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Public Disclosure of Payments to Physicians From Industry

Public Disclosure of Payments to Physicians From Industry A hallmark of the patient-physician relationship is trust, including trust that patients will be truthful with physicians about what ails them, as well as trust that physicians will make the best decisions for patients, irrespective of any competing interests. But for physicians and patients who are not content to leave such decisions to faith, finding additional information about physicians has, until recently, been challenging. For instance, when a physician prescribed an expensive new drug, patients and their families could not find out if the physician had financial ties to the manufacturer of the drug, short of asking the physician. Nor was there a place to compare the physician’s prescription drug choices to those of peers to determine whether additional questions should be asked about the recommended course of treatment. This veil of secrecy began to lift in the late 2000s. From 2009 through 2014, at least 11 pharmaceutical companies settled whistleblower lawsuits contending illegal marketing and kickbacks.1 As part of the settlements, companies agreed to disclose payments to physicians for promotional speaking, consulting, and other services. Companies began posting this information on their websites, but in ways that were difficult to find, search, and analyze. It was practically impossible to determine which physicians received the most money. Two developments represent important progress in promoting transparency regarding financial interactions between industry and physicians—the federal Open Payments program and initiatives by ProPublica, a nonprofit investigative news organization. These initiatives have spurred widespread discussion and increasing awareness about some of the financial relationships between physicians and industry, and the resulting information has been personally useful for patients. More broadly, the availability of information on payments to physicians and the relationship to prescribing has prompted uncomfortable, and perhaps overdue, questions about whose interests should come first—physicians’ privacy or patients’ right to know. The Open Payments Program The Open Payments program came into being as a result of the 2010 Affordable Care Act, section 6002, which became known as the Physician Payments Sunshine Act. The law required that all pharmaceutical and medical device manufacturers publicly report payments of value to covered recipients, including teaching hospitals, medical doctors, dentists, osteopathic physicians, optometrists, podiatrists, and chiropractors. These transfers included general payments (eg, for meals, travel, speaking and consulting payments), research payments, and ownership interests. Beginning in September 2014, payments were posted on a website run by the Centers for Medicare & Medicaid Services (CMS).2 The first report covered August 2013 to December 2013. Subsequent reports (published annually and updated 1 additional time per year) cover entire calendar years. The site allows users to search for particular physicians and to download the entire data sets. It is not easy, however, to discover which companies spent the most per year or which products were the focus of the most promotion. Companies are required to attest to the accuracy of their data and are subject to audits and civil monetary penalties of up to $1.15 million per year for reporting payments late or inaccurately.2 Most of the analyses of the Open Payments data have been descriptive in nature, examining prevalence of payments within a particular specialty, such as the recent report by Marshall et al.3 However, data reported by companies are not complete and sometimes contain errors. Companies do not have to report pharmaceutical samples provided to physicians, which some consider an inducement to prescribe, or certain payments related to continuing medical education. In addition, payments to nurse practitioners and physician assistants are not covered by the law. Even though physicians are given a 45-day window in which to review and dispute any payments attributed to them before the data become public, a very small percentage of physicians do so. For the 2015 payment year, 16 653 records were disputed, or about 0.13% of all payments.2 Indeed, many physicians still are not aware that the government publishes the Open Payments data online. ProPublica’s Initiatives Since 2010, ProPublica has made important contributions in bringing transparency to 2 important areas of health care: the financial relationships between physicians and drug companies, and the way in which the prescribing habits of physicians compare with their peers. Dollars for Docs In October 2010, ProPublica unveiled Dollars for Docs,4 a central search engine for physician payments that initially synthesized the information on payments to physicians from 7 companies. The tool also provided useful context, including the names of the top-selling drugs made by each company, as well as possible questions consumers could ask their physicians if they wanted more information. Although conflicts of interest in medicine had been well covered in the medical literature, Dollars for Docs made the issue personal for patients, giving them the ability to research a key question: does their physician have relationships with drug companies? The tool also held revelations for a range of other users, including those in the health care industry. Physicians looked up their peers. Law enforcement used it. To date, the tool has logged more than 13 million page views and has been featured in at least 200 different media outlets. Dollars for Docs, which now includes all companies and payments from Open Payments, has also yielded surprising insights and has been cited as a source in medical literature. Despite what pharmaceutical companies had long maintained, some of the physicians who collected the most industry payments were not experts in their fields, and