Key Points
Question
Was the initiation of the Open Payments program associated with changes in financial interactions between medical oncologists and industry in 2014 to 2019?
Findings
From 2014 to 2019, a cohort of 15 585 US medical oncologists became less likely to receive industry payments, but the overall value of the payments increased. Over time, medical oncologists receiving lower-value payments (<$10 000) accepted smaller amounts and those receiving higher-value payments (>$10 000) accepted larger amounts.
Meaning
The trend in industry payments to medical oncologists since the inception of the Open Payments program highlights the limitations of transparency without accountability in policy making.
This cohort study of medical oncologists in the US examines trends in physician-level payments in 2014 to 2019 to determine if implementation of the Open Payments program is associated with changes in the frequency and value of industry-oncologist payments.
Abstract
Importance
Given the potential for undue influence of industry-physician payments on oncology care, it is important to understand how a national transparency program may be associated with financial interactions between industry and medical oncologists.
Objective
To identify trends in industry payments to medical oncologists from 2014 to 2019 and determine if the implementation of the Open Payments program is associated with changes in the frequency or value of payments or any shift in the nature of industry-oncologist financial interactions.
Design, Setting, and Participants
This retrospective, population-based, observational cohort study analyzed Open Payments reports of industry payments made in 2014 to 2019 to a cohort of licensed medical oncologists practicing in the US in 2014, using data from the National Plan and Provider Enumeration System.
Exposures
Receipt of an industry payment from January 1, 2014, to December 31, 2019.
Main Outcomes and Measures
General industry payments to medical oncologists, including the proportion receiving payments, total annual value and number of payments, and average annual trends over time, by aggregate value and by nature-of-payment category. Trends over time were analyzed using linear regression and generalized estimating equations.
Results
In 2014 to 2019, there were 15 585 medical oncologists who received a total of 2.2 million industry payments with a total value of $509 million. The absolute number of oncologists receiving payments decreased from 10 498 in 2014 to 8918 in 2019 (−15.1%). The annual per-physician payment value decreased among those receiving less than $10 000 in aggregate by −3.2% yearly (95% CI, −4.1% to −2.3%; P < .001), but increased for those receiving more than $10 000. Payments increased for consulting (13.7%; 95% CI, 12.4%-15.0%; P < .001) and for entertainment, meals, travel or lodging, and gifts (0.8%; 95% CI, 0.1%-1.5%; P = .03).
Conclusions and Relevance
The number of medical oncologists accepting industry payments has decreased; however, high-value industry payments have been consolidated in a relatively small number of medical oncologists accepting higher payment values over time. The nature of payments has shifted toward consulting. These findings highlight the limitations of transparency without accountability.
Introduction
Industry-physician financial relationships can be beneficial by driving scientific advances that improve patient care; however, they also have the potential to introduce bias into clinical care, scientific research, and medical education.1 In the US, increased attention to these financial conflicts of interest energized a movement to improve transparency around industry-physician relationships.2 That movement culminated in the creation of the Open Payments program.3 Open Payments, a mandatory nationwide transparency program, has collected and published data on industry-physician financial interactions since 2013. Open Payments was created in part to discourage transactions identified by the medical community as inappropriate,1,4 including gifts, meals, and certain speaking engagements. The program was also a response to concerns that industry-physician financial relationships might skew treatment decisions, increase health care costs, and drive inappropriate use of medical services.1,5,6
Data from Open Payments have revealed the scope of industry-physician relationships in the US, highly relevant to the medical oncology field where these relationships are common7 and industry investments are lucrative and increasing.1,8 Industry and physician ties merit attention because they may influence oncologists’ clinical decision-making9 and undermine public trust in the integrity of oncologic research and care.10
The association of Open Payments with interactions between industry and medical oncologists is not well understood. This study examined trends in physician-level payments to evaluate whether the implementation of Open Payments has been associated with changes in the prevalence, value, and/or nature of financial interactions between medical oncologists and industry.
