Background

Federal lobbying spending in 2022 reached $4.1 billion, with >13,000 organizations employing >12,000 lobbyists.¹ Lobbying provides stakeholders with access to lawmakers who can influence key health policy decisions.² According to the Centers for Medicare & Medicaid Services (CMS), health care expenditures were >$4.3 trillion in 2021, which accounted for 18.3% of the gross domestic product.³ In accordance with this high spending, among all lobbying industries, health care accounted for the largest lobbying spending in 2022, with >$700 million spent.⁴ Spending on lobbying has been notable, especially with an increase in spending correlating with the increase in health care costs and the discussion of important legislation, such as the Inflation Reduction Act, which was the most lobbied congressional bill in 2022.^5,6

As health care payment issues remain an important topic in the political arena, health professional lobbying has become increasingly salient.⁷ The American Medical Association (AMA) represents a key group in this area, describing themselves as “representing physicians with a unified voice in courts and legislative bodies across the nation.”⁸ In addition, specialty society lobbying has increased over time as more specialty-specific issues become relevant.³ In particular, the field of oncology has many ongoing policy-relevant issues, such as the costs of pharmaceutical products as well as care more generally.^9–11 However, the degree to which societies actively engage with policymaking through lobbying efforts in oncology-focused areas remains unknown.

With this study, we sought to understand lobbying spending in oncology, inclusive of different interest groups, such as provider networks, oncology physician professional organizations (OPPOs), prospective payment system (PPS)–exempt cancer hospitals, and patient groups. We hypothesized that lobbying spending related to oncology has increased over time, reflecting growth in health care spending on cancer. By describing the lobbying efforts in health care, with a focus on oncology, findings from this work will help to motivate efforts to better understand the importance of lobbying spending in health care. In addition, we hope that elucidating this spending will enhance physician’s understanding of this area and encourage them to consider the need for further action.

Methods

We collected data regarding lobbying activities using Open Secrets (www.opensecrets.org)³ and the Federal Election Commission website (www.fec.gov).¹² Specifically, we obtained data about overall lobbying by sector, lobbying within the health care industry, and lobbying within author-identified hematologic and oncologic groups from 2014 to 2022. Within the health sector, lobbying was divided by OpenSecrets into 4 separate areas: (1) pharmaceuticals/health products (eg, Pharmaceutical Research and Manufacturers of America [PhRMA], Pfizer); (2) health services/health maintenance organizations (HMOs; eg, Aetna, Blue Cross Blue Shield); (3) hospitals/nursing homes (eg, American Hospital Association [AHA], Genesis HealthCare); and (4) health professionals (eg, AMA, National Community Pharmacists Association).

Health professionals included physician groups and other medical groups, such as pharmacists, nurses, and physician assistants; from within this group of health professionals, we identified physician-only groups for further analysis.

Additionally, we searched the OpenSecrets database for hematology/oncology-related organizations that engaged in lobbying by using a detailed keyword search (see Table S1 in the supplementary materials, available online with this article). The data of individual oncology lobbying organizations were categorized into 4 separate groups: (1) OPPOs (eg, ASCO, American Society of Hematology [ASH], Community Oncology Alliance); (2) PPS-exempt cancer hospitals (eg, Dana-Farber Cancer Institute, City of Hope); (3) patient advocacy organizations (eg, American Cancer Society [ACS], Children’s Tumor Foundation); and (4) provider networks (eg, US Oncology Network, Vantage Oncology).

PPS-exempt cancer hospitals are hospitals with oncologic care that are not subject to the hospital inpatient quality measure, and their payment is based on reported cost as opposed to a diagnosis related group (DRG)–based methodology. We chose to use these hospitals because a majority of them provided oncology-specific lobbying amounts, unlike other university-affiliated hospitals, which aggregate their lobbying spending at the university level (ie, including lobbying for nonmedical work, such as lobbying for the cost of attending the university). For PPS-exempt cancer hospitals, oncology-specific lobbying was not available for 3 of 11 hospitals (USC Kenneth Norris Jr. Cancer Hospital, University of Miami Hospital and Clinics, and Arthur G. James Cancer Hospital and Research Institute), because their oncology lobbying is not distinguished from the overall university’s lobbying.¹³ We excluded health care organizations that have some oncology involvement but are not specifically oncology-focused (eg, McKesson Corporation). The divisions we chose were exhaustive for the first 3 areas. For provider networks, these are generally parts of larger groups that may be only partially involved in health care. OpenSecrets provides the lobbying expenditures only for the overarching group/company as opposed to the individual entities. These divisions were chosen because they represent groups of different populations whose lobbying is most directly related to hematology/oncology.