some lacked specialty board certification. Other physicians receiving payments had been sanctioned by their state medical boards—in some cases, for abusive prescribing—prompting companies to acknowledge they did not review such actions as part of their screening process.5 To the surprise of some major universities, some faculty members had been receiving drug company payments in violation of policies that forbid accepting certain industry payments.6 As a result of this and other information, pharmaceutical companies tightened their screening practices and some universities began reviewing their faculty in the database to verify disclosures on financial relationships that, until then, had been self-reported by faculty. Prescriber Checkup Understanding the financial relationships between physicians and the drug industry is only 1 window into prescribing habits. It is just as important, if not more so, to understand how prescribing practices of physicians compare with their peers. Most physicians generally are not aware if their drug choices are similar to other physicians in their fields; there has been no definition of what constitutes “normal” prescribing. Under the Freedom of Information Act, ProPublica requested data on prescribing by each physician under Medicare’s drug program, known as part D, which covers more than 1 in 4 of the prescriptions dispensed in the United States. In 2013, ProPublica rolled out Prescriber Checkup, a tool that allowed users to see how a physician’s prescribing compared with others practicing in the same specialties and in the same states. Reports based on these data showed odd patterns of prescribing by physicians and staggeringly different rates of brand-name prescribing across the country.7 An early analysis showed that many of the top prescribers of heavily marketed drugs also received payments from the companies that made the drugs. Virtually all of the top prescribers of 1 expensive, brand-name blood pressure drug were being paid by its maker.8 A subsequent analysis of the merged payments and prescribing databases showed that physicians who received industry payments tended to prescribe a higher percentage of brand-name drugs, on average, than others in the same specialty who did not receive payments.9 A dose-response relationship was also evident: the more money physicians received, on average, the higher their rates of brand-name prescribing. The analyses to date have only established an association. Further research is needed to determine if there is a causal relationship between payments and prescribing. It may well be that physicians who have a preference for brand-name prescriptions are more inclined to accept industry payments. But if payments are shown to cause a physician to prescribe a specific drug, that may trigger a discussion about kickback laws and lead to greater use of prior authorization by insurance companies. Prescriber Checkup is limited; it does not include prescribing data beyond Medicare and the release of Medicare data are often delayed by more than a year, making the information less timely than ideal to assess trends in real time. In addition, as an example of unintended consequences of increasing the availability of information on the drugs physicians prescribed, some patients seeking opioids began sharing data on top prescribers in online forums. Conclusions Transparency regarding public disclosure of payments to physicians from industry, and the relationship between payments and prescribing is still in its infancy. Going forward, as additional data become available, it will be imperative to continue improving the tools available for consumers and provide information and context on how to use them. Back to top Article Information Corresponding Author: Charles Ornstein, BA, ProPublica, 155 Avenue of the Americas, New York, NY 10013 (charles.ornstein@propublica.org). Conflict of Interest Disclosures: Mr Ornstein has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. He reports writing this piece as a senior reporter at ProPublica. Since 2015, ProPublica’s health coverage has been supported by grants from the Robert Wood Johnson Foundation. References 1. Groeger L. Big pharma’s big fines. http://projects.propublica.org/graphics/bigpharma. Published February 24, 2014. Accessed April 3, 2017. 2. Centers for Medicare & Medicaid Services. Open Payments data website. https://openpaymentsdata.cms.gov/. Accessed April 13, 2017. 3. Marshall DC, Moy B, Jackson ME, Mackey TK, Hattangadi-Gluth JA. Distribution and patterns of industry-related payments to oncologists in 2014. J Natl Cancer Inst. 2016;108(12):pii: djw163. PubMedGoogle ScholarCrossref 4. ProPublica. Dollars for Docs. https://projects.propublica.org/docdollars/. Updated December 13, 2016. Accessed April 3, 2017. 5. Ornstein C, Weber T, Nguyen D. Docs on pharma payroll have blemished records, limited credentials. https://www.propublica.org/article/dollars-to-doctors-physician-disciplinary-records. Published October 18, 2010. Accessed April 3, 2017. 6. Weber T, Ornstein C. Med schools flunk at keeping faculty off pharma speaking circuit. https://www.propublica.org/article/medical-schools-policies-on-faculty-and-drug-company-speaking-circuit. Published December 19, 2010. Accessed April 3, 2017. 7. Ornstein C, Weber T, LaFleur J. Medicare’s failure to track doctors wastes billions on name-brand drugs. https://www.propublica.org/article/medicare-wastes-billions-on-name-brand-drugs. Published November 18, 2013. Accessed March 22, 2017. 8. Ornstein C, Weber T, LaFleur J. Top Medicare prescribers rake in speaking fees from drugmakers. https://www.propublica.org/article/top-medicare-prescribers-rake-in-speaking-fees-from-drugmakers. Published June 25, 2013. Accessed March 22, 2017. 9. Jones RG; Ornstein C. Matching industry payments to Medicare: an analysis. https://static.propublica.org/projects/d4d/20160317-matching-industry-payments.pdf?22. Accessed April 3, 2017. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Public Disclosure of Payments to Physicians From Industry

