (0.8)	$2,823 (1,406 – 6,200)
Travel and lodging	$1,126,998 (5.9)	988 (3.8)	$912 (436 – 1,482)	$11,553,439 (12.7)	712 (96.1)	$6,138 (2,537 – 15,161)	$12,680,437 (11.5)	1,700 (6.4)	$1,546 (760 – 4,588)
Otherb)	$21,901 (0.1)	12 (<0.1)	$186 (77 – 2,556)	$201,618 (0.2)	7 (0.9)	$22,500 (361 – 50,000)	$223,520 (0.2)	19 (0.1)	$1,000 (88 – 8,857)

Note:

^a)includes serving as faculty or a speaker at a venue, for a non-accredited and noncertified continuing education program, or for an accredited or certified continuing education program

^b)includes current or prospective ownership or investment interest, entertainment, non-research grant, or royalty or license. IQR stands for interquartile range.

^*Columns may add to more than 100.0% as psychiatrists may have received more than one type of payment.

The majority of payments to psychiatrists (84.1%) were made by 10 pharmaceutical companies out of more than 360 different pharmaceutical or device manufacturing companies (Table 2). Otsuka Pharmaceuticals, Inc. spent more than $20.4 million to 13,470 psychiatrists in the US. Other top pharmaceutical companies that spent most to psychiatrists included: Alkermes, Inc. ($14.9 million), Sunovion Pharmaceuticals ($14.8 million), Allergan, Inc. ($13.9 million), and Takeda Pharmaceuticals, Inc. ($10.6 million).

Table 2.

Payment characteristics to psychiatrists by pharmaceutical company, 2016–2017 CMS Open Payments Data

Manufacturer or GPO		Total payment (%)	50th percentile payment	90th percentile payment	Max payment	Number of payments	No. of psychiatrists	No. of psychiatrists receiving > $20,000	No. of psychiatrists receiving > $100,000
1	Otsuka America Pharmaceutical, Inc.	$20,446,829 (18.5)	18.26	141.85	$40,000	130,285	13,470	557	206
2	Alkermes, Inc.	$14,871,564 (13.5)	20.15	412.94	$353,175	53,716	8,423	452	180
3	Sunovion Pharmaceuticals, Inc.	$14,780,622 (13.4)	13.40	101.44	$ 64,142	147,763	11,815	551	206
4	Allergan, Inc.	$13,929,387 (12.6)	14.18	200.00	$ 12,600	108,583	9,227	511	188
5	Takeda Pharmaceuticals, Inc.	$10,599,055 (9.6)	16.38	920.00	$ 40,218	44,339	5,865	432	165
6	Janssen Pharmaceuticals, Inc	$4,928,120 (4.5)	16.23	95.77	$ 10,130	56,945	7,968	370	140
7	Merck Sharp & Dohme Corp.	$3,853,508 (3.5)	15.51	584.62	$ 70,000	17,954	4,032	319	124
8	Shire North American Group, Inc.	$3,259,393 (2.9)	15.45	24.89	$ 20,000	49,120	6,523	361	117
9	Avanir Pharmaceuticals, Inc.	$3,237,007 (2.9)	21.39	1,400.00	$ 50,000	10,042	2,051	237	97
10	Acadia Pharmaceuticals, Inc.	$2,928,596 (2.7)	45.36	2,300.00	$ 11,500	6,271	1,579	172	81
	*Other companies	$17,678,525 (16.0)	15.51	54.00	$ 108,000	187,859	15,904	669	229
Total		$110,512,607 (100.0)	15.87	124.19	$ 353,175	812,877	26,422	741	253

Note:

^*Includes data from over 350 different pharmaceutical or medical device manufacturing companies.

DISCUSSION

To our knowledge, this is the first detailed reporting of data from the Sunshine Act in the field of psychiatry. Consistent with other specialties (Feng, Wu, & Leger, 2016; Jutras & Khosa, 2019; Parikh, Fleischman, & Agrawal, 2016), the data were highly skewed and show that the large majority (>80%) of pharmaceutical payment amount (in US dollar) went to a very small number (<3%) of psychiatrists that receive any pharmaceutical payments. While the median payments per psychiatrist was similar to physicians in other specialties (Fleischman, Ross, et al., 2016; Parikh et al., 2016; Rhee et al., 2020), we were unable to make direct comparisons because different pharmaceutical companies market different brand-name drugs to physicians of different specialties. Furthermore, the data demonstrate that, in the context of 47,409 active psychiatrists (2017 data) (Association of American Medical Colleges, 2017), over half (55.7%) had some payment over $10 from pharmaceutical or other manufacturing companies (Campbell et al., 2007).

Gifts and food/beverage payments were the most common payment type (received by at least 97.2% of psychiatrists) but accounted for a relatively low amount (14.5%) of the total payment. In contrast, compensation for services (e.g., speakers bureaus, etc.) or consulting fees were received by only approximately 10.4% of psychiatrists while these payment types comprised 71.4% of the total payment amount. Notably, payments for food/beverage can be viewed in a more negative light by patients, whereas providers who engage in speaking bureaus may be viewed by patients as leaders in their field and on the “cutting edge” (Brett, Burr, & Moloo, 2003; Gibbons et al., 1998).

Research in other specialties has shown that manufacturers tend to select physicians for speaking engagement and other promotional activities who are key opinion leaders and can influence practice patterns of other providers (Campbell et al., 2007); it is likely that the small proportion of psychiatrists that receive the majority of payment represent these opinion leaders. While it is critical to allow for collaboration among practicing psychiatrists, investigators, and pharmaceutical companies, further characterization of these “top earners” is warranted to optimize transparency and maintain public trust in the process of new therapeutic development and marketing.

Financial relationships with the industry can affect medical education, clinical practice and research in the field of psychiatry, and the enactment of PPSA was to foster increased transparency of such physician-industry relationships. Because the CMS has a process to review and dispute financial payments from industry to physicians at any time, active psychiatrists should proactively review the payments made to them and dispute payment data if any errors were found. In addition, because pharmaceutical and/or medical device companies have a keen interest targeting young physicians in training as they develop their own clinical practice patterns (Feng et al., 2016), medical students and residents should recognize the potential benefits and harms of industry payments through training provided by the academic departments. For example, while most residents may not be exposed to any direct contact from pharmaceutical manufacturers, they would still benefit from training regarding this issue, so that they can understand potential benefits and harms of the alliance between academic psychiatry (or psychiatric profession) and the pharmaceutical industry (e.g., medical education, patient safety, cost-effectiveness of newer products to available alternatives) in their practice. Further, more research is needed in this emerging line of research to better understand how these payments can influence psychiatrists, their clinical practice, and patient outcomes.