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Exploring the Industry-Dermatologist Financial Relationship: Insight From the Open Payment Data

Exploring the Industry-Dermatologist Financial Relationship: Insight From the Open Payment Data Key Points Question What are the characteristics of industry payments to dermatologists? Findings In this retrospective study, 8333 dermatologists received 208 613 payments totaling more than $34 million, with the median total payment per dermatologist of $298. The payment distribution is highly skewed, with a minority of dermatologists receiving most of the total payments from pharmaceutical companies. Meaning There are potential conflicts of interest among dermatologists. Abstract Importance Significant ties exist between clinicians and industry. Little is known about the characteristics of industry payments to dermatologists. Objective To analyze the nature and extent of industry payments to dermatologists. Design, Setting, and Participants This was a retrospective review using the publicly available Centers for Medicare and Medicaid Services (CMS) Sunshine Act Open Payment database. Data were downloaded from the publically available CMS website under General Payment and Research Payment data sets. All payments to dermatologists from companies making products reimbursed by a government-run health program were reviewed. Main Outcomes and Measures Mean, median, and range of payments made, including quantity and total sum of payments, per clinician. Total payments and number of transactions per category of payment, geographic region, and payment source were also assessed. Results A total of 8333 dermatologists received 208 613 payments totaling more than $34 million. The median total payment per dermatologist was $298 with an interquartile range of $99 to $844. The top 10% of dermatologists (n = 833) received more than $31.2 million, 90% of the total payments. The top 1% each (n = 83) received at least $93 622 and accounted for 44% of total payments. While 83% of payment entries were for food and beverage, they accounted for only 13% of total amount of payments. Speaker fees (31.7%), consulting fees (21.6%), and research payments (16.5%) comprised 69.8% of total payment amount. The top 15 companies were all pharmaceutical manufacturers and paid dermatologists $28.7 million, representing 81% of total disbursement. Conclusions and Relevance Dermatologists received substantial payments from the pharmaceutical industry. The nature and amount of payments varied widely. The impact of the data on patient care, physicians practice patterns, and patient perception of physicians is unclear. Introduction In today’s complex economic and health care environment, the interactions between physicians, hospitals, and health care manufacturing companies are under increased scrutiny. Under the Patient Protection and Affordable Care Act, the Physician Payments Sunshine Act requires manufacturers and group-purchasing organizations that make products reimbursed by a government-run health program to report on all payments and other transfers of value to physicians in categories, such as consulting, speaking fees, food, travel, and research.1 Specifically, amounts greater than $10 or aggregates of payment greater than $100 during a calendar year are mandatory reports.1 Industry-physician interaction is common in all medical specialties, and dermatology is no exception.2-4 While the types of interaction between dermatologists and industry have been described,2,4 there is very little literature on the amount and geographic distribution of financial distributions by industry to dermatologists. To better understand the qualitative and quantitative characteristics of physician payments from industry sources, we probed the Centers for Medicare and Medicaid Services (CMS) Sunshine Act Open Payments database, the largest public nationwide database detailing financial relationships of industry and physicians and the first of its kind. The purpose of this study was to characterize the extent and nature of industry payments to dermatologists for 2014, the first year that a full 12 months of financial data have been released. Specifically, we examined the number, amount, and type of payments dermatologists received, the geographic distribution of industry payments, and the manufacturers that are contributing the highest total payments. Methods In this retrospective database analysis, we used publicly available data from the CMS Sunshine Act Open Payments,5 which contains records of payments to physicians by applicable medical manufacturers or group-purchasing organizations operating in the United States. We used the general payment and research payment data sets from 2014, which contains payments made between January 1, 2014, and December 31, 2014. The data within do not contain physician ownership and/or investment interests, which can be found in a separate database on the Open Payments website, because these payments may be reported without adequate context for interpretation. Payments without an associated clinician were excluded from the study. After filtering the payment data by the physician’s primary specialty and excluding payment data made to physicians who were not classified as practicing dermatology in the Open Payment physician profile data file, the data were downloaded. To ensure uniformity, one individual (H. F.) reviewed and collected the information from the database. Data management and analysis were performed with Microsoft Excel software (Microsoft Excel for Mac 2011, version 14.2.3; Microsoft Corp). Information on sex and academic affiliation of payment recipients was obtained from internet searches. Descriptive statistics such as mean, median, interquartile range (IQR), and percentages were calculated. We chose to use primarily median and IQR instead of mean and standard deviation to describe data because of skewed distribution. Geographic analysis of payment data was conducted based on divisions created by the US Census Bureau: New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), Mid-Atlantic (New Jersey, New York, and Pennsylvania), East North Central (Illinois, Indiana, Michigan, Ohio, and Wisconsin), West North Central (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota), South Atlantic (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington, DC, and West Virginia), East South Central (Alabama, Kentucky, Mississippi, and Tennessee), West South Central (Arkansas, Louisiana, Oklahoma, and Texas), Mountain (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming), Pacific (Alaska, California, Hawaii, Oregon, and Washington). Puerto Rico, US military bases abroad, and US Virgin Islands are classified under Other. Divisions were used instead of regions (Northeast, South, Midwest, and West) to better provide more detailed insight of geographic payment differences. Geographic data