Methods
This was a retrospective, population-based cohort study of US allopathic and osteopathic physicians practicing in 2014 using data from the National Plan and Provider Enumeration System (https://nppes.cms.hhs.gov/#/). We excluded other clinicians (eg, nurses, dentists), physicians activating or deactivating in 2014 to 2019, and any payments made in 2013 (owing to partial-year reporting).11 Physicians with a primary specialty of hematology-oncology, medical oncology, or pediatric hematology-oncology, per the provider taxonomy classification,12 were selected. The National Plan and Provider Enumeration System and Open Payments identifiers were linked by text string using cross-referenced files capturing the beginning and end of the period.
Open Payments data on general (nonresearch) industry payments from January 2014 to December 2019 were matched to the 2014 cohort. General payments were chosen to reflect payments to individual oncologists. Payments were aggregated per physician annually, then categorized by cumulative aggregate value (≤$10 000; $10 001-$50 000; $50 001-$500 000; >$500 000). Values were adjusted to the 2019 Consumer Price Index.13 Payments were classified by nature-of-payment category: nonaccredited education (honoraria, education, nonresearch grants, and faculty/speaker compensation at a venue other than a continuing education program or at a nonaccredited/noncertified continuing education program); consulting; accredited education (serving as faculty/ speaker for an accredited or certified continuing education program); investment interest, royalty, and licensing fees; charity; and entertainment, meals, travel or lodging, and gifts.
Study outcomes included the proportion of medical oncologists receiving payments and the total and median or mean annual per-physician payment values. Total-value and number trends were tested using linear regression. To assess outcomes over time, trends in proportions of physicians receiving payments and annual per-physician payment values were tested using logistic and linear (gamma distribution, log-transformed) generalized estimating equations, respectively, controlling for physician-level correlation with year as the independent variable. Analyses were stratified by aggregate value of payment and nature-of-payment categories. Two-tailed P values (α < .05) were applied using SPSS, version 26 (IBM). In accordance with the Regulations for the Protection of Human Subjects (45 CFR §46), this study was exempted from review by the Mount Sinai Institutional Review Board.
Results
Among the study cohort of 15 585 US medical oncologists, 10 498 (67.4%) oncologists received at least 1 payment in 2014, a number that declined to 8918 (57.2%) in 2019 (Table 1). This decline indicates an overall relative decrease of −15.1% and relative annual decrease of −4.9% (95% CI, −5.0% to −4.9%; P < .001). During 2014 to 2019, these physicians received 2.2 million payments totaling $509 million. The total value of payments increased (yearly change, 4.9%; 95% CI, 2.6%-6.8%; P = .01), while the total number of payments remained stable (yearly change, 1.0%; 95% CI, −3.1% to 4.7%; P = .5).
Table 1. Trends in Receipt and Value of Industry Payments to Medical Oncologists in the US, 2014 to 2019a.
| Measure | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | Average yearly % change (95% CI)b | P valuec |
|---|---|---|---|---|---|---|---|---|
| Physicians (n = 15 585) receiving payments, No. (%)d | 10 498 (67.4) | 10 275 (65.9) | 9844 (63.2) | 9586 (61.5) | 9562 (61.4) | 8918 (57.2) | −4.9 (−5.0 to −4.9) | <.001e |
| Total payments | ||||||||
| Value, $ | 76 151 707 | 73 521 378 | 84 819 692 | 89 526 765 | 91 692 182 | 93 441 867 | 4.9 (2.6 to 6.8) | .01f |
| No. | 337 896 | 361 166 | 387 002 | 391 426 | 378 241 | 353 606 | 1.0 (−3.1 to 4.7) | .5f |
| Per-physician value of payments, $ | ||||||||
| Mean (SD) | 7254 (98 699) | 7155 (27 542) | 8616 (34 204) | 9339 (33 878) | 9589 (34 761) | 10 478 (37 120) | 1.7 (0.8 to 2.5) | <.001g |
| Median (IQR) | 583 (124- 2350) | 590 (124- 2722) | 718 (131- 3588) | 765 (127-3912) | 716 (123-3901) | 791 (126-4447) | ||
Abbreviation: IQR, interquartile range.
2019 US dollars and the number of medical oncologists in the US in 2014 according to data from the National Plan and Provider Enumeration System.