Ornstein, Charles
JAMA , Volume 317 (17) – May 2, 2017
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References (7)

Publisher
American Medical Association
Copyright
Copyright © 2017 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2017.2613
pmid
28464158
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Abstract

A hallmark of the patient-physician relationship is trust, including trust that patients will be truthful with physicians about what ails them, as well as trust that physicians will make the best decisions for patients, irrespective of any competing interests. But for physicians and patients who are not content to leave such decisions to faith, finding additional information about physicians has, until recently, been challenging. For instance, when a physician prescribed an expensive new drug, patients and their families could not find out if the physician had financial ties to the manufacturer of the drug, short of asking the physician. Nor was there a place to compare the physician’s prescription drug choices to those of peers to determine whether additional questions should be asked about the recommended course of treatment. This veil of secrecy began to lift in the late 2000s. From 2009 through 2014, at least 11 pharmaceutical companies settled whistleblower lawsuits contending illegal marketing and kickbacks.1 As part of the settlements, companies agreed to disclose payments to physicians for promotional speaking, consulting, and other services. Companies began posting this information on their websites, but in ways that were difficult to find, search, and analyze. It was practically impossible to determine which physicians received the most money. Two developments represent important progress in promoting transparency regarding financial interactions between industry and physicians—the federal Open Payments program and initiatives by ProPublica, a nonprofit investigative news organization. These initiatives have spurred widespread discussion and increasing awareness about some of the financial relationships between physicians and industry, and the resulting information has been personally useful for patients. More broadly, the availability of information on payments to physicians and the relationship to prescribing has prompted uncomfortable, and perhaps overdue, questions about whose interests should come first—physicians’ privacy or patients’ right to know. The Open Payments Program The Open Payments program came into being as a result of the 2010 Affordable Care Act, section 6002, which became known as the Physician Payments Sunshine Act. The law required that all pharmaceutical and medical device manufacturers publicly report payments of value to covered recipients, including teaching hospitals, medical doctors, dentists, osteopathic physicians, optometrists, podiatrists, and chiropractors. These transfers included general payments (eg, for meals, travel, speaking and consulting payments), research payments, and ownership interests. Beginning in September 2014, payments were posted on a website run by the Centers for Medicare & Medicaid Services (CMS).2 The first report covered August 2013 to December 2013. Subsequent reports (published annually and updated 1 additional time per year) cover entire calendar years. The site allows users to search for particular physicians and to download the entire data sets. It is not easy, however, to discover which companies spent the most per year or which products were the focus of the most promotion. Companies are required to attest to the accuracy of their data and are subject to audits and civil monetary penalties of up to $1.15 million per year for reporting payments late or inaccurately.2 Most of the analyses of the Open Payments data have been descriptive in nature, examining prevalence of payments within a particular specialty, such as the recent report by Marshall et al.3 However, data reported by companies are not complete and sometimes contain errors. Companies do not have to report pharmaceutical samples provided to physicians, which some consider an inducement to prescribe, or certain payments related to continuing medical education. In addition, payments to nurse practitioners and physician assistants are not covered by the law. Even though physicians are given a 45-day window in which to review and dispute any payments attributed to them before the data become public, a very small percentage of physicians do so. For the 2015 payment year, 16 653 records were disputed, or about 0.13% of all payments.2 Indeed, many physicians still are not aware that the government publishes the Open Payments data online. ProPublica’s Initiatives Since 2010, ProPublica has made important contributions in bringing transparency to 2 important areas of health care: the financial relationships between physicians and drug companies, and the way in which the prescribing habits of physicians compare with their peers. Dollars for Docs In October 2010, ProPublica unveiled Dollars for Docs,4 a central search engine for physician payments that initially synthesized the information on payments to physicians from 7 companies. The tool also provided useful context, including the names of the top-selling drugs made by each company, as well as possible questions consumers could ask their physicians if they wanted more information. Although conflicts of interest in medicine had been well covered in the medical literature, Dollars for Docs made the issue personal for patients, giving them the ability to research a key question: does their physician have relationships with drug companies? The tool also held revelations for a range of other users, including those in the health care industry. Physicians looked up their peers. Law enforcement used it. To date, the tool has logged more than 13 million page views and has been featured in at least 200 different media outlets. Dollars for Docs, which now includes all companies and payments from Open Payments, has also yielded surprising insights and has been cited as a source in medical literature. Despite what pharmaceutical companies had long maintained, some of the physicians who collected the most industry payments were