were based on the state listed in the physician profile data file. The New York University School of Medicine's institutional review board reviewed this study and granted it exempt status. Results A total of 208 613 payments totaling $34 810 661.57 were made to 8333 dermatologists in 2014. This represented 0.54% of the total $6.49 billion disbursement and 1.8% of the 11.41 million records of all industry payment to clinicians. For dermatology, the median amount per payment was $15.93 (IQR, $10.89-$25.94) with the minimum and maximum payment per entry of $0.00 and $249 641.60, respectively. The mean (SD) amount per payment was $171 ($1400). Seventy-nine percent of payments were less than $50 and 94.6% of payments were less than $500. The distribution of payments is shown in Table 1. The median total industry payment to each dermatologist was $297.59 (IQR, $99.10-$843.58) (mean [SD], $4177.45 [$22 527.43]). The median (mean) number of payment per dermatologist was 10 (25). In total, 25%, 63%, 78%, and 91% of dermatologists received less than $100, $500, $1000, and $5000, respectively. The top 10% of dermatologists receiving payments (n = 833) each received at least $3940 and accounted for over $31.2 million in total payments, or 90% of total payments to the specialty. Of these recipients, 527 (63.3%) were men, 306 (36.7%) were women, 138 (16.6%) were affiliated with academic centers, and 695 (83.4%) were in private practice. The top 1% (n = 83) each received at least $93 622 and accounted for 44% of total payments. Of these 83 dermatologists, 17 (20.5%) were affiliated with academic centers, and 20 (24.1%) were women. The 10 individual dermatologists who received the highest total payments collectively accounted for $4.09 million, or 12% of all payments. One (10%) was affiliated with an academic center, and 3 (30%) were women. The distribution of payments per dermatologist is shown in Table 1. Physicians have the option of reviewing and challenging the accuracy of the published data. In 2014, 7 physicians disputed 36 payments (19.5%) totaling $61 278.47 (47.1%) out of a total of 185 payments totaling $130 072.05. Three of the 7 physicians disputed all of the payments made under their names, totaling $58 615.78. Of the disputed payments, 11 entries were for food and beverages totaling $468.14, and 25 entries were for consulting fees totaling $60 810.33. The distribution of payment categories is shown in Table 2. Of all categories, services other than consulting received the greatest share of all payments. These services included serving as faculty or as a speaker at a venue other than a continuing education program (29.9%). Consulting services received 21.6% of all payments, followed by payments for research activities (16.5%), and food and beverages (13.3%). The greatest number of payments made was for food and beverages at 172 690 disbursements. The 3 categories with the largest single payment amount were research ($249 642), consulting fees ($235 674), and royalty or license fees ($83 903). The distribution of payment categories by physician affiliations with academic center and private practice for the top 10% (n = 833) dermatologists receiving industry payments is shown in Table 3. In total, 279 companies with distinct payment identification numbers made payments to dermatologists. The top 15, 10, and 5 companies accounted for $28.7 million (82.3%), $25.1 million (72.0%), and $18.6 million (53.5%) of the total payment, respectively. The top 15 manufacturers by total payment amount were all pharmaceutical companies. Their total payment amounts and payment type distributions are shown in Figure 1 and Figure 2, respectively. A physician may direct a company to pay another entity instead of the physician. When this occurs, many payments attributed to the third-party entity are for biologic medications and small molecules. The highest number and sum of payments went to dermatologists in the Mid-Atlantic, South Atlantic, and Pacific areas. The mean payment received per dermatologist was highest in the Mid-Atlantic ($5277) and East South Central ($5106). Dermatologists in the West North Central division received the lowest total payment per individual. Discussion In recent years, legislative measures at the state and national level have been implemented to make relationships between physicians and industry more transparent.1,6,7 In this study, we demonstrated that interactions between industry and dermatologists are widely prevalent and highly variable, with a small fraction of dermatologists receiving a large share of all payments. With roughly 11 363 active dermatologists in the United States8 and 8333 dermatologists (73.3%) receiving payment in this study, those without industry interaction are in the minority. The high percentage of physicians receiving industry payment is consistent with a national survey across all specialties.9 There are variations across specialties, but the percentage of physicians receiving payments in dermatology is similar to those of other procedural specialties.10-13 While dermatologist-industry interaction resulted in $34.8 million worth of transactions, payments ranged widely across recipients. Sixty-three percent of dermatologists received less than $500 in compensation, and a small fraction received a disproportionately large percentage of total payments to the specialty. This positively skewed distribution of industry payments has also been observed in other specialties.10-15 Most individual payments were relatively small, with 79% of payments less than $50 and median amount of $15.93, reflecting payments primarily for food and beverages. This was also consistent with data from other specialties.10-14 The large standard deviation of payments reflects wide variation in payment amounts. Although food and beverage payments comprised 83% of the number of payments made, they made up only 13% of the total payment amount to the specialty as a whole. This finding is consistent with other specialties.9,10,13-15 Interestingly, patients may view payments of food more negatively.14,16,17 Studies show that patients often interpret food and beverage as a personal gift to the physician without direct benefit to patients. Themes of dishonesty and selfishness seem to be at the center of patient concerns.16,17 Compensation for speaking arrangements and consulting fees made up over half of the total payment amount to the specialty, compared with a much more modest 16.5% for research. Consulting and speaking arrangements brought in the highest median payment per category, at $1360 and $1500 each, respectively. These amounts do not take into account nonfinancial gains accrued from these activities, such as publicity or the perception of becoming a more notable figure in the field. For companies, having key knowledge holders and thought leaders being advocates and spokespersons may help shift clinical practices.9,18 In