Abstract
This study uses Medicare Open Payments data to characterize trends in the prevalence and value of physicians’ interactions with industry overall and by specialty between January 2014 and December 2018 after implementation of the federal Open Payments transparency program in 2013.
Open Payments, a federal transparency program reporting industry-physician financial relationships since 2013, was established out of concern for undue industry influence on health care decision-making and costs.1 The effect of Open Payments is not fully understood. We sought to determine trends in physician-level payments to evaluate whether the implementation of Open Payments has been associated with a decrease in the prevalence or value of physicians’ interactions with industry.
Methods
We performed a retrospective, population-based cohort study of US allopathic and osteopathic physicians practicing in 2014 per the National Plan and Provider Enumeration System, excluding other clinicians (eg, nurses, dentists) and physicians activating or deactivating their records between 2014 and 2018. Specialties were grouped by Medicare Data on Provider Practice and Specialty taxonomy classifications: primary care, medical specialty, surgical specialty, obstetrics/gynecology, hospital-based specialty, and psychiatry. National Plan and Provider Enumeration System and Open Payments identifiers were linked by text string using cross-referenced files from the beginning and end of the period.
Open Payments data on general (nonresearch) industry payments between January 2014 and December 2018 (excluding 2013 because of partial-year reporting2) were matched to the 2014 physician cohort. Payments were aggregated per physician annually, then categorized by cumulative aggregate value (≤$10 000; $10 001-$25 000; $25 001-$50 000; $50 001-$100 000; $100 001-$500 000; and >$500 000). Values were adjusted to the 2018 Consumer Price Index.3
Outcomes included proportion of physicians receiving payments, and total and median/mean annual per-physician payment values. Total-value trends were tested using linear regression. Trends in proportions of physicians receiving payments and annual per-physician payment values were tested using logistic and linear generalized estimating equations, respectively, controlling for physician-level correlation, with year as the independent variable. Analyses were stratified by specialty group and aggregate value of payment category. Two-sided P values (α < .05) were applied to tests using SPSS version 26 (IBM Inc). This study was exempted from review by the Mount Sinai institutional review board.
Results
Of the 2014 cohort of 878 308 physicians, 458 269 (52.2%) received at least 1 payment in 2014, declining to 394 991 (45.0%) in 2018 (Table 1), representing a relative overall decrease of −13.8% and relative annual decrease of −3.5% (95% CI, −3.5% to −3.4%). From 2014 to 2018, these physicians received 49.8 million payments totaling $9.3 billion. The total value was highest in medical and surgical specialties ($3.4 and $3.9 billion in aggregate, respectively). The annual proportion of physicians receiving payments decreased over time across all specialties. However, total and annual payment values remained stable across specialties except for primary care, for which total value decreased.
Table 1. Trends in the Receipt of and Value of General Industry Payments to a Cohort of US Physicians by Specialty, 2014-2018a.
| Measures | 2014 | 2015 | 2016 | 2017 | 2018 | Overall change, % | Mean yearly change in value, % (95% CI)b | P valuec |
|---|---|---|---|---|---|---|---|---|
| All physicians | ||||||||
| Physicians receiving payments, No. (%) [n = 878 308]d | 458 269 (52.2) | 446 359 (50.8) | 428 572 (48.8) | 412 609 (47.0) | 394 991 (45.0) | −13.8 | −3.5 (−3.5 to −3.4) | <.001e |
| Payment value, $f | 1 935 923 681 | 1 884 665 537 | 1 896 661 943 | 1 797 344 428 | 1 819 487 016 | −6.0 | −1.7 (−3.5 to −0.1) | .05g |
