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Invited Commentary
Health Policy
April 12, 2019

Truth, Trust, and Transparency—The Highly Complex Nature of Patients’ Perceptions of Conflicts of Interest in Medicine

Author Affiliations
  • 1Department of Internal Medicine, Kaiser Permanente Southern California, Los Angeles
  • 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
  • 3Center for Multimodal Imaging and Genetics, University of California, San Diego, La Jolla
JAMA Netw Open. 2019;2(4):e191929. doi:10.1001/jamanetworkopen.2019.1929

Half of all US physicians receive payments from the biomedical industry, totaling $2.4 billion in 2015.1 While this phenomenon reflects critical physician-industry collaboration, we cannot ignore the conflicts of interest (COIs) that these financial relationships introduce into medical practice. Motivated by the notion that patients should have access to this payment information to make more informed medical decisions, the Physician Payments Sunshine Act was implemented in 2013. Under the 2010 Patient Protection and Affordable Care Act, pharmaceutical and medical device manufacturers are required to report all gifts and payments they make to physicians. Run by the Centers for Medicare & Medicaid Services, this information is publicly available, with the aim of increased transparency to engender patient trust and (ideally) improve care.2 To this end, Kanter et al3 attempted to ask: did it work? Do patients trust their physicians (and the medical field) more now that they can access information on industry payments?

In their national study of 1388 US adults, Kanter et al3 performed a difference-in-difference analysis comparing the longitudinal change in trust among respondents in states where industry payments were newly disclosed via Open Payments with states where industry payment information was already available due to state disclosure laws. After controlling for demographic variables, they concluded that there was an “unintended consequence” of Open Payments: the authors found a greater decline in trust among states with newly available Open Payments information compared with states with preexisting publicly available financial disclosure data. Is it possible that increased payment transparency actually undermined patient trust in physicians?

Several major assumptions must be made to attribute this nationwide decline in patient trust to Open Payments. First, we would have to assume that respondents even know that Open Payments exists; however, prior research shows that only 12% of US adults are aware of the data.4 Second, we would have to assume that patients care about these payments. A study5 interviewing patients in cancer research trials specifically about their attitudes toward financial COIs revealed that they did not care much about whether their physicians were involved with industry, and most actually classified speaker and consulting fees as “ethical.” Another study6 found that some patients viewed physicians without payments as inexperienced or professionally isolated, and they alternatively viewed physicians with consulting payments as experts and better informed. Third, the biggest assumption is that we can attribute the nation’s trust in health care from 2014 to 2016 specifically to Open Payments as opposed to the myriad of other variables surfacing during this time. Health care is dynamic, and important factors like rising health care costs, frustrations with insurance coverage, availability of physicians, access to care, media coverage of health care, and publicized physician scandals (to name a few) can all potentially influence patients’ perceptions of trust. While Kanter et al3 attempted to account for confounding variables by comparing states, this approach cannot control for possible state-specific factors (ie, managed health care groups and state-run insurance programs).7

Nevertheless, if we make these assumptions and thus conclude that increased transparency of payments is associated with decreased trust, should we be that surprised? Is it so clear-cut that increased transparency should automatically engender trust? Research in nonmedical fields tells us otherwise. In government, transparency was historically thought to improve decision making, impede corruption, enhance accountability, and lead to a more informed citizenry; yet, evidence reveals that increased transparency can overwhelm citizens, leading to confusion and undermining government legitimacy and trustworthiness.8 In business, corporate transparency has increased in response to prominent corporate scandals, although this may have led to a paradoxical effect of causing “information overload,” second-guessing of senior executives’ decisions, and reducing creativity.9 Do these parallel phenomena mirror how Open Payments possibly contributed to information overload for patients or undermined the trustworthiness of physicians?