fact, studies have shown that patients see the physician with this association positively, viewing him or her at the forefront of the field and being an influential figure.17,19,20 The exact nature of the consulting fees and agreements are not described in the database, preventing a full understanding of the relationship. The amount and percentage of total payouts for royalties and patent licenses to dermatologists were less compared with payouts for ophthalmologists and orthopedic surgeons.12,14 The exact nature of research compensation cannot be discerned owing to lack of reporting uniformity across companies, but the available data suggest that most research payments were for the study of safety, efficacy, and pharmacokinetics of various medications, including small molecules, biological medications, topical acne medications, and injectable neuromodulators. It is unclear what expenses the research payments actually covered, such as stipend, supplies, equipment, clinical study services, publication support, travel expenses, and meeting costs. Both dermatologists affiliated with academic centers and those with private practices received industry payments. However, among the top 10% of all payment recipients (n = 833), only 16.6% of these were academic dermatologists. Given that approximately 6% of the nation’s dermatologists work in academic settings,21 their disproportionately higher representations among top industry payment recipients may be related to their position as thought leaders. This idea is supported by the fact that 45.3% of payments made toward dermatologists at academic centers were in the form of consulting fees, compared with 18.2% for those in private practice. However, among the same top recipients, those affiliated with private practices received a higher percentage of their total payments for research and non–continuing medical education program speaking fees than their counterparts at academic centers. Sex differences in the amount of money received from industry have been reported.22 In dermatology, men outnumbered women among top industry payment recipients, although apparently less than in other fields.23,24 Recent research examined sex disparities in academic dermatology, specifically looking at principal investigator funding from the National Institutes of Health.25 More granular research on sex and industry connections would be useful. It is important to note that there is likely variability in the classification of payment activities among companies, as evidenced by the uneven payment distribution across categories by different companies. For example, consulting fees and speaker fees were prominent for some companies, whereas honoraria were prominent for others. The CMS defines consulting fees as payments made “for advice and expertise on a particular medical product or treatment, typically provided under a written agreement and in response to a particular business need,” speaking fees as those made “for speaking, training, and education engagements,” and honoraria as “similar to consulting fees, but generally reserved for a one-time, short duration activity… generally provided for services which custom prohibits a price from being set.”5 Dermatologists received $5.7 million in total payments from industry for research, which is significantly less than the $73 million from the National Institute of Arthritis and Musculoskeletal and Skin Diseases for skin-related investigations.26 The results of investigative endeavors from physician-industry interactions can be beneficial or misleading.4,27,28 Given the trends in the past few decades of increased research funding by the pharmaceutical companies, decreased funding by government, and more aggressive marketing competition among pharmaceutical companies for physician attention,4,29 dermatologists of the present and future will likely continue to interact with industry to advance the field and address skin diseases. More than ever, investigators will need to adhere to rigorous standards of integrity and transparency to manage potential conflicts of interest in today’s research environment. The Open Payment database can be used to help verify that physician investigators are disclosing their sources of financial support and potential conflicts of interest. The 15 highest-paying manufacturers and most of the companies making payments to dermatologists in the Open Payment data set belong to the pharmaceutical industry. The predominance of pharmaceutical payments in dermatology contrasts sharply with other specialties, such as otolaryngology,11 orthopedic surgery,12,15 and ophthalmology,14 in which surgical and diagnostic manufacturers play a larger role. It should not come as any surprise that surgical subspecialties that depend on technology for operative success also received a proportionally higher share of payments from device manufacturers. Similarly, it is not surprising that pharmaceutical companies have financial incentives to promote their medications to dermatologists given the profitability, frequent use, and large number of patients who depend on topical and systemic medications for skin ailments. Because treatment with lasers and other cosmetic instruments is generally not reimbursed by government-sponsored insurances, companies specializing in these areas are not required to report to CMS, and payments from this category may thus be underrepresented in the database for dermatology. There were significant regional differences in the total amount of payments made to dermatologists. This likely relates to the high number and concentration of dermatologists, academic medical centers, and patient populations in the Mid-Atlantic, South Atlantic, and Pacific areas. Regional payment distribution varies by specialty.11,14,15 While the primary advantage of this study is the use of nationwide payment information, it has several limitations. Since the Sunshine Act requires reporting only by companies making products covered by government-sponsored programs, such as Medicare, Medicaid, and Children’s Health Insurance Program, the data represent only a fraction of the total physician-industry financial relationships. Cosmetic devices and lasers, for example, are not included. Furthermore, the database relies on accurate reports from manufacturers. There may be inaccurate attribution of payments into categories, individuals, or affiliated institution by reporting companies on the database. Although physicians have the option of reviewing and challenging the accuracy of the published data, it is unclear how many have done so. Physicians have been known to encounter challenges while registering with the CMS to dispute claims.1,7 These data do not include payments to medical students, residents, nurses, physician assistants, and pharmacists. However, interactions between dermatology residents and pharmaceutical companies are common in the form of sponsored