Cardiologists Stand Out for Their Ties to Industry in US Government Database
Not all cardiologists receive payments from industry, but they are more likely to do so than physicians belonging to any other specialty, a new analysis shows. Moreover, the payments to cardiovascular specialists tend to be larger, according to 2013 numbers from the Open Payments program.
The Centers for Medicare & Medicaid Services’ Open Payments Program stems from what has been referred to shorthand as the “Sunshine Act,” signed into law in 2010 as part of President Obama’s healthcare plan.
In a paper published in the January 2016 issue of Mayo Clinic Proceedings, Jona A. Hattangadi-Gluth, MD, of the University of California, San Diego School of Medicine (La Jolla, CA), and colleagues delved into the first wave of data released from the program, which covered payments made to physicians between August and December 2013. A total of 4.4 million payments adding up to $2.6 billion were reported during this time frame. Of this sum, 2.6 million payments totaling $475 million were detailed to the degree that the researchers could identify individual physicians and the type of payment—whether compensation for services, charitable contributions, consulting fees, royalty/license payments, or education-related.
Nearly 4 in 5 physicians (78%) specializing in cardiovascular disease received some sort of payments, compared with, for example, 77% of neurosurgeons and 63% of dermatologists. On the opposite end of the spectrum were pathologists at 9%. Although the median paid per cardiologist for payments unrelated to research was only $175, these added up to nearly $34 million over the 5-month timespan. The largest payment in cardiovascular medicine to an individual physician was $445,000.
Only thoracic surgeons had a higher median payment ($181). Emergency medicine physicians had the lowest median payment ($28), and pediatric oncologists had the lowest value for their largest payment ($51,320) among all specialties.
Notably, only 0.36% of cardiovascular specialists had an ownership interest in a company.
The Appearance of Impropriety
James C. Blankenship, MD, of Geisinger Medical Center (Danville, PA), said that public reporting of physician payments could, like public reporting of PCI outcomes, have unintended consequences. “Clearly, we’re in an age of greater transparency, and the prudent cardiologist will avoid not only improper relationships but even, to the extent they can, the appearance of improper relationships,” he told TCTMD, pointing out that “what constitutes a conflict of interest” has varying definitions.
For example, Blankenship said, the American College of Cardiology mandates that half of guideline writing group members be free of any relationships with industry, including participating in industry-funded research trials. “It is difficult to find individuals to be on a guideline writing group who are not involved in research,” he reported, predicting that the policy might discourage some physicians from pursuing research.
Blankenship called the current findings a “wake-up call for cardiologists to avoid the appearance of impropriety because, if you’re on the list and it looks like you’re taking money from industry,” people may draw conclusions without knowing exactly how the interaction occurred.
In an interview with TCTMD, James N. Kirkpatrick, MD, of UW Medical Center (Seattle, WA), who wrote a 2011 paper about conflicts of interest and American College of Cardiology/American Heart Association guidelines, said that he has been impressed overall by the wide range of opinions among cardiologists about these issues, with most falling in the middle of the spectrum. Certainly, some reading the current study are likely to find its airing of cardiology’s conflicts as “something that’s unhelpful,” he noted.
As to why 78% of cardiologists are on the Open Payments list, Blankenship said that “cardiology is one of the fastest advancing fields of medicine with more new drugs, more new devices, and more new procedures compared to other specialties. So there is more new knowledge out there to be shared…. [Also,] since cardiology is a high-stakes profession, of course industry is going to be out there trying to educate physicians about the appropriate use of new devices and medicines. So there is no shortage of industry-funded dinners and symposia to go to, and any time you go to one of them you’re on the list.”
Simply eating dinner while attending an event could come across as a dollar amount that reflects upon you poorly, he observed. This scenario might explain the “vast majority of these payments,” Blankenship suggested.
Even if many of the payments can be explained by dinners, Kirkpatrick said, that is not a justification. “Well, you shouldn’t be doing the dinners. For some people, that’s going to be disturbing, that there is even that going on, because it does suggest that you are receiving some compensation from industry. It may only be a small amount, but if it was a good dinner, that might influence you,” he stressed, joking that a bad dinner might also leave an impression.
“Presumably what’s happening is the companies are then passing on the costs to patients,” Kirkpatrick said. “Is that really fair? Should we really be receiving this benefit, since you’re getting paid to learn in some cases? And then there’s the question about whether that learning is highly biased and it’s all just advertising.”
A Culture Shift With Still Unknown Effects
There is also the possibility that what was seen in 2013 may no longer hold true, Blankenship noted. “I suspect that when they look at data for August through December 2015, they will see a different pattern,” now that awareness has grown.
As the culture shifts, physicians receiving smaller amounts may be more likely to avoid them in the future, Kirkpatrick predicted, since they know they are being watched and possibly even noticed by their own patients. Another aspect is that professional societies, which might be more concerned than individuals about public perception, can now double check whether physicians are fully self-reporting conflicts, he said.
There may be unexpected fallout from the Open Payments program, Kirkpatrick added. “Part of the reason that cardiologists have gotten in trouble, not just for conflicts of interest but other things, is because the [US Department of Justice] has been much more interested in going after fraud, because fraud and abuse are what’s driving up a good chunk of the healthcare expenditure rise. If you can go and get somebody, and it can be a high profile case, that will theoretically discourage other people from putting their hands in the cookie jar.”
Looking at how the Sunshine Act is written, “it is very intentional that this information can be used by the Justice Department and in fact can also be used by the [Internal Revenue Service], he noted. “Theoretically, that is also going to trickle down to malpractice cases and things like that.”
These data could be used productively to “ferret out” bad behavior or they could be misused, he noted.
Marshall DC, Jackson ME, Hattangadi-Gluth JA. Disclosure of industry payments to physicians: an epidemiologic analysis of early data from the open payments program. Mayo Clin Proc. 2016;91:84-96.
- Hattangadi-Gluth reports receiving a research grant from Varian Medical Systems unrelated to the current study.
- Blankenship reports serving as a site principal investigator for studies funded by approximately 8 different companies. He currently is president of the Society for Cardiovascular Angiography and Interventions.
- Kirkpatrick reports no relevant conflicts of interest. He specifies that his expressed opinions are his alone and do not reflect the position of the University of Washington.