About two thirds of American adults in our national survey saw a physician in 2013–2014 who had accepted payments from industry within the past year, indicating that the reach of industry payments into patient care is extensive.
To our knowledge, this is the first nationally representative study examining the prevalence of industry payments among the general patient population. Prior studies using payment data have calculated the percentage of physicians, overall and by specialty, who received industry payments.17
22 Our physician-based estimates of industry contact, based on the percentage of physicians receiving industry payments, were similar to those in these earlier studies, but we found that these estimates understated the prevalence of patient contact with industry. Although 4 of every 10 physicians had received a payment during the 12 months under study, almost 7 of 10 respondents were seen over the same period by a physician who had received a payment.
The physicians whom patients visited also tended to have received unusually high payments. The median payment received by these physicians was 1.2–2.7 times greater, depending on the specialty, than the median payment among all physicians in Open Payments in the same specialty.
These findings suggest that although physicians who accept industry payments are in the minority, they are caring for a very substantial portion of America’s adult patient population. These estimates are, moreover, likely to be an underestimate of Americans’ exposure to doctors with industry ties. Although we did not examine the professional or social status of recipient physicians, drug and device companies tend to pursue relationships with “key opinion leaders” in medicine because of these leaders’ potential to influence the clinical practice of others, even those who themselves do not accept industry payments.26 Our analysis also did not include research payments, an additional route of industry contact for physicians.
Despite the broad reach of industry payments and substantial previous literature documenting patients’ interest in and concern about their physicians’ conflicts of interest,8 few respondents knew about the contact that their physicians had with industry. Only 12% had heard about industry payments, and only 5% knew whether their own doctor had received payments. We anticipate that these percentages will increase as Open Payments becomes more widely known and accessed.
We found that the proportion of respondents who saw physicians who received industry payments was about twice as high in states that had not made payment data public (66%) than in the few states that had (34%). Our cross-sectional data do not allow us to pinpoint the causes of this difference—whether payment disclosure affected patients’ choice of physicians, leading them to choose physicians without industry ties, or perhaps acted as a deterrent for some doctors, leading them to shun industry ties—but the difference in the prevalence of industry payments across these two types of states is striking and will be important to monitor with the expansion of payment disclosure at a national level.
Our study has several limitations. First, we focused on general payments and did not include research payments, primarily because public concern about the effects of industry ties on patient care appears to be lower for research grants than for personal income.8 Because of this research payment exclusion, our estimates should be considered a lower bound for consumer exposure to physicians who accept industry payments. Second, we used a conservative and very high threshold (see online Appendix S1 for details) in determining whether the physicians that respondents named were indeed a match to the physicians reported in Open Payments. Because of this high threshold, some physicians who may have received payments were classified as not having received them, which may have led us to underestimate the prevalence of payments. Third, our estimates were based on our verified sample, the subgroup of respondents who named physicians whose identity we could verify based on the physician’s name and location. Individuals in our verified sample were similar along many dimensions to those whose named physicians could not be verified at our match threshold, although our verified sample does appear to be older, sicker, wealthier, and more likely to have health insurance (see online Appendix S1, Table A1, for a detailed comparison of these two groups). Finally, although our survey response rate was good relative to other consumer and web surveys, there may be nonresponse bias. In our nonresponse analysis (online Appendix S1, Table A2), we found that respondents were more likely to have health insurance than nonrespondents. Most other characteristics, including education and health status, were similar.
These findings provide a new, population-based view of the reach of the industry. Our estimates point to a far greater industry reach at the population level than physician-based estimates of industry contact have suggested. They also illuminate the prevalence of industry payments and awareness of industry-physician ties at the moment Open Payments became the national standard, providing a useful baseline by which to evaluate the law’s effects.
Our results raise important questions about what policymakers can do to improve patients’ awareness of industry payment information. Perhaps CMS, which also collects other information on providers, could establish a one-stop shop website where patients could view industry payments along with other information about their providers. It could require physicians to notify patients about this website, as they do with privacy provisions of the Health Insurance Portability and Accountability Act. Payers, who also benefit from their patients being more knowledgeable about their doctors, could include industry payment information in the descriptive information they provide online about physicians in their network. Given patients’ stated interest in this kind of information,8 it seems important to preserve transparency initiatives like Open Payments even if other aspects of the Affordable Care Act are repealed.
The extent to which and the way in which patients and providers use this information should also be investigated more thoroughly. Some patients will want to initiate conversations with their doctors, whereas others may view industry ties as unimportant relative to other considerations. In other areas of health care quality, such as cardiac surgery outcomes reporting, transparency initiatives appear to have had little effect on consumer decisions, yet have had interesting effects on providers.27
28 How Open Payments implementation will unfold remains to be seen, but it will—and should—be closely watched.