dinners, board-review materials, samples, and conferences.2 The industry has an keen interest to target young physicians in training as they develop their own prescription and disease treatment patterns.30 Finally and most importantly, while the database provides certain valuable insights as outlined herein, it does not offer an opportunity to accomplish the important and difficult task of differentiating nonbeneficial or even harmful relationships from beneficial ones that advance scientific knowledge and improve patient care.31-34 Not all industry payments should be viewed the same way, and the relative dearth of contextual information often makes the interpretation of each payment difficult, especially when considering that dermatologists who did not receive industry payments are in the minority. While we have limited data in dermatology, recent studies35,36 in other fields show that receipt of industry payments and industry-sponsored meals was associated with an increased rate of prescribing several class of brand-name medications. Similar investigations into dermatologic medications would be of interest. Conclusions Seventy-three percent of dermatologists received payments from industry with 63% receiving less than $500. The relationships between dermatologists and industry are varied, complex, and robust. This study helps to delineate the specific nature and extent of industry payments to dermatologists nationwide. We encourage all physicians to review their Open Payments data at https://openpaymentsdata.cms.gov. We hope this study will promote discussions among physicians, regulators, and the public regarding various topics such as national policies, physician behaviors, and potential for conflict of interest. Ultimately, the impact of financial disclosure from industry to dermatologists, and physicians in general, remains to be seen. Further investigations examining the impact on clinician behavior, outcomes of clinical care, and patient perception are merited. Back to top Article Information Corresponding Author: Marie Leger, MD, PhD, Department of Dermatology, Weill Cornell Medical College, 156 William St, 11th Floor, New York, NY 10038 (macleger@gmail.com). Accepted for Publication: June 28, 2016. Published Online: October 5, 2016. doi:10.1001/jamadermatol.2016.3037 Author Contributions: Dr Feng had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: All authors. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Feng, Wu. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Feng, Wu. Study supervision: Leger. Conflict of Interest Disclosures: None reported. References 1. Kirschner NM, Sulmasy LS, Kesselheim AS. Health policy basics: the Physician Payment Sunshine Act and the Open Payments program. Ann Intern Med. 2014;161(7):519-521.PubMedGoogle ScholarCrossref 2. Sams WM, Freedberg IM. The dermatology-industry interface: defining the boundaries. J Am Acad Dermatol. 2000;43(3):550-554.PubMedGoogle ScholarCrossref 3. Hurley MP, Stafford RS, Lane AT. Characterizing the relationship between free drug samples and prescription patterns for acne vulgaris and rosacea. JAMA Dermatol. 2014;150(5):487-493.PubMedGoogle ScholarCrossref 4. Williams HC, Naldi L, Paul C, Vahlquist A, Schroter S, Jobling R. Conflicts of interest in dermatology. Acta Derm Venereol. 2006;86(6):485-497.PubMedGoogle ScholarCrossref 5. Centers for Medicare and Medicaid Services. https://openpaymentsdata.cms.gov. Accessed December 12, 2015. 6. Kesselheim AS, Robertson CT, Siri K, Batra P, Franklin JM. Distributions of industry payments to Massachusetts physicians. N Engl J Med. 2013;368(22):2049-2052.PubMedGoogle ScholarCrossref 7. Agrawal S, Brennan N, Budetti P. The Sunshine Act: effects on physicians. N Engl J Med. 2013;368(22):2054-2057.PubMedGoogle ScholarCrossref 8. Association of American Medical Colleges. Physician Specialty Data Book. 2014. https://members.aamc.org/eweb/upload/Physician%20Specialty%20Databook%202014.pdf. Accessed December 28, 2015. 9. Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician-industry relationships. N Engl J Med. 2007;356(17):1742-1750.PubMedGoogle ScholarCrossref 10. Fleischman W, Ross JS, Melnick ER, Newman DH, Venkatesh AK. Financial ties between emergency physicians and industry: insights from Open Payments data. Ann Emerg Med. 2016;(Mar):10.PubMedGoogle Scholar 11. Rathi VK, Samuel AM, Mehra S. Industry ties in otolaryngology: initial insights from the Physician Payment Sunshine Act. Otolaryngol Head Neck Surg. 2015;152(6):993-999.PubMedGoogle ScholarCrossref 12. Samuel AM, Webb ML, Lukasiewicz AM, et al. Orthopaedic surgeons receive the most industry payments to physicians but large disparities are seen in Sunshine Act Data. Clin Orthop Relat Res. 2015;473(10):3297-3306.PubMedGoogle ScholarCrossref 13. Tierney NM, Saenz C, McHale M, Ward K, Plaxe S. Industry payments to obstetrician-gynecologists: an analysis of 2014 Open Payments data. Obstet Gynecol. 2016;127(2):376-382.PubMedGoogle ScholarCrossref 14. Chang JS. The Physician Payments Sunshine Act: data evaluation regarding payments to ophthalmologists. Ophthalmology. 2015;122(4):656-661.PubMedGoogle ScholarCrossref 15. Cvetanovich GL, Chalmers PN, Bach BR Jr. Industry financial relationships in orthopaedic surgery: analysis of the Sunshine Act Open Payments database and comparison with other surgical subspecialties. J Bone Joint Surg Am. 2015;97(15):1288-1295.PubMedGoogle ScholarCrossref 16. Licurse A, Barber E, Joffe S, Gross C. The impact of disclosing financial ties in research and clinical care: a systematic review. Arch Intern Med. 2010;170(8):675-682.PubMedGoogle ScholarCrossref 17. Perry JE, Cox D, Cox AD. Trust and transparency: patient perceptions of physicians’ financial relationships with pharmaceutical companies. J Law Med Ethics. 2014;42(4):475-491.PubMedGoogle ScholarCrossref 18. Norris SL, Holmer HK, Ogden LA, Burda BU, Fu R. Characteristics of physicians receiving large payments from pharmaceutical companies and the accuracy of their disclosures in publications: an observational study. BMC Med Ethics. 2012;13:24.PubMedGoogle ScholarCrossref 19. Khan MH, Lee JY, Rihn JA, et al. The surgeon as a consultant for medical device manufacturers: what do our patients think? Spine (Phila Pa 1976). 2007;32(23):2616-2618.PubMedGoogle ScholarCrossref 20. Hampson LA, Agrawal M, Joffe S, Gross CP, Verter J, Emanuel EJ. Patients’ views on financial conflicts of interest in cancer research trials. N Engl J Med. 2006;355(22):2330-2337.PubMedGoogle ScholarCrossref 21. Resneck JS Jr, Tierney EP, Kimball AB. Challenges facing academic dermatology: survey data on the faculty workforce. J Am Acad Dermatol. 2006;54(2):211-216.PubMedGoogle ScholarCrossref 22. Rose SL, Sanghani RM, Schmidt C, Karafa MT, Kodish E, Chisolm GM. Gender differences in physicians’ financial ties to industry: a study of National Disclosure Data. PLoS One. 2015;10(6):e0129197.PubMedGoogle ScholarCrossref 23. Ornstein C. Men dominate list of doctors receiving largest payments from drug companies. New York Times. 