To assess whether the changes in oncology lobbying over time were changing in relation to the increasing number of physicians in oncology, we obtained numbers of practicing physicians from the American Association of Medical Colleges (AAMC).¹⁴ These data are updated every 2 years, and thus we estimated physician numbers during non-update years as the linear extrapolation from adjacent years.

Results

In 2022, more than $4 billion was spent on lobbying across all sectors, which had not significantly changed over time since 2014 (Table 1). However, health sector lobbying spending had increased from being the third largest in 2014 to being the largest in 2016, and remained the largest as of 2022 (Table 1). Health sector spending continued to increase since 2014, from >$624 million to >$731 million in 2022. Health sector lobbying increased as a percentage of overall lobbying spending, from 15.1% in 2014 to a high of 18.2% in 2022.

Table 1.

Inflation-Adjusted Health Sector and Overall Lobbying Spending

View Table

Lobbying spending by the pharmaceuticals/health products industry increased faster than for other health care groups within the health sector. Overall lobbying spending for this group increased from $294 million in 2014 to >$376 million in 2022 in inflation-adjusted dollars (Figure 1). Of the other 3 groups, only the health services/HMOs group increased lobbying spending. Spending by health professionals group did not change substantially, remaining at $96 million in both 2014 and 2022 (P=.35). Physician spending decreased from $73 million in 2014 to $60 million in 2022, although this change did not reach statistical significance (P=.12) (Table 2 and Supplementary Table S2).

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Breakdown of inflation-adjusted health sector lobbying spending among lobbying groups.

Abbreviation: HMO, health maintenance organization.

^aIncludes physicians as well as nurses, physical therapists, and others in the health care field directly involved in providing care to patients.

Citation: Journal of the National Comprehensive Cancer Network 22, 4; 10.6004/jnccn.2023.7120

Table 2.

Inflation-Adjusted Lobbying Spending Among Physician Professional Organizations^a and OPPOs

View Table

Spending by patient advocacy organizations did not change significantly over time, with inflation-adjusted spending at $8.3 million in 2014 and at $8.4 million in 2022 (P=.18). However, spending for OPPOs increased significantly over this same period, from $0.8 million in 2014 to $2.3 million in 2022 (P=.016). The primary organizations within this group are the Community Oncology Alliance (COA) and ASCO, which have increased spending from $328,850 to $673,600 and from $135,126 to $574,996, respectively, from 2014 to 2022. In addition, PPS-exempt cancer hospitals also had a significant increase in spending for lobbying, from $2.4 million in 2014 to $3.9 million in 2022 (P=.009) (Figure 2).

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Breakdown of inflation-adjusted lobbying spending among different groups of hematology/oncology organizations based on organization type.

Abbreviations: AMA, American Medical Association; PPS, prospective payment system.

^aPhysician professional organizations include larger physician organizations such as the AMA as well as specialty-specific organizations such as ASCO.

Citation: Journal of the National Comprehensive Cancer Network 22, 4; 10.6004/jnccn.2023.7120

OPPO lobbying spending significantly increased over time in comparison with overall physician lobbying spending. Specifically, OPPO lobbying increased as a percentage of overall lobbying from 1.16% in 2014 to 3.76% in 2022 (P=.02) (Table 2). Further breaking this spending down per oncologist, there was an increase in per-oncologist spending over time from $60 in 2014 to $134 in 2022. Additionally, PPS-exempt cancer hospitals showed a spending increase beyond the increase in number of oncologists, from $168 per oncologist in 2014 to $226 per oncologist in 2022. For patient advocacy organizations, spending per physician was not significantly different in 2014 versus 2022 (P=.18) (Table 3).