Only 3% of respondents in the study by Kanter et al3 reported knowing whether their physician had received industry payments. Therefore, the authors conclude that the decline in trust was not associated with by respondents’ firsthand interactions with Open Payments but rather with the newfound awareness that physician-industry financial relationships exist. As the authors discuss, without personally viewing Open Payments data, it is possible that these individuals discovered physician-industry ties through media reporting, which tends to focus on the newsworthy minority of physicians with the most egregious, highest-valued payments.1 As we veer away from a culture of having a long-term primary care physician, it is possible that when asked about trust in “their physician” respondents thought about the last physician they encountered. Perhaps this was a specialist, such as a cardiologist, resulting in a biased sample of physicians receiving significantly higher-valued payments,1 thus negatively painting all physicians “with a broad brush.”3 Yet, COIs are more complicated than direct correlations between higher-valued payments and greater influence on medical decision making. In fact, even physicians receiving a single industry-sponsored meal were associated with a significantly increased rate of prescribing brand-name medications.10 If small but powerful payments to primary care physicians undermine patient trust, this could arguably have a greater effect on patient care given the critical role of trust in one’s adherence to treatment, self-management, and use of preventive care services.3

The small (but vital) subanalysis by Kanter et al3 of respondents who confirmed they had looked their physician up on Open Payments revealed an interesting plot twist: trust in their physician actually increased if they knew that he or she did not receive payments, and trust in the medical field increased whether or not their own physician received payments. This small subset of respondents (only 3%) may represent a selection bias; perhaps they have a regular physician in mind whom they looked up, and they are inherently more likely to be trusting given their ongoing relationship. In addition, if they consider the physician of interest to be their physician, this may represent primary care physicians, who have lower payment values. As opposed to the “proceduralist effect” of losing trust after discovering high-valued payments, these respondents may be pleasantly surprised by the relatively small-valued payments (which is ironic given our previous discussion of the powerful potential influence of even 1 low-cost, pharmaceutical-sponsored meal). Or, perhaps this distinct subset of more trusting respondents reflects the important role of interacting with the data and developing one’s own opinion to achieve the true “transparency” that promotes trust.

Trust is complex, dynamic, and highly variable. Recent events, both big and small, can greatly influence trust in a physician. Still, the findings in the study by Kanter et al3 suggest that there could be powerful but subtle influences of physician-industry financial ties on patients’ perceptions of the medical field. It forces us to question the notion that public disclosure equates to transparency and that this transparency is enough to guarantee patient trust. Releasing the data is the first step; whether patients access it, and how they process and accept this information, is a complicated process fundamental to either engendering or undermining trust. Ultimately, the onus is on health care professionals to discuss implications of their industry relationships and develop trusting relationships with their patients to improve care. We can thank the implementation of Open Payments for starting the conversation, but it is up to us now to continue an honest, face-to-face discussion with our patients if we want to earn and maintain their trust.

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Article Information

Published: April 12, 2019. doi:10.1001/jamanetworkopen.2019.1929

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Tringale KR et al. JAMA Network Open.

Corresponding Author: Jona A. Hattangadi-Gluth, MD, Department of Radiation Medicine and Applied Sciences, University of California, San Diego, 3855 Health Sciences Dr, La Jolla, CA 92037 (jhattangadi@ucsd.edu).

Conflict of Interest Disclosures: Dr Tringale reported receiving grants from the National Institutes of Health (contract 1TL1TR001443) outside the present work. Dr Hattangadi-Gluth reported receiving grants from Varian Medical Systems unrelated to the present work and reported receiving other support from Vision RT outside the present work.