2014. http://www.nytimes.com/2014/10/09/upshot/men-dominate-list-of-doctors-receiving-largest-payments-from-drug-companies.html. Accessed December 19, 2015. 24. Ornstein C. Dollars for dudes: almost no women among medical industry’s top-paid speakers, consultants. 2014. https://www.propublica.org/article/dollars-for-dudes-almost-no-women-among-medical-industrys-top-paid-speakers. Accessed December 19, 2015. 25. Cheng MY, Sukhov A, Sultani H, Kim K, Maverakis E. Trends in National Institutes of Health funding of principal investigators in dermatology research by academic degree and sex. JAMA Dermatol. 2016;152(8):883-888.PubMedGoogle ScholarCrossref 26. Karimkhani C, Boyers LN, Margolis DJ, et al. Comparing cutaneous research funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases with 2010 Global Burden of Disease results. PLoS One. 2014;9(7):e102122.PubMedGoogle ScholarCrossref 27. Stuetz A. Partnership among dermatology, the Society for Investigative Dermatology, and industry: suggestions for change. J Invest Dermatol. 2007;127(11):2487-2489.PubMedGoogle ScholarCrossref 28. Prendergast MM, Abramovits W, Boguniewicz M, Lebwohl M, Tokar M, Tong KB. Look beyond financial conflicts of interest in evaluating industry-academia collaborations in burden-of-illness and outcomes research studies in dermatology. J Invest Dermatol. 2004;123(3):452-454.PubMedGoogle ScholarCrossref 29. Uitto J, Rodeck U. Integration of investigative dermatology into the global biomedical research enterprise: past, present, and future. J Invest Dermatol. 2012;132(3, pt 2):1029-1032.PubMedGoogle ScholarCrossref 30. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? a randomized trial. Am J Med. 2005;118(8):881-884.PubMedGoogle ScholarCrossref 31. Frishman WH. The patient-physician-industry-government partnership: a societal good. Am J Med. 2009;122(10):886-887.PubMedGoogle ScholarCrossref 32. Frishman WH. Reflections on the Physicians Payment Sunshine Act. Am J Med. 2015;(Aug):17.PubMedGoogle Scholar 33. Morain SR, Flexner C, Kass NE, Sugarman J. Forecast for the Physician Payment Sunshine Act: partly to mostly cloudy? Ann Intern Med. 2014;161(12):915-916.PubMedGoogle ScholarCrossref 34. Santhakumar S, Adashi EY. The Physician Payment Sunshine Act: testing the value of transparency. JAMA. 2015;313(1):23-24.PubMedGoogle ScholarCrossref 35. Yeh JS, Franklin JM, Avorn J, Landon J, Kesselheim AS. Association of industry payments to physicians with the prescribing of brand-name statins in Massachusetts. JAMA Intern Med. 2016;176(6):763-768.PubMedGoogle ScholarCrossref 36. DeJong C, Aguilar T, Tseng CW, Lin GA, Boscardin WJ, Dudley RA. Pharmaceutical industry-sponsored meals and physician prescribing patterns for Medicare beneficiaries. JAMA Intern Med. 2016;176(8):1114-1122.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Dermatology American Medical Association

Exploring the Industry-Dermatologist Financial Relationship: Insight From the Open Payment Data

Feng, Hao; Wu, Paula; Leger, Marie
JAMA Dermatology , Volume 152 (12) – Dec 1, 2016
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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6068
eISSN
2168-6084
DOI
10.1001/jamadermatol.2016.3037
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27706478
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Abstract

Key Points Question What are the characteristics of industry payments to dermatologists? Findings In this retrospective study, 8333 dermatologists received 208 613 payments totaling more than $34 million, with the median total payment per dermatologist of $298. The payment distribution is highly skewed, with a minority of dermatologists receiving most of the total payments from pharmaceutical companies. Meaning There are potential conflicts of interest among dermatologists. Abstract Importance Significant ties exist between clinicians and industry. Little is known about the characteristics of industry payments to dermatologists. Objective To analyze the nature and extent of industry payments to dermatologists. Design, Setting, and Participants This was a retrospective review using the publicly available Centers for Medicare and Medicaid Services (CMS) Sunshine Act Open Payment database. Data were downloaded from the publically available CMS website under General Payment and Research Payment data sets. All payments to dermatologists from companies making products reimbursed by a government-run health program were reviewed. Main Outcomes and Measures Mean, median, and range of payments made, including quantity and total sum of payments, per clinician. Total payments and number of transactions per category of payment, geographic region, and payment source were also assessed. Results A total of 8333 dermatologists received 208 613 payments totaling more than $34 million. The median total payment per dermatologist was $298 with an interquartile range of $99 to $844. The top 10% of dermatologists (n = 833) received more than $31.2 million, 90% of the total payments. The top 1% each (n = 83) received at least $93 622 and accounted for 44% of total payments. While 83% of payment entries were for food and beverage, they accounted for only 13% of total amount of payments. Speaker fees (31.7%), consulting fees (21.6%), and research payments (16.5%) comprised 69.8% of total payment amount. The top 15 companies were all pharmaceutical manufacturers and paid dermatologists $28.7 million, representing 81% of total disbursement. Conclusions and Relevance Dermatologists received substantial payments from the pharmaceutical industry. The nature and amount of payments varied widely. The impact of the data on patient care, physicians practice patterns, and patient perception of physicians is unclear. Introduction In today’s complex economic and health care environment, the interactions between physicians, hospitals, and health care manufacturing companies are under increased scrutiny. Under the Patient Protection and Affordable Care Act, the Physician Payments Sunshine Act requires manufacturers and group-purchasing organizations that make products reimbursed by a government-run health program to report on all payments and other transfers of value to physicians in categories, such as consulting, speaking fees, food, travel, and research.1 Specifically, amounts greater than $10 or aggregates of payment greater than $100 during a calendar year are mandatory reports.1 Industry-physician interaction is common in all medical specialties, and dermatology is no exception.2-4 While the types of interaction between dermatologists and industry have been described,2,4 there is very little literature on the amount and geographic distribution of financial distributions by industry to dermatologists. To better understand the qualitative and quantitative