Table 3.

Inflation-Adjusted Lobbying Spending Among 3 Groups of OPPOs and Spending per Hematologist/Oncologist^a

View Table

Discussion

In this study, we investigated temporal trends in spending on lobbying efforts in health care, with a particular focus on oncology-related lobbying. Specifically, we found that overall lobbying spending by health professionals did not change significantly over time. However, our results demonstrate that OPPOs had a significant increase in lobbying spending from 2014 to 2022. Collectively, our findings provide evidence supporting increased OPPO lobbying spending, among both physician-only groups and PPS-exempt cancer hospitals. These results are particularly notable, given the lack of change in spending on overall health professional lobbying during the period.

Our work identifies that health care lobbying spending, despite representing the largest category of lobbying spending overall, continues to increase at a rapid pace. The increase can be seen in comparison with the 5 other largest lobbying groups since 2014 (supplementary Table S1). The overall increase is fueled by the pharmaceuticals/health products industry, potentially related to the concerns regarding the substantial cost of new treatments. However, other areas of health care also play a significant role in the amount spent on lobbying.¹⁵ Within this study, we assessed lobbying spending within the oncology space, noting an increasing amount spent on lobbying by OPPOs and PPS-exempt cancer hospitals. Specifically, spending by OPPOs has more than doubled as a percentage of overall physician lobbying spending over the past 9 years. This increase in oncology lobbying belies the importance of addressing the political aspect of oncology care, as health care costs come to the forefront with passage of the recent Inflation Reduction Act or the new bipartisan-supported Pharmacy Benefit Manager Transparency Act. Thus, the overall increase in oncology lobbying appears to align with growing acknowledgment of the rapidly increasing oncology care costs.

To our knowledge, this study is the first to report on lobbying spending in oncology. Few studies have investigated health care lobbying in general, with most focused on overall lobbying spending or pharmaceutical spending but not assessing spending beyond these areas.^7,15,16 Future work will need to further assess ongoing lobbying trends to better understand how specific lobbying efforts reflect the agenda of oncology-related interest groups. However, by reporting on oncology-related spending, our work may help inform the necessity and utility of lobbying spending to enhance cancer care delivery and outcomes over time. Additionally, our current work helps set the stage for further efforts in this area by examining specific lobbying points espoused by various oncology groups.

This study has several limitations that merit discussion. First, although OpenSecrets.org provides information about lobbying spending, a lobbying firm does not have to report data for clients that have spent <$3,000 during a quarter, and firms with in-house lobbyists must provide good-faith estimates rounded to the nearest $10,000.⁴ Thus, the reported lobbying spending likely represents an underestimate of actual lobbying spending. Second, we have data on funds directly spent on lobbying, but we lack information on indirect expenditures, such as the purchase of a new office to facilitate lobbying. Third, lobbying spending is not always clearly delineated within an organization, as can be seen with 3 of the PPS-exempt cancer hospitals. They report their total spending on lobbying at the level of the university, and thus oncology lobbying spending is grouped together with all other lobbying spending across the university. This limited our ability to provide a full assessment for PPS-exempt cancer hospitals. Finally, although all issues that were lobbied for are noted in the forms that must be filled out to track lobbying, these forms only give total amount spent on lobbying across areas as opposed to money spent on each area. This prevented us from fully understanding how much money, and the specifics thereof, was spent lobbying for a particular issue.

Conclusions

We found that health care lobbying spending represents the largest category of lobbying spending overall. We also observed significant increases in lobbying spending for both physician-specific oncology organizations and PPS-exempt cancer hospitals. Plausibly, lobbying may have become more relevant in the field of oncology due to increasing costs of care, but further work is needed to fully understand the potential mechanisms of increased lobbying spending in this realm.^17,18 This is a growing area of interest, particularly for oncology clinicians, in order to continue to increase their knowledge in this area and to help further elucidate trends in cancer spending. Continued efforts to understand the utility and value of lobbying in health care and across oncology are needed, as the costs of care continue to increase and the need to advocate for our patients remains a guiding principle.