Tringale  KR, Marshall  D, Mackey  TK, Connor  M, Murphy  JD, Hattangadi-Gluth  JA.  Types and distribution of payments from industry to physicians in 2015.  JAMA. 2017;317(17):1774-1784. doi:10.1001/jama.2017.3091PubMedGoogle ScholarCrossref
Centers for Medicare & Medicaid Services. Open Payments. https://www.cms.gov/openpayments/. Accessed March 2, 2019.
Kanter  GP, Carpenter  DP, Lehmann  LS, Mello  MM.  US nationwide disclosure of industry payments and public trust in physicians.  JAMA Netw Open. 2019;2(4):e191947. doi:10.1001/jamanetworkopen.2019.1947Google Scholar
Pham-Kanter  G, Mello  MM, Lehmann  LS, Campbell  EG, Carpenter  D.  Public awareness of and contact with physicians who receive industry payments: a national survey.  J Gen Intern Med. 2017;32(7):767-774. doi:10.1007/s11606-017-4012-3PubMedGoogle ScholarCrossref
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. doi:10.1056/NEJMsa064160PubMedGoogle ScholarCrossref
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. doi:10.1111/jlme.12169PubMedGoogle ScholarCrossref
Thom  DH, Hall  MA, Pawlson  LG.  Measuring patients’ trust in physicians when assessing quality of care.  Health Aff (Millwood). 2004;23(4):124-132. doi:10.1377/hlthaff.23.4.124PubMedGoogle ScholarCrossref
Porumbescu  GA.  Using transparency to enhance responsiveness and trust in local government: can it work?  State Local Gov Rev. 2015;47(3):205-213. doi:10.1177/0160323X15599427Google ScholarCrossref
Birkinshaw  J, Cable  D. The dark side of transparency. McKinsey Quarterly. https://www.mckinsey.com/business-functions/organization/our-insights/the-dark-side-of-transparency. Published February 2017. Accessed March 2, 2019.
DeJong  C, Aguilar  T, Tseng  CW, Lin  GA, Boscardin  WJ, Dudley  RA.  Pharmaceutical industry-sponsored meals and physician prescribing patterns for Medicare beneficiaries [published correction appears in JAMA Intern Med. 2016;176(9):1411-1412].  JAMA Intern Med. 2016;176(8):1114-1122. doi:10.1001/jamainternmed.2016.2765PubMedGoogle ScholarCrossref
1 Comment for this article
Authors' response to commentary
Genevieve Kanter, PhD | University of Pennsylvania
Thank you to Drs. Tringale and Hattangadi-Gluth for this thoughtful and informative commentary. We very much agree that trust in physicians is a complex product of patient, provider, and institutional factors. We hope that our paper will continue to spark conversation about trust in physicians and the role that financial relationships and conflicts of interest play in trust and in physicians' trustworthiness.

In the interest of stimulating further engagement on this topic, we thought it might be helpful to expand on a few points mentioned in the commentary and our paper.

One subject that merits further discussion
is whether, for our findings to be valid, one must assume that respondents know that Open Payments exist. We don't think this is the case. The main thrust of the paper is that most people are *not* aware of Open Payments but get their information about the issue of industry payments through other sources such as the media. We particularly wanted to evaluate public disclosure in a real-world setting, where there were likely to be only a small subset of patients who looked up their doctors in the database, many others who were not at all aware of Open Payments, and still others who received their information in repackaged form through intermediaries like the media.

There is no doubt that confounding is an important consideration. We note that for a difference-in-difference analysis to be valid, the assumption that must hold is that the *changes* in relevant factors like insurance coverage (not the levels of these factors) be similar in Sunshine states and in non-Sunshine states. Thus, our estimates would not be biased if, say, Sunshine states had greater levels of managed care penetration than non-Sunshine states. Our estimates, however, would be biased if the *change* in managed care penetration in Sunshine states were greater than the change in managed care in non-Sunshine states between 2014 and 2016.

We had conducted a variety of robustness checks examining factors potentially affecting trust (including, for example, managed care penetration, the Medicaid expansion, and insurer coverage) but did not find differential changes along these dimensions between 2014 and 2016 in Sunshine vs. non-Sunshine states. If there are specific factors affecting trust that the commenters believe to have changed differentially between the two sets of states during this period, we would be happy to investigate these further.

We agree that distinctions should be made between primary care physicians and specialty physicians. In the survey, we asked respondents to name (and answer questions about) the physician they saw most frequently in the previous 12 months (please see eAppendix2 for question wording). The majority of these physicians reported specialties in family medicine and internal medicine.

The commenters raised some very important points about how transparency interacts with patients' information overload and the degree to which patients care about industry payments relative to other considerations. We concur with the commenters that the multi-dimensional aspects of transparency suggest that policymakers may be asking too much of transparency programs and of patients.

We appreciate the insightful points on this topic and look forward to further conversation on trust in physicians vis-à-vis conflicts of interest and financial relationships with industry.