characteristics of physician payments from industry sources, we probed the Centers for Medicare and Medicaid Services (CMS) Sunshine Act Open Payments database, the largest public nationwide database detailing financial relationships of industry and physicians and the first of its kind. The purpose of this study was to characterize the extent and nature of industry payments to dermatologists for 2014, the first year that a full 12 months of financial data have been released. Specifically, we examined the number, amount, and type of payments dermatologists received, the geographic distribution of industry payments, and the manufacturers that are contributing the highest total payments. Methods In this retrospective database analysis, we used publicly available data from the CMS Sunshine Act Open Payments,5 which contains records of payments to physicians by applicable medical manufacturers or group-purchasing organizations operating in the United States. We used the general payment and research payment data sets from 2014, which contains payments made between January 1, 2014, and December 31, 2014. The data within do not contain physician ownership and/or investment interests, which can be found in a separate database on the Open Payments website, because these payments may be reported without adequate context for interpretation. Payments without an associated clinician were excluded from the study. After filtering the payment data by the physician’s primary specialty and excluding payment data made to physicians who were not classified as practicing dermatology in the Open Payment physician profile data file, the data were downloaded. To ensure uniformity, one individual (H. F.) reviewed and collected the information from the database. Data management and analysis were performed with Microsoft Excel software (Microsoft Excel for Mac 2011, version 14.2.3; Microsoft Corp). Information on sex and academic affiliation of payment recipients was obtained from internet searches. Descriptive statistics such as mean, median, interquartile range (IQR), and percentages were calculated. We chose to use primarily median and IQR instead of mean and standard deviation to describe data because of skewed distribution. Geographic analysis of payment data was conducted based on divisions created by the US Census Bureau: New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), Mid-Atlantic (New Jersey, New York, and Pennsylvania), East North Central (Illinois, Indiana, Michigan, Ohio, and Wisconsin), West North Central (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota), South Atlantic (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington, DC, and West Virginia), East South Central (Alabama, Kentucky, Mississippi, and Tennessee), West South Central (Arkansas, Louisiana, Oklahoma, and Texas), Mountain (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming), Pacific (Alaska, California, Hawaii, Oregon, and Washington). Puerto Rico, US military bases abroad, and US Virgin Islands are classified under Other. Divisions were used instead of regions (Northeast, South, Midwest, and West) to better provide more detailed insight of geographic payment differences. Geographic data were based on the state listed in the physician profile data file. The New York University School of Medicine's institutional review board reviewed this study and granted it exempt status. Results A total of 208 613 payments totaling $34 810 661.57 were made to 8333 dermatologists in 2014. This represented 0.54% of the total $6.49 billion disbursement and 1.8% of the 11.41 million records of all industry payment to clinicians. For dermatology, the median amount per payment was $15.93 (IQR, $10.89-$25.94) with the minimum and maximum payment per entry of $0.00 and $249 641.60, respectively. The mean (SD) amount per payment was $171 ($1400). Seventy-nine percent of payments were less than $50 and 94.6% of payments were less than $500. The distribution of payments is shown in Table 1. The median total industry payment to each dermatologist was $297.59 (IQR, $99.10-$843.58) (mean [SD], $4177.45 [$22 527.43]). The median (mean) number of payment per dermatologist was 10 (25). In total, 25%, 63%, 78%, and 91% of dermatologists received less than $100, $500, $1000, and $5000, respectively. The top 10% of dermatologists receiving payments (n = 833) each received at least $3940 and accounted for over $31.2 million in total payments, or 90% of total payments to the specialty. Of these recipients, 527 (63.3%) were men, 306 (36.7%) were women, 138 (16.6%) were affiliated with academic centers, and 695 (83.4%) were in private practice. The top 1% (n = 83) each received at least $93 622 and accounted for 44% of total payments. Of these 83 dermatologists, 17 (20.5%) were affiliated with academic centers, and 20 (24.1%) were women. The 10 individual dermatologists who received the highest total payments collectively accounted for $4.09 million, or 12% of all payments. One (10%) was affiliated with an academic center, and 3 (30%) were women. The distribution of payments per dermatologist is shown in Table 1. Physicians have the option of reviewing and challenging the accuracy of the published data. In 2014, 7 physicians disputed 36 payments (19.5%) totaling $61 278.47 (47.1%) out of a total of 185 payments totaling $130 072.05. Three of the 7 physicians disputed all of the payments made under their names, totaling $58 615.78. Of the disputed payments, 11 entries were for food and beverages totaling $468.14, and 25 entries were for consulting fees totaling $60 810.33. The distribution of payment categories is shown in Table 2. Of all categories, services other than consulting received the greatest share of all payments. These services included serving as faculty or as a speaker at a venue other than a continuing education program (29.9%). Consulting services received 21.6% of all payments, followed by payments for research activities (16.5%), and food and beverages (13.3%). The greatest number of payments made was for food and beverages at 172 690 disbursements. The 3 categories with the largest single payment amount were research ($249 642), consulting fees ($235 674), and royalty or license fees ($83 903). The distribution of payment categories by physician affiliations with academic center and private practice for the top 10% (n = 833) dermatologists receiving industry payments is shown in Table 3. In total, 279 companies with distinct payment identification numbers made payments to dermatologists. The top 15, 10, and 5 companies accounted for $28.7 million (82.3%), $25.1 million (72.0%), and $18.6 million (53.5%) of the total payment, respectively. The top 15 manufacturers by total payment amount were all pharmaceutical companies. Their total payment amounts and payment type distributions are shown in Figure 1 and Figure 2, respectively. A physician may direct a company