not experts in their fields, and some lacked specialty board certification. Other physicians receiving payments had been sanctioned by their state medical boards—in some cases, for abusive prescribing—prompting companies to acknowledge they did not review such actions as part of their screening process.5 To the surprise of some major universities, some faculty members had been receiving drug company payments in violation of policies that forbid accepting certain industry payments.6 As a result of this and other information, pharmaceutical companies tightened their screening practices and some universities began reviewing their faculty in the database to verify disclosures on financial relationships that, until then, had been self-reported by faculty. Prescriber Checkup Understanding the financial relationships between physicians and the drug industry is only 1 window into prescribing habits. It is just as important, if not more so, to understand how prescribing practices of physicians compare with their peers. Most physicians generally are not aware if their drug choices are similar to other physicians in their fields; there has been no definition of what constitutes “normal” prescribing. Under the Freedom of Information Act, ProPublica requested data on prescribing by each physician under Medicare’s drug program, known as part D, which covers more than 1 in 4 of the prescriptions dispensed in the United States. In 2013, ProPublica rolled out Prescriber Checkup, a tool that allowed users to see how a physician’s prescribing compared with others practicing in the same specialties and in the same states. Reports based on these data showed odd patterns of prescribing by physicians and staggeringly different rates of brand-name prescribing across the country.7 An early analysis showed that many of the top prescribers of heavily marketed drugs also received payments from the companies that made the drugs. Virtually all of the top prescribers of 1 expensive, brand-name blood pressure drug were being paid by its maker.8 A subsequent analysis of the merged payments and prescribing databases showed that physicians who received industry payments tended to prescribe a higher percentage of brand-name drugs, on average, than others in the same specialty who did not receive payments.9 A dose-response relationship was also evident: the more money physicians received, on average, the higher their rates of brand-name prescribing. The analyses to date have only established an association. Further research is needed to determine if there is a causal relationship between payments and prescribing. It may well be that physicians who have a preference for brand-name prescriptions are more inclined to accept industry payments. But if payments are shown to cause a physician to prescribe a specific drug, that may trigger a discussion about kickback laws and lead to greater use of prior authorization by insurance companies. Prescriber Checkup is limited; it does not include prescribing data beyond Medicare and the release of Medicare data are often delayed by more than a year, making the information less timely than ideal to assess trends in real time. In addition, as an example of unintended consequences of increasing the availability of information on the drugs physicians prescribed, some patients seeking opioids began sharing data on top prescribers in online forums. Conclusions Transparency regarding public disclosure of payments to physicians from industry, and the relationship between payments and prescribing is still in its infancy. Going forward, as additional data become available, it will be imperative to continue improving the tools available for consumers and provide information and context on how to use them. Back to top Article Information Corresponding Author: Charles Ornstein, BA, ProPublica, 155 Avenue of the Americas, New York, NY 10013 (charles.ornstein@propublica.org). Conflict of Interest Disclosures: Mr Ornstein has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. He reports writing this piece as a senior reporter at ProPublica. Since 2015, ProPublica’s health coverage has been supported by grants from the Robert Wood Johnson Foundation. References 1. Groeger L. Big pharma’s big fines. http://projects.propublica.org/graphics/bigpharma. Published February 24, 2014. Accessed April 3, 2017. 2. Centers for Medicare & Medicaid Services. Open Payments data website. https://openpaymentsdata.cms.gov/. Accessed April 13, 2017. 3. Marshall DC, Moy B, Jackson ME, Mackey TK, Hattangadi-Gluth JA. Distribution and patterns of industry-related payments to oncologists in 2014. J Natl Cancer Inst. 2016;108(12):pii: djw163. PubMedGoogle ScholarCrossref 4. ProPublica. Dollars for Docs. https://projects.propublica.org/docdollars/. Updated December 13, 2016. Accessed April 3, 2017. 5. Ornstein C, Weber T, Nguyen D. Docs on pharma payroll have blemished records, limited credentials. https://www.propublica.org/article/dollars-to-doctors-physician-disciplinary-records. Published October 18, 2010. Accessed April 3, 2017. 6. Weber T, Ornstein C. Med schools flunk at keeping faculty off pharma speaking circuit. https://www.propublica.org/article/medical-schools-policies-on-faculty-and-drug-company-speaking-circuit. Published December 19, 2010. Accessed April 3, 2017. 7. Ornstein C, Weber T, LaFleur J. Medicare’s failure to track doctors wastes billions on name-brand drugs. https://www.propublica.org/article/medicare-wastes-billions-on-name-brand-drugs. Published November 18, 2013. Accessed March 22, 2017. 8. Ornstein C, Weber T, LaFleur J. Top Medicare prescribers rake in speaking fees from drugmakers. https://www.propublica.org/article/top-medicare-prescribers-rake-in-speaking-fees-from-drugmakers. Published June 25, 2013. Accessed March 22, 2017. 9. Jones RG; Ornstein C. Matching industry payments to Medicare: an analysis. https://static.propublica.org/projects/d4d/20160317-matching-industry-payments.pdf?22. Accessed April 3, 2017.

Journal

JAMA – American Medical Association

Published: May 2, 2017

Keywords: disclosure,physician payment,prescribing behavior,pharmaceutical company,health evaluation

There are no references for this article.