Physician Interactions With Industry: Striking the Right Balance

The Open Payments database, required pursuant to the Physician Payment Sunshine Act (Sunshine Act), was created as part of the passing of the Patient Protection and Affordable Care Act implemented in 2010.¹ The Open Payments database is the most comprehensive source of industry payments to physicians to date. Prior to the first Open Payments data being reported for a portion of calendar year 2013, and annually thereafter, several drug and device manufacturers reported these payments and other transfers of value either voluntarily, under court order, or under state-specific legislation.² Under the Sunshine Act, manufacturers of covered drugs, devices, biologics, and medical supplies must report payments and other transfers of value to physicians and teaching hospitals to the Centers for Medicare & Medicaid Services (CMS). CMS provides teaching hospitals and physicians the opportunity to review and dispute the data, and thereafter makes it publicly available via the Open Payments site.

Many published reports trend this publicly available data, both before and following the first report of the Open Payments data. These analyses show that physician characteristics associated with higher payments have been identified, and include gender,^3–5 years in practice,⁵ medical school,⁵ institution,³ and specialty.^4,5 Furthermore, with these data and other publicly available data sources, such as Medicare Part D prescribing data, many researchers have been able to identify associations between payments and prescribing patterns.^6,7 Other analyses conclude that industry payments are associated with more favorable publications of research results and editorials.^8,9

Prior to the passing of the Sunshine Act, some people speculated and hoped that publishing the payment and other transfers of value data would cause a decrease in payments or other transfers of value from industry. That objective of the law’s enactment has not come to fruition. Each year, with the explainable exception of the calendar year 2020 due to COVID-19, the total amount of general payments to physicians has increased. It is largely assumed that the decrease in 2020 was associated with less travel and fewer meals and events due to the COVID-19 pandemic.

In evaluating payments to oncologists and internists from 2014 through 2017, Rahman et al¹⁰ add to this growing body of literature with a novel examination of industry payments associated with PD-1 and PD-L1 immunotherapy drugs. The recent approval of these products allows for the unique opportunity to evaluate the initial payment pattern for a new and expensive class of drugs. This evaluation by Rahman et al provides several novel and useful insights. They identify a 165% increase in payments to physicians from companies marketing PD-1 or PD-L1 drugs during the study period, compared with a 31% increase from benchmark companies not marketing those drugs. Interestingly, the authors hypothesized that there may be higher payments associated with the annual meeting of the specialty, but that was not substantiated in the data. Lower payments were identified in the summer and the first and last weeks of the year, likely correlating with common vacation times. The authors also found that there was no decrease in the willingness of more recent medical school graduates to accept payments from industry. This demonstrates that the Sunshine Act did not have the intended effect of reducing these relationships. The authors also confirm differences in the number of payments based on physician specialty, years in service, and gender, which have previously been identified in the literature.

The study had a few limitations, and some conclusions may have alternative explanations not directly addressed. The authors indicate that they selected internists for the control group because they would be unlikely to receive payments related to cancer drugs. However, given the known differences in payment associated with specialty and between internists and subspecialists, it may have been more appropriate to use another subspecialty for comparison instead of general internists. In 2017, the authors report that 67.3% of oncologists received a payment or other transfer of value from industry with a mean value of $5,854, whereas 44.1% of internists received a payment with a mean value of $450. In practice, an oncologist’s salary is also generally higher than that of an internist. During the reporting period, the authors found that payments to oncologists increased more dramatically than payments to internists. The authors ascribe the greater increase in payments to a potentially higher return to pharmaceutical companies given the price of oncology drugs compared with drugs an internist may prescribe. Although this may be one reason for the difference, another may be associated with physician collaboration and research required as new cancer drugs are developed and brought forward for approval. The authors identified that physicians who serve on NCCN Guidelines panels during the relevant period of 2014–2017 received more payments and other transfers of value from industry than other oncologists during this period, and the increase in payments over the time period was greater than that of other oncologists. Notably, the median increased by 173% for NCCN Guideline contributors compared with 31% for other oncologists. Based on these data, the authors concluded that drug companies intentionally target guideline contributors due to their ability to influence use of the companies’ products. An alternative possibility not credited is that certain oncologists, due to their leadership and expertise in the field, are sought after by companies as well as to serve as guideline developers. The authors did recognize that these NCCN Guideline panelists are more likely to be academic oncologists involved in research, which is associated with consulting and other ancillary payments.

It may be important to take this opportunity to acknowledge that physician relationships with industry are not inherently good or bad. There are positive interactions between physicians and industry that help advance medical breakthroughs with input by physicians. Physicians are and should be compensated for this work, but such relationships certainly create the potential for bias. This is why these relationships need to be appropriately structured and managed. In addition, there are inappropriate relationships and payments that should be monitored and eliminated. Rahman et al¹¹ focus on the negative aspects of relationships with industry and eventually conclude that action should be taken to reduce and eventually eliminate acceptance of payments by physicians. A more balanced approach could recognize beneficial collaborations between physicians and industry while eliminating inappropriate relationships such as sham payments, promotional activities, industry representative–provided meals, and speakers’ bureau activities.