to pay another entity instead of the physician. When this occurs, many payments attributed to the third-party entity are for biologic medications and small molecules. The highest number and sum of payments went to dermatologists in the Mid-Atlantic, South Atlantic, and Pacific areas. The mean payment received per dermatologist was highest in the Mid-Atlantic ($5277) and East South Central ($5106). Dermatologists in the West North Central division received the lowest total payment per individual. Discussion In recent years, legislative measures at the state and national level have been implemented to make relationships between physicians and industry more transparent.1,6,7 In this study, we demonstrated that interactions between industry and dermatologists are widely prevalent and highly variable, with a small fraction of dermatologists receiving a large share of all payments. With roughly 11 363 active dermatologists in the United States8 and 8333 dermatologists (73.3%) receiving payment in this study, those without industry interaction are in the minority. The high percentage of physicians receiving industry payment is consistent with a national survey across all specialties.9 There are variations across specialties, but the percentage of physicians receiving payments in dermatology is similar to those of other procedural specialties.10-13 While dermatologist-industry interaction resulted in $34.8 million worth of transactions, payments ranged widely across recipients. Sixty-three percent of dermatologists received less than $500 in compensation, and a small fraction received a disproportionately large percentage of total payments to the specialty. This positively skewed distribution of industry payments has also been observed in other specialties.10-15 Most individual payments were relatively small, with 79% of payments less than $50 and median amount of $15.93, reflecting payments primarily for food and beverages. This was also consistent with data from other specialties.10-14 The large standard deviation of payments reflects wide variation in payment amounts. Although food and beverage payments comprised 83% of the number of payments made, they made up only 13% of the total payment amount to the specialty as a whole. This finding is consistent with other specialties.9,10,13-15 Interestingly, patients may view payments of food more negatively.14,16,17 Studies show that patients often interpret food and beverage as a personal gift to the physician without direct benefit to patients. Themes of dishonesty and selfishness seem to be at the center of patient concerns.16,17 Compensation for speaking arrangements and consulting fees made up over half of the total payment amount to the specialty, compared with a much more modest 16.5% for research. Consulting and speaking arrangements brought in the highest median payment per category, at $1360 and $1500 each, respectively. These amounts do not take into account nonfinancial gains accrued from these activities, such as publicity or the perception of becoming a more notable figure in the field. For companies, having key knowledge holders and thought leaders being advocates and spokespersons may help shift clinical practices.9,18 In fact, studies have shown that patients see the physician with this association positively, viewing him or her at the forefront of the field and being an influential figure.17,19,20 The exact nature of the consulting fees and agreements are not described in the database, preventing a full understanding of the relationship. The amount and percentage of total payouts for royalties and patent licenses to dermatologists were less compared with payouts for ophthalmologists and orthopedic surgeons.12,14 The exact nature of research compensation cannot be discerned owing to lack of reporting uniformity across companies, but the available data suggest that most research payments were for the study of safety, efficacy, and pharmacokinetics of various medications, including small molecules, biological medications, topical acne medications, and injectable neuromodulators. It is unclear what expenses the research payments actually covered, such as stipend, supplies, equipment, clinical study services, publication support, travel expenses, and meeting costs. Both dermatologists affiliated with academic centers and those with private practices received industry payments. However, among the top 10% of all payment recipients (n = 833), only 16.6% of these were academic dermatologists. Given that approximately 6% of the nation’s dermatologists work in academic settings,21 their disproportionately higher representations among top industry payment recipients may be related to their position as thought leaders. This idea is supported by the fact that 45.3% of payments made toward dermatologists at academic centers were in the form of consulting fees, compared with 18.2% for those in private practice. However, among the same top recipients, those affiliated with private practices received a higher percentage of their total payments for research and non–continuing medical education program speaking fees than their counterparts at academic centers. Sex differences in the amount of money received from industry have been reported.22 In dermatology, men outnumbered women among top industry payment recipients, although apparently less than in other fields.23,24 Recent research examined sex disparities in academic dermatology, specifically looking at principal investigator funding from the National Institutes of Health.25 More granular research on sex and industry connections would be useful. It is important to note that there is likely variability in the classification of payment activities among companies, as evidenced by the uneven payment distribution across categories by different companies. For example, consulting fees and speaker fees were prominent for some companies, whereas honoraria were prominent for others. The CMS defines consulting fees as payments made “for advice and expertise on a particular medical product or treatment, typically provided under a written agreement and in response to a particular business need,” speaking fees as those made “for speaking, training, and education engagements,” and honoraria as “similar to consulting fees, but generally reserved for a one-time, short duration activity… generally provided for services which custom prohibits a price from being set.”5 Dermatologists received $5.7 million in total payments from industry for research, which is significantly less than the $73 million from the National Institute of Arthritis and Musculoskeletal and Skin Diseases for skin-related investigations.26 The results of investigative endeavors from physician-industry interactions can be beneficial or misleading.4,27,28 Given the trends in the past few decades of increased research funding by the pharmaceutical companies, decreased funding by government, and