Mean yearly change can be interpreted as the relative percentage difference per year for each outcome.
A 2-sided P value of <.05 indicates significance of the trend.
Generalized estimating equation logistic regression model of the proportion of medical oncologists 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.
Based on the number of individual medical oncologists receiving 1 or more general industry payment(s) in Open Payments from January 1, 2014, to December 31, 2019, compared with the total number of medical oncologists in the 2014 cohort.
Linear regression model of the total value of payments by year. Estimates can be interpreted as the annual change in the dependent variable, total value of payments, reported as a relative percentage.
Generalized estimating equation 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.
During the study period, 9108 (69.1%) medical oncologists received payments of less than $10 000 in aggregate (Table 2), with annual values decreasing over time (yearly change, −3.2%; 95% CI, −4.1% to −2.3%; P < .001). Among the 2362 (17.9%) oncologists who received $10 001 to $50 000 in aggregate, annual per-physician values increased yearly by 5.6% (95% CI, 3.8%-7.5%; P < .001). The 1720 oncologists who received more than $50 000 in aggregate accounted for 13.1% of the study cohort receiving payments but 85.8% of the total value during the period. For these oncologists, annual payment values increased over time (annual change: $50 001-$500 000, 14.4% [95% CI, 11.6%-17.4%; P < .001]; >$500 000, 14.5% [95% CI, 8.3%-21.1%; P < .001]).
Table 2. Summary and Trends in General Industry Paymentsa to Medical Oncologists, by Aggregate Per-Physician Value of Payments Received From 2014 to 2019.
| Aggregate per-physician value, $ | Physicians receiving payments, No. (%) | Total value of payments, all years, $ (%) | Annual total value, $ | Average annual % change (95% CI), $b | P valuec | |
|---|---|---|---|---|---|---|
| Median (IQR) | Mean (SD) | |||||
| Total | 13 190 (100) | 509 153 590 (100) | 3107 (437-14 533) | 38 601 (171 091) | 1.7 (0.8 to 2.5) | <.001 |
| ≤10 000 | 9108 (69.1) | 20 159 291 (4.0) | 1031 (197-3497) | 2213 (2613) | −3.2 (−4.1 to −2.3) | <.001 |
| 10 001-50 000 | 2362 (17.9) | 52 124 372 (10.2) | 18 744 (13 304-28 607) | 22 068 (10 714) | 5.6 (3.8 to 7.5) | <.001 |
| 50 001-500 000 | 1514 (11.5) | 234 919 235 (46.1) | 118 416 (76 474-202 910) | 155 165 (103 155) | 14.4 (11.6 to 17.4) | <.001 |
| >500 000 | 206 (1.6) | 201 950 691 (39.7) | 740 520 (588 770-1 116 937) | 980 343 (865 781) | 14.5 (8.3 to 21.1) | <.001 |
Abbreviation: IQR, interquartile range.
2019 US dollars.
Generalized estimating equation linear regression model of the annual per-physician value of general payments by year to account for physician effects. Estimates can be interpreted as the yearly change in the dependent variable to annual per-physician value of payments.
A 2-sided P value of <.05 indicates significance of the trend.
Two million (90.2%) of the industry’s 2.2 million payments were for entertainment, meals, travel or lodging, and gifts (Table 3). The nature-of-payment categories with the greatest values were nonaccredited education ($219 million, 42.9%) and consulting ($159 million, 31.1%). Trends in nature-of-payment categories showed increases in consulting (13.7%; 95% CI, 12.4%-15.0%; P < .001) and entertainment, meals, travel or lodging, and gifts (0.8%; 95% CI, 0.1%-1.5%; P < .001).