| Per-physician payment value, $f | −0.6 (−2.8 to 1.6) | .62h | ||||||
| Median (IQR) | 215 (63-823) | 220 (65-873) | 223 (67-887) | 215 (63-865) | 216 (62-857) | 0.5 | ||
| Mean (SD) | 4224 (119 719) | 4222 (92 320) | 4426 (78 197) | 4356 (66 482) | 4606 (94 101) | 9.0 | ||
| Specialty group | ||||||||
| Primary care | ||||||||
| Physicians receiving payments, No. (%) [n = 321 910]d | 160 371 (49.8) | 155 847 (48.4) | 147 170 (45.7) | 141 142 (43.9) | 134 036 (41.6) | −16.4 | −3.7 (−3.8 to −3.6) | <.001e |
| Payment value, $f | 202 363 012 | 170 396 081 | 172 719 788 | 152 139 904 | 144 490 312 | −28.6 | −8.0 (−15.6 to −2.5) | .02g |
| Per-physician payment value, $f | −4.8 (−18.1 to 5.7) | .40h | ||||||
| Median (IQR) | 166 (49-582) | 168 (50-602) | 170 (52-615) | 163 (49-585) | 156 (46-548) | −6.2 | ||
| Mean (SD) | 1262 (116 360) | 1093 (12 602) | 1174 (37 671) | 1078 (9377) | 1078 (9664) | −14.6 | ||
| Medical specialty | ||||||||
| Physicians receiving payments, No. (%) [n = 150 435]d | 101 051 (67.2) | 98 708 (65.6) | 95 451 (63.4) | 92 995 (61.8) | 90 174 (59.9) | −10.8 | −4.8 (−5.0 to −4.7) | <.001e |
| Payment value, $f | 688 947 039 | 696 594 683 | 681 853 115 | 689 480 174 | 633 860 547 | −8.0 | −1.7 (−4.9 to 1.2) | .16g |
| Per-physician payment value, $f | −0.1 (−1.7 to 1.4) | .89h | ||||||
| Median (IQR) | 472 (124-1787) | 517 (131-1953) | 530 (131-1947) | 515 (125-1869) | 500 (123-1827) | 6.1 | ||
| Mean (SD) | 6818 (100 530) | 7057 (43 499) | 7143 (43 107) | 7414 (49 851) | 7029 (35 563) | 3.1 | ||
| Surgical specialty | ||||||||
| Physicians receiving payments, No. (%) [n = 125 842]d | 85 590 (68.0) | 83 928 (66.7) | 82 209 (65.3) | 79 664 (63.3) | 77 434 (61.5) | −9.5 | −4.5 (−4.7 to −4.4) | <.001e |
| Payment value, $f | 750 814 102 | 787 667 477 | 798 837 633 | 727 656 545 | 799 571 925 | 6.5 | 0.5 (−4.5 to 5.0) | .77g |
| Per-physician payment value, $f | 0.8 (−2.0 to 3.4) | .55h | ||||||
| Median (IQR) | 331 (107-1327) | 348 (111-1413) | 347 (112-1438) | 325 (104-1408) | 341 (108-1466) | 3.1 | ||
| Mean (SD) | 8772 (145 281) | 9385 (201 901) | 9717 (153 331) | 9134 (135 790) | 10 326 (197 788) | 17.7 | ||
| Obstetrics/gynecology | ||||||||
| Physicians receiving payments, No. (%) [n = 45 069]d | 27 488 (61.0) | 26 738 (59.3) | 25 646 (56.9) | 24 642 (54.7) | 24 179 (53.6) | −12.0 | −4.3 (−4.6 to −4.1) | <.001e |
| Payment value, $f | 63 370 735 | 32 283 603 | 33 087 303 | 40 819 819 | 37 930 660 | −40.1 | −10.2 (−65.4 to 14.5) | .36g |
| Per-physician payment, $f | −5.6 (−28.8 to 9.7) | .53h | ||||||
| Median (IQR) | 170 (58-431) | 169 (60-422) | 166 (60-380) | 161 (58-366) | 175 (63-413) | 2.6 | ||
| Mean (SD) | 2305 (121 339) | 1207 (8143) | 1290 (18 615) | 1657 (48 696) | 1569 (19 058) | −32.0 | ||
| Hospital-based specialty | ||||||||
| Physicians receiving payments, No. (%) [n = 185 304]d | 61 832 (33.4) | 61 676 (33.3) | 60 008 (32.4) | 56 349 (28.3) | 53 426 (28.3) | −15.2 | −1.8 (−1.9 to −1.8) | <.001e |
| Payment value, $f | 166 687 125 | 144 512 515 | 155 137 516 | 131 906 272 | 148 020 131 | −11.2 | −3.3 (−12.6 to 4.1) | .27g |
| Per-physician payment value, $f | −1.6 (−15.6 to 9.6) | .80h | ||||||
| Median (IQR) | 98 (27-278) | 103 (29-301) | 105 (30-318) | 102 (28-311) | 100 (27-309) | 2.2 | ||
| Mean (SD) | 2696 (136 502) | 2343 (50 442) | 2585 (68 198) | 2341 (26 325) | 2823 (77 923) | 4.7 | ||
| Psychiatry | ||||||||
| Physicians receiving payments, No. (%) [n = 49 748]d | 21 937 (44.1) | 19 462 (39.1) | 18 088 (36.4) | 17 817 (35.8) | 16 742 (33.7) | −23.7 | −3.7 (−3.8 to −3.6) | <.001e |
| Payment value, $f | 63 741 667 | 53 211 176 | 55 026 587 | 55 341 715 | 55 613 442 | −12.8 | −2.5 (−10.5 to 4.2) | .34g |
| Per-physician payment value, $f | −1.0 (−3.1 to 0.9) | .30h | ||||||
| Median (IQR) | 191 (66-608) | 179 (62-561) | 192 (65-599) | 180 (56-595) | 177 (54-606) | −7.3 | ||
| Mean (SD) | 2906 (19 316) | 2734 (20 083) | 3042 (21 845) | 3106 (22 641) | 3322 (23 950) | 14.3 | ||
Abbreviation: IQR, interquartile range.