more aggressive marketing competition among pharmaceutical companies for physician attention,4,29 dermatologists of the present and future will likely continue to interact with industry to advance the field and address skin diseases. More than ever, investigators will need to adhere to rigorous standards of integrity and transparency to manage potential conflicts of interest in today’s research environment. The Open Payment database can be used to help verify that physician investigators are disclosing their sources of financial support and potential conflicts of interest. The 15 highest-paying manufacturers and most of the companies making payments to dermatologists in the Open Payment data set belong to the pharmaceutical industry. The predominance of pharmaceutical payments in dermatology contrasts sharply with other specialties, such as otolaryngology,11 orthopedic surgery,12,15 and ophthalmology,14 in which surgical and diagnostic manufacturers play a larger role. It should not come as any surprise that surgical subspecialties that depend on technology for operative success also received a proportionally higher share of payments from device manufacturers. Similarly, it is not surprising that pharmaceutical companies have financial incentives to promote their medications to dermatologists given the profitability, frequent use, and large number of patients who depend on topical and systemic medications for skin ailments. Because treatment with lasers and other cosmetic instruments is generally not reimbursed by government-sponsored insurances, companies specializing in these areas are not required to report to CMS, and payments from this category may thus be underrepresented in the database for dermatology. There were significant regional differences in the total amount of payments made to dermatologists. This likely relates to the high number and concentration of dermatologists, academic medical centers, and patient populations in the Mid-Atlantic, South Atlantic, and Pacific areas. Regional payment distribution varies by specialty.11,14,15 While the primary advantage of this study is the use of nationwide payment information, it has several limitations. Since the Sunshine Act requires reporting only by companies making products covered by government-sponsored programs, such as Medicare, Medicaid, and Children’s Health Insurance Program, the data represent only a fraction of the total physician-industry financial relationships. Cosmetic devices and lasers, for example, are not included. Furthermore, the database relies on accurate reports from manufacturers. There may be inaccurate attribution of payments into categories, individuals, or affiliated institution by reporting companies on the database. Although physicians have the option of reviewing and challenging the accuracy of the published data, it is unclear how many have done so. Physicians have been known to encounter challenges while registering with the CMS to dispute claims.1,7 These data do not include payments to medical students, residents, nurses, physician assistants, and pharmacists. However, interactions between dermatology residents and pharmaceutical companies are common in the form of sponsored dinners, board-review materials, samples, and conferences.2 The industry has an keen interest to target young physicians in training as they develop their own prescription and disease treatment patterns.30 Finally and most importantly, while the database provides certain valuable insights as outlined herein, it does not offer an opportunity to accomplish the important and difficult task of differentiating nonbeneficial or even harmful relationships from beneficial ones that advance scientific knowledge and improve patient care.31-34 Not all industry payments should be viewed the same way, and the relative dearth of contextual information often makes the interpretation of each payment difficult, especially when considering that dermatologists who did not receive industry payments are in the minority. While we have limited data in dermatology, recent studies35,36 in other fields show that receipt of industry payments and industry-sponsored meals was associated with an increased rate of prescribing several class of brand-name medications. Similar investigations into dermatologic medications would be of interest. Conclusions Seventy-three percent of dermatologists received payments from industry with 63% receiving less than $500. The relationships between dermatologists and industry are varied, complex, and robust. This study helps to delineate the specific nature and extent of industry payments to dermatologists nationwide. We encourage all physicians to review their Open Payments data at https://openpaymentsdata.cms.gov. We hope this study will promote discussions among physicians, regulators, and the public regarding various topics such as national policies, physician behaviors, and potential for conflict of interest. Ultimately, the impact of financial disclosure from industry to dermatologists, and physicians in general, remains to be seen. Further investigations examining the impact on clinician behavior, outcomes of clinical care, and patient perception are merited. Back to top Article Information Corresponding Author: Marie Leger, MD, PhD, Department of Dermatology, Weill Cornell Medical College, 156 William St, 11th Floor, New York, NY 10038 (macleger@gmail.com). Accepted for Publication: June 28, 2016. Published Online: October 5, 2016. doi:10.1001/jamadermatol.2016.3037 Author Contributions: Dr Feng had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: All authors. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Feng, Wu. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Feng, Wu. Study supervision: Leger. Conflict of Interest Disclosures: None reported. References 1. Kirschner NM, Sulmasy LS, Kesselheim AS. Health policy basics: the Physician Payment Sunshine Act and the Open Payments program. Ann Intern Med. 2014;161(7):519-521.PubMedGoogle ScholarCrossref 2. Sams WM, Freedberg IM. The dermatology-industry interface: defining the boundaries. J Am Acad Dermatol. 2000;43(3):550-554.PubMedGoogle ScholarCrossref 3. Hurley MP, Stafford RS, Lane AT. Characterizing the relationship between free drug samples and prescription patterns for acne vulgaris and rosacea. JAMA Dermatol. 2014;150(5):487-493.PubMedGoogle ScholarCrossref 4. Williams HC, Naldi L, Paul C, Vahlquist A, Schroter S, Jobling R. Conflicts of interest in dermatology. Acta Derm Venereol. 2006;86(6):485-497.PubMedGoogle ScholarCrossref 5. Centers for Medicare and Medicaid Services. https://openpaymentsdata.cms.gov. Accessed December 12, 2015. 6. Kesselheim AS, Robertson CT, Siri K, Batra P, Franklin JM. 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Journal

JAMA Dermatology – American Medical Association

Published: Dec 1, 2016

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