Open Payments goes live with pharma to doctor fee data: first analysisBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6003 (Published 01 October 2014) Cite this as: BMJ 2014;349:g6003
- Duncan Jarvies, multimedia editor, The BMJ, London, UK,
- Rebecca Coombes, magazine editor, The BMJ, London, UK,
- Will Stahl-Timmins, data graphics designer, The BMJ, London, UK
- Correspondence to: D Jarvies
It’s just 24 hours since the Centers for Medicare and Medicaid Services (CMS) transparency database went live, detailing for the first time payments by US drug and device makers to doctors and teaching hospitals in the country. Open Payments (http://cms.gov/openpayments/) has already attracted 11 million hits. What the headline data show is that 4.4 million payments totaling $3.5bn (£2.2bn; €2.8bn) were made to more than 546 000 physicians and 1360 teaching hospitals in the last five months of 2013.
The collection and public release of those data is made possible by The Physician Payment Sunshine Act (PPSA). The data are free to access and fully searchable, and the CMS will update annually. So far the database shows only a partial view, covering payments made in the last five months of 2013. Going forward, the CMS will collect data from 1 January to 31 December, and release it the following June.
What kind of payments are reported?
The law demands disclosure of payments of more than $10 to doctors, other healthcare staff, and teaching hospitals for a range of activities. And it is a wide range. Consulting fees, speaker fees, honoraria, gifts such as promotional gadgets or vacations, and entertainment such as sports or concert tickets must all be declared. Also covered are food and drink, travel and hotels, textbooks, and research activity, including enrolling patients in clinical trials. The CMS also gathers data from companies on physician ownership or investment interests. So it is really talking about anything—there’s no such thing as a free lunch. You’ll also have to declare if you transfer that payment to a charity.
Here’s an example on the CMS site:
“A sales representative brings a catered lunch costing $165 to a 10-physician group practice. Six of the ten physicians and five support staff participate in the meal. Because the meal cost $15 per participant ($165/11 participants=$15), the meal needs to be reported for the 6 physicians who participated in it. However, the meal does not need to be reported for the 4 other physicians in the group who did not participate in the meal (that is, did not eat or drink any of the offerings).”
The data are collected in three main sets: general (non-research) payments, research payments, and investment payments. A free app (Open Payments Mobile for Physicians) is available to help doctors track the payments they receive.
What does this initial “data dump” tell us?
When royalties are excluded the list of top five drugs looks different (table 3⇓). Ticagrelor (Brilinta), the only drug to appear in both tables, is a relatively recent (FDA approval 2011) antiplatelet drug for use in patients with acute coronary syndrome with or without ST elevation. The PLATO study, funded by AstraZeneca, suggested that it is superior to clopidagrel.1 The National Institute for Health and Care Excellence approved its use in October 2011. Payments for ticagrelor were all associated with “compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program.”
Latuda (lurasidone), a novel atypical antipsychotic, was approved by the FDA in October 2010 and by the European Medicines Agency in 2014. Canagliflozin (Invokana) was the first sodium-glucose co-transporter 2 inhibitor to be approved for type 2 diabetes in the United States (March 2013). Rivaroxaban (Xarelto) and Apixaban (Eliquis) are both anticoagulants.
The five most highly paid doctors are all orthopedic surgeons (table 4⇓), but the majority of that money comes in the form of royalty or license payment—a figure that is echoed in the ownership dataset below.
Which medical specialty received the most payments?
Orthopedic surgery—$80 157 503.04
Internal medicine—$26 616 544.66
Internal medicine/cardiovascular disease—$24 291 090.52
Psychiatry—$18 724 216.32
Other service providers/specialist—$17 475 702.37
A separate CMS dataset allows you to look at the value of shares held by doctors. Below is a breakdown by specialty, a list topped by orthopedic surgeons. There are a couple of big individual shareholders with stock in excess of $40m.