Table 3. Summary and Trends in General Industry Paymentsa to Medical Oncologists, by Nature-of-Payment Category, From 2014 to 2019.
| Nature-of-payment category | Total payments, all years, No. (%) | Total value of payments, all years, $ (%) | Annual total value, $ | Estimated yearly % change (95% CI)b | P valuec | |
|---|---|---|---|---|---|---|
| Median (IQR) | Mean (SD) | |||||
| Total, all years | 2 209 337 (100) | 509 153 590 (100) | NA | NA | NA | NA |
| Accredited education | 174 (0.008) | 490 610 (0.1) | 1209 (235-4000) | 3634 (7997) | −9.3 (−25.7 to 10.7) | .34 |
| Charity | 32 (0.001) | 289 411 (0.1) | 762 (500-27 900) | 10 719 (20 681) | 2.9 (−7.9 to 14.9) | .62 |
| Consulting | 60 977 (2.8) | 158 520 168 (31.1) | 3999 (1582-9931) | 9638 (25 266) | 13.7 (12.4 to 15.0) | <.001 |
| Entertainment, meals, travel or lodging, and gifts | 1 992 743 (90.2) | 112 773 564 (22.1) | 489 (117-1643) | 2040 (5497) | 0.8 (0.1 to 1.5) | .03 |
| Investment interest to royalty or licensing fees | 110 (0.005) | 18 419 060 (3.6) | 30 966 (1056-279 028) | 558 153 (1 694 642) | 2.3 (−35.3 to 61.8) | .92 |
| Nonaccredited education | 155 301 (7.0) | 218 660 767 (42.9) | 113 (41-1829) | 6983 (26 112) | 0.8 (−0.6 to 2.1) | .25 |
Abbreviations: IQR, interquartile range; NA, not applicable.
2019 US dollars.
Generalized estimating equation linear regression model of the annual per-physician value of general payments by year to account for physician effects. Estimates can be interpreted as the yearly change in the dependent variable to annual per-physician value of payments.
A 2-sided P value of <.05 indicates significance of the trend.
Discussion
These findings demonstrate that since the inception of Open Payments, industry payments to medical oncologists have continued to be highly prevalent, accounting for more than $500 million from 2014 to 2019. While the proportion of medical oncologists accepting industry payments decreased overall, 57% continued accepting payments in 2019, and the total annual value of payments increased by $17 million during the study period.
Similar to other studies, we found that most medical oncologists receive relatively low-value payments from industry,14 mostly for entertainment, meals, travel or lodging, and gifts, representing more than 90% of the total number of payments overall. The influence of low-value payments should not be understated as their association with medical oncologists’ prescribing practices has been documented in the literature,3,9 and they have been implicated in the rising cost of prescriptions.15 That said, the study data reveal that these physicians have accepted similar or lesser amounts from industry since the inception of Open Payments, suggesting that medical oncologists who receive low-value payments may have less financial incentive to continue accepting payments in an environment of heightened public and peer scrutiny.
We found that 80% of the total value of industry payments is concentrated among less than 15% of medical oncologists, reflecting previously illustrated patterns.7 Moreover, payments to medical oncologists accepting more than $10 000 have increased annually since the inception of Open Payments, with the greatest increases among medical oncologists receiving more than $50 000. At the same time, we observed increasing values in consulting payments that were frequently of higher value compared with entertainment, meals, travel or lodging, and gifts. Overall, these findings point to a consolidation of industry interest in select medical oncologists, possibly in the face of evolving institutional regulation or economic forces.8
Together these data raise the question of whether mechanisms beyond transparency are needed to increase accountability related to financial conflicts of interest in medical oncology, especially given the association of industry payments with increased health care costs.6 The study findings also point to the need to foster collaboration among professional societies, hospital systems, and government to address financial conflicts of interest in medical oncology.
Limitations
This study has limitations. First, the data do not account for confounding factors, such as the evolution of industry practices and market forces. Second, there may be inaccuracies in payment reporting. Third, the data likely underestimated the prevalence of industry-physician relationships because only general payments were included, thereby excluding often higher-value and more influential research payments and other payments that are legally exempt from reporting. Lastly, the analysis may include some hematology physicians in the hematology-oncology specialty.
Conclusions
Since the inception of the Open Payments program, the overall number of medical oncologists accepting industry payments has decreased. However, high-value industry payments have been consolidated in a relatively small number of medical oncologists who are accepting higher payment values over time. The nature of payments has shifted toward consulting. These findings point to the limits of transparency and the need for additional measures to ensure integrity and public trust in oncological research and practice.
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