Trends in Industry Payments to Physicians in the United States From 2014 to 2018

Open Payments, a federal transparency program reporting industry-physician financial relationships since 2013, was established out of concern for undue industry influence on health care decision-making and costs.¹ The effect of Open Payments is not fully understood. We sought to determine trends in physician-level payments to evaluate whether the implementation of Open Payments has been associated with a decrease in the prevalence or value of physicians’ interactions with industry.

We performed a retrospective, population-based cohort study of US allopathic and osteopathic physicians practicing in 2014 per the National Plan and Provider Enumeration System, excluding other clinicians (eg, nurses, dentists) and physicians activating or deactivating their records between 2014 and 2018. Specialties were grouped by Medicare Data on Provider Practice and Specialty taxonomy classifications: primary care, medical specialty, surgical specialty, obstetrics/gynecology, hospital-based specialty, and psychiatry. National Plan and Provider Enumeration System and Open Payments identifiers were linked by text string using cross-referenced files from the beginning and end of the period.

Open Payments data on general (nonresearch) industry payments between January 2014 and December 2018 (excluding 2013 because of partial-year reporting²) were matched to the 2014 physician cohort. Payments were aggregated per physician annually, then categorized by cumulative aggregate value (≤$10 000; $10 001-$25 000; $25 001-$50 000; $50 001-$100 000; $100 001-$500 000; and >$500 000). Values were adjusted to the 2018 Consumer Price Index.³

Outcomes included proportion of physicians receiving payments, and total and median/mean annual per-physician payment values. Total-value trends were tested using linear regression. Trends in proportions of physicians receiving payments and annual per-physician payment values were tested using logistic and linear generalized estimating equations, respectively, controlling for physician-level correlation, with year as the independent variable. Analyses were stratified by specialty group and aggregate value of payment category. Two-sided P values (α < .05) were applied to tests using SPSS version 26 (IBM Inc). This study was exempted from review by the Mount Sinai institutional review board.

Of the 2014 cohort of 878 308 physicians, 458 269 (52.2%) received at least 1 payment in 2014, declining to 394 991 (45.0%) in 2018 (Table 1), representing a relative overall decrease of −13.8% and relative annual decrease of −3.5% (95% CI, −3.5% to −3.4%). From 2014 to 2018, these physicians received 49.8 million payments totaling $9.3 billion. The total value was highest in medical and surgical specialties ($3.4 and $3.9 billion in aggregate, respectively). The annual proportion of physicians receiving payments decreased over time across all specialties. However, total and annual payment values remained stable across specialties except for primary care, for which total value decreased.

In 2014-2018, 90.1% of physicians who accepted payments received less than $10 000 (Table 2). Among physicians receiving lesser aggregate payments, annual values decreased over time (yearly change: for ≤$10 000, −$11 [95% CI, −$12 to −$11]; for $10 001-$25 000, −$100 [95% CI, −$117 to −$84]; and for $25 001-$50 000, −$135 [95% CI, −$199 to −$71]; P < .001). Those receiving more than $50 000 accounted for 3.4% of physicians receiving payments but 82% of the total value. For these physicians, annual payment values increased or remained stable over time (yearly change: for $50 001-$100 000, $42 [95% CI, −$96 to $179]; P = .55; for $100 001-$500 000, $866 [95% CI, $567 to $1165]; P < .001; and for >$500 000, −$8487 [95% CI, −$21 316 to $4342]; P = .20).

Since the inception of Open Payments in 2013, the proportion of physicians receiving industry payments decreased across all specialties, while the total value of payments remained stable except for a decrease in primary care. Similar to other studies, surgical and medical specialties received the highest value of payments,⁴ and value was concentrated among a minority of physicians.⁵

Annual payment values decreased for physicians receiving lower-value total payments (≤$50 000), potentially due to transparency,¹ organizational restrictions on industry interactions,¹ or decreased direct-to-physician marketing.⁶ Physicians receiving higher-value total payments (>$50 000) continued to receive similar or greater amounts, perhaps reflecting evolving industry strategy that concentrates payments, for which greater return on investment is anticipated.

Study limitations include unmeasured confounding such as physician or market factors. Prevalence of payments are underestimated, because Open Payments only reports certain payment types and the analysis is limited to general payments. Prevalence and value of payments may be overestimated or underestimated because of misattribution of data to a physician or specialty. Additionally, these data are generalizable only to allopathic and osteopathic physicians.

Corresponding Author: Deborah C. Marshall, MD, MAS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029 (deborah.marshall@mountsinai.org).

Accepted for Publication: June 8, 2020.

Author Contributions: Dr Marshall 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: Marshall, Tarras, Rosenzweig, Chimonas.

Acquisition, analysis, or interpretation of data: Marshall, Tarras, Korenstein, Chimonas.

Drafting of the manuscript: Marshall, Tarras.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Marshall.

Obtained funding: Marshall.

Administrative, technical, or material support: Rosenzweig.

Supervision: Marshall, Rosenzweig, Chimonas.

Conflict of Interest Disclosures: Dr Korenstein’s spouse serves on the scientific advisory board of Vedanta Biosciences and provides consulting for Takeda. No other disclosures were reported.

Funding/Support: Dr Marshall’s contribution to this project was supported in part by the National Institutes of Health/National Cancer Institute (grant T32 CA225617). Dr Korenstein’s contribution to this project was supported in part by a Cancer Center Support Grant to Memorial Sloan Kettering Cancer Center (grant P30 CA008748) from the National Cancer Institute.

Role of the Funder/Sponsor: The National Cancer Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: The contents of this publication are the sole responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.