Specialties with the highest value of shares
Orthopedic surgery—$48 702 415.57
Obstetrics and gynecology—$42 701 713.89
Internal medicine/gastroenterology—$41 910 224.26
Internal medicine/cardiovascular disease—$35 744 397.64
Ophthalmology—$31 160 068.76
It looks like lots of US physicians are doing well from their stock and shares. A comparison of dollar values at investment with current value show that they have gone up from $295 775 423 to $444 484 561.
Data health warnings
There is widespread concern about the accuracy of the data and what the public will make of it. CMS says that 40% of the 4.4 million records are de-identified because of concerns over whether the data is accurate. This means the data appears without the name of the physician or teaching hospital that received a payment, but just includes the identity of the donating company. The data will be republished with name by next June.
ProPublica, a non-profit body that produces investigative journalism in the public interest, has run a microversion of Open Payments for the past four years called Dollars for Docs using data from the websites of 17 drug companies. Senior reporter Charles Ornstein yesterday co-published with the New York Times the five “takeaways” from the Dollars for Docs project.2
Many, many health professionals have relationships with industry
Some doctors have relationships with many companies
The biggest companies aren’t always the ones that spend the most. Some smaller drug companies spend big too
Meals vastly outnumber all other interactions between drug companies and doctors, but they account for a much smaller share of costs
From year to year, doctors cycle in and out of relationships with companies
Doctors heavily lobbied the Obama administration to stall the launch of the database for six months (US intends to publish drug company payments to doctors from October despite calls for delay.3 American Medical Association president Robert Wah feared inadequately checked data posed a risk to members. “If the government releases incorrect information to the public it can lead to misinterpretations, harm reputations, and cause patients to question their trust in physicians,” he said.
A group of academics from Johns Hopkins University in Baltimore are already calling for the law to be changed so that research payments are more fairly recorded. At the moment, industry must record payments to researchers engaged in clinical trials. But this total payment includes the cost of investigational drugs used in the trial and recorded on the federal database as a donation to an individual investigator.
“One may presume that the public may have difficulty distinguishing between donated drugs for research and transfers of financial value to physicians. Such confusion frustrates the purpose of the PPSA, casting shadows where bright light had been promised,” the academics write in Annals of Internal Medicine.4
The AMA is urging members to take matters into their own hands and closely track any record of payments before it is made public. Its top tips include asking industry representatives to let you review reportable transfers before they submit to federal officials. Physicians also have the right to review and challenge reports that are false, misleading, or inaccurate. Doctors will be able to view their individual consolidated industry report via an online CMS portal (https://portal.cms.gov/wps/portal/unauthportal/registration) before the information is made public and will have at least 45 days to challenge the information. Doctors must register with the CMS online portal to receive the reports.
Anecdotally, the registration process has been onerous. Physicians have to provide all kinds of personal information, which has to correspond to the data held, and then wait a day or so to be registered.
For those who managed to register, website outages made it difficult for many to access the information stored about them. A US doctor who also works for The BMJ estimates that she probably spent about half an hour on four occasions trying to view things before being able to do so. Another US doctor told how he tried to register less than 10 days before launch, but the site seemed be closed.
Some employers have issued detailed instructions to their staff about how to check details, but for those without that support the system seems virtually un-navigable.
What Open Payments doesn’t include
The act doesn’t cover payment to medical residents, nurse practitioners, or pharmacists.
Disputed data are also excluded. Before the data were released, physicians were able to contest the data that was held by them. If that dispute wasn’t resolved by the end of the period set by CMS (different groups had different deadlines) then it’s been removed from the record.
Certain payments are excluded from the data by the legislation, notably drug samples and educational material aimed at patients. If a manufacturer receives less than 10% of their revenue from the manufacture of drugs, devices, biological, etc that fall under the medical umbrella, they only have to disclose payments directly related to one or more of those products.
Cite this as: BMJ 2014;349:g6003
Competing interests: We have read and understood BMJ Group policy on declaration of interests and have no relevant interests to declare.