The number of allopathic and osteopathic physicians in the US in 2014 is from the National Plan and Provider Enumeration System database.
Mean yearly change can be interpreted as the relative percentage difference per year for each outcome.
P < .05 (2-sided) indicates significance of the trend.
Based on the number of individual physicians receiving 1 or more industry payment(s) in Open Payments between January 1, 2014, and December 31, 2018, compared with the total number of physicians in the 2014 cohort.
Generalized estimating equation (GEE) logistic regression model of the proportion of physicians receiving 1 or more general payment(s) by year, accounting for physician effects. Estimates can be interpreted as the yearly change in the dependent variable, receipt of 1 or more general payment(s), reported as a relative percentage.
In 2018 US dollars.
Linear regression model of the total value of payments by year. Estimates can be interpreted as the yearly change in the dependent variable, total value of payments, reported as a relative percentage.
GEE (gamma distribution) linear regression model of the annual per-physician value of general payments by year, accounting for physician effects. Estimates can be interpreted as the yearly change in the dependent variable, annual per-physician value of payments.
In 2014-2018, 90.1% of physicians who accepted payments received less than $10 000 (Table 2). Among physicians receiving lesser aggregate payments, annual values decreased over time (yearly change: for ≤$10 000, −$11 [95% CI, −$12 to −$11]; for $10 001-$25 000, −$100 [95% CI, −$117 to −$84]; and for $25 001-$50 000, −$135 [95% CI, −$199 to −$71]; P < .001). Those receiving more than $50 000 accounted for 3.4% of physicians receiving payments but 82% of the total value. For these physicians, annual payment values increased or remained stable over time (yearly change: for $50 001-$100 000, $42 [95% CI, −$96 to $179]; P = .55; for $100 001-$500 000, $866 [95% CI, $567 to $1165]; P < .001; and for >$500 000, −$8487 [95% CI, −$21 316 to $4342]; P = .20).
Table 2. Summary and Trends in General Industry Payments to US Physicians by Aggregate Per-Physician Value of Payments Received, 2014-2018.
| Aggregate per-physician value, 2014-2018, $a | Physicians, No. (%) (total receiving payments: 628 360) | Value of payments, all years, $ (%) (total value: $9 334 082 605) | Annual per-physician value, $ | P valueb | ||
|---|---|---|---|---|---|---|
| Median (IQR) | Mean (SD) | Estimated yearly change (95% CI)b | ||||
| ≤10 000 | 566 038 (90.1) | 808 254 612 (8.7) | 160 (51-496) | 438 (741) | −11 (−12 to −11) | <.001 |
| 10 001-25 000 | 29 514 (4.7) | 473 117 299 (5.1) | 2532 (1215-4294) | 3421 (3412) | −100 (−117 to −84) | <.001 |
| 25 001-50 000 | 11 206 (1.8) | 417 412 296 (4.5) | 5920 (1970-11 374) | 7917 (7704) | −135 (−199 to −71) | <.001 |
| 50 001-100 000 | 8242 (1.3) | 617 982 544 (6.6) | 12 763 (5054-12 900) | 15 581 (13 943) | 42 (−96 to 179) | .55 |
| 100 001-500 000 | 10 578 (1.7) | 2 430 438 088 (26.0) | 38 143 (20 093-64 046) | 46 953 (39 157) | 866 (567 to 1165) | <.001 |
| >500 000 | 2782 (0.4) | 4 586 877 766 (49.1) | 176 054 (115 463-283 612) | 334 564 (1 100 357) | −8487 (−21 316 to 4342) | .20 |
Abbreviation: IQR, interquartile range.
In 2018 US dollars.
Generalized estimating equation (gamma distribution) linear regression model of the annual per-physician value of general payments by year, accounting for physician effects. Estimates can be interpreted as the yearly change in the dependent variable, annual per-physician value of payments. P < .05 (2-sided) indicates significance of the trend.
Discussion
Since the inception of Open Payments in 2013, the proportion of physicians receiving industry payments decreased across all specialties, while the total value of payments remained stable except for a decrease in primary care. Similar to other studies, surgical and medical specialties received the highest value of payments,4 and value was concentrated among a minority of physicians.5
Annual payment values decreased for physicians receiving lower-value total payments (≤$50 000), potentially due to transparency,1 organizational restrictions on industry interactions,1 or decreased direct-to-physician marketing.6 Physicians receiving higher-value total payments (>$50 000) continued to receive similar or greater amounts, perhaps reflecting evolving industry strategy that concentrates payments, for which greater return on investment is anticipated.
Study limitations include unmeasured confounding such as physician or market factors. Prevalence of payments are underestimated, because Open Payments only reports certain payment types and the analysis is limited to general payments. Prevalence and value of payments may be overestimated or underestimated because of misattribution of data to a physician or specialty. Additionally, these data are generalizable only to allopathic and osteopathic physicians.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
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