The American pharmaceutical and medical device industry paid physicians $12.1bn over nearly a decade, with orthopaedic surgeons being the highest earners, followed by neurologists, a review of the US federal Open Payments database has found.
The study, published online in JAMA, showed that almost two-thirds of eligible physicians – 826 313 doctors – received a payment from a pharmaceutical or device manufacturer from 2013 to 2022. Overall, the median payment was $48 per physician.
Most of the products were top-end quality.
Orthopaedic surgeons received the most in aggregate, $1.3bn, followed by neurologists and psychiatrists at $1.2bn and cardiologists at $1.29bn, reports Medscape Medical News.
Geriatric and nuclear medicine specialists and trauma and paediatric surgeons received the least amount of money in aggregate, the mean amount paid to a paediatric surgeon in the top 0.1% was just $338 183 over the nine-year study period.
Excluding 2013 (the database was established in August that year), the total value of payments was highest in 2019 at $1.6bn, up from $1.34bn in 2014. It was lowest in 2020, the peak year of the Covid-19 pandemic, but only dipped to $864bn that year and rebounded to $1.28bn in 2022, wrote the authors.
The Open Payments database, administered by the Centres for Medicare & Medicaid Services, requires drug and device makers and group purchasing organisations to report payments made to physicians, including for consulting services, speaking fees, food and beverages, travel and lodging, education, gifts, grants and honoraria.
The database was created to shed light on these payments, which have been linked in multiple studies to more prescribing of a particular drug or more use of a particular device.
The JAMA review appeared to show that with the exception of the pandemic year, the relationships have more or less stayed the same since Open Payments began.
“There’s been no sea change, no massive shift in how these interactions are happening,” said Deborah Marshall, MD, an assistant professor in the Department of Radiation Oncology at the Icahn School of Medicine at Mount Sinai in New York City, who has studied industry payments.
“There’s no suggestion that anything is really changing other than that’s there is transparency,” said Robert Steinbrook, MD, director of the Health Research Group at Public Citizen.
Still, Steinbrook told Medscape, “it’s better to know this than to not know this”.
The unchanging nature of industry-physician relationships suggests that “to reduce the volume and magnitude of payments, more would need to be done”, he added.
Ban gifts
“Really, this should be banned. Doctors should not be allowed to get gifts from pharmaceutical companies,” said Adriane Fugh-Berman, MD, professor of pharmacology and physiology at Georgetown University, and director of PharmedOut, a project that advances evidence-based prescribing and educates healthcare professionals about pharmaceutical marketing practices.
“The interactions wouldn’t be happening unless there was a purpose for them,” said Marshall. The relationships are “built with intention”.
Top earners
Payments to the median physician over the study period ranged from $0 to $2 339, but the mean payment to top earners – those in the top 0.1% – ranged from $194 933 for hospitalists to $4.8m for orthopaedic specialists.
While the median payment was “just” $48 per physician, small dollar amounts should not be discounted – even if it's just a $25-catered lunch – said Aaron Mitchell, MD, a medical oncologist and assistant attending physician at Memorial Sloan Kettering Cancer Centre who has studied industry-physician relationships.
“The influence is not just in the dollar value,” Mitchell said. “It’s about the time listening to and the time in personal contact with industry representatives that these dollars are a marker for.”
Marshall agreed that “there’s no such thing as a free lunch”.
“It’s pretty well established that lower-value payments do have influence, which is why academic institutions have established policies limiting gifts and meals and other payments from industry, she said.
The top 25 drugs and devices related to industry payments tended to be high-cost brand-name products.
Heading the drug list was Janssen’s Xarelto, an anticoagulant first approved in 2011 that costs about $600 a month, according to GoodRx. The drug has had annual sales of $4bn to $6bn.
Xarelto was followed by Eliquis, another anticoagulant; Humira, used for a variety of autoimmune conditions, including plaque psoriasis, rheumatoid arthritis, Crohn’s disease, and ulcerative colitis; Invokana, Jardiance, and Farxiga, all for type 2 diabetes.
The top medical devices included the Da Vinci Surgical System, Mako SmartRobotics, CoreValve Evolut, Natrelle Implants, and Impella, a heart pump that received a US Food and Drug Administration (FDA) warning of being associated with a heightened risk for death.
Influence may affect care
Multiple studies have shown that payments to physicians tend to lead to increased prescribing and, often, higher costs for Medicare, a health system, or patients.
“I’m sure there are still physicians out there who think they’re getting away with something, that they can take meals, or consulting fees and not be influenced, but there’s overwhelming data showing that it always influences you,” said Fugh-Berman.
One study in 2020 that used the Open Payments database found that physicians increase prescribing of the drugs for which they receive payment in the months just after the payment.
The authors also showed that physicians who are paid may prescribe lower-quality drugs after the payment, “although the magnitude is small and unlikely to be clinically significant”.
Marshall said more studies are needed to determine whether quality of care is being affected when a physician prescribes a drug after an industry payment.
For now, there seems to be little appetite among physicians to sacrifice the payments, said Marshall and others.
Physicians in some specialties see the payments as “an implicit statement about their value”, said Marshall.
In oncology, having received a lot of payments “gets worn more as a badge of honour”, said Mitchell.
The clinicians believe that “by collaborating with industry we are providing scientific expertise to help develop the next generation of technology and cures”, and see the payments “as a mark of their impact”.
See more from MedicalBrief archives:
How drug industry payments to doctors affect patient care
Pharmaceutical perks have significant impact on prescribing rates
Excessive knee jabs linked to industry’s marketing payouts