Correspondence with a Reporter Regarding Industry Payments to US Physicians

This topic requires nuance not hyperbole

Last week I was involved with a research letter published in JAMA that characterized industry payments to US physicians from 2013-2022 using the CMS Open Payments database.

Dr. Mandrola, one of the co-authors, has already provided a nice summary and commentary on his Substack. Note to readers, I am plagiarizing the next section from John’s writeup.

Here are the main findings:

• 57% of doctors received an industry payment

• the median payment was $48 per doctor—more than 93% of payments were associated with a marketed product.

• A small number of physicians received the largest amounts, often exceeding $1 million, while the median physician received much less.

• Orthopedic surgeons received the most at $1.36 billion, followed by neurologists and psychiatrists at $1.32 billion, and then cardiologists at $1.29 billion.

• Within each specialty, payment distributions were skewed, with payments to the median physician ranging from $0 to $2339, whereas the mean amount paid to the top 0.1% of physicians ranged from ≈ $190K for hospitalists to more than $4.8 million for orthopedic surgeons.

• The 3 drugs associated with the most payments were rivaroxaban (Xarelto) at $176 million, apixaban (Eliquis) at $102 million, and adalimumab (Humira) at $100 million. Right behind these were the SGLT2 inhibitors empagliflozin and dapagliflozin.

• The 3 medical devices associated with the most payments were the da Vinci Surgical System ($307 million), Mako SmartRobotics ($50 million), and CoreValve Evolut ($44 million).

• Other cardiology devices that made the list were Sapien 3 (TAVR), Impella (ventricular assist device), LifeVest (wearable defibrillator), Watchman (left atrial appendage occlusion), and MitraClip (mitral valve repair).

Plagiarizing over.

Over the past week I have corresponded with reporters and physicians interested in the findings. I wanted to share one of my email responses since it summarizes my position on this well and it took some time to write.

Reporter

What do the findings say about the relationship between the drug and medical device industry and physicians?

The analysis obviously showed that many physicians are still receiving payments from industry, albeit some larger than others, but how might this affect the way they interact with their patients, and/or could it influence other areas of medicine as well, such as clinical trials, studies, or advisory committees?

My response

Hi XXX, in regard to the relationship between physicians and industry, I believe our paper shows that it is strong but in fairness there are many indicators of this – so I don’t know that our paper shows anything new from that standpoint. For example, it’s not uncommon for industry ads to be featured on the homepages of major medical journals (Journal of the American College of Cardiology has ads for Amgen on its homepage as of the time I’m sending this email JACC Journals) or if you go to almost any major medical conference or meeting you will be immediately bombarded with industry advertising. When I experience this at conferences I feel like industry is not only welcome at these events but that the event is built around industry and its involvement. There’s certainly no attempt to hide these relationships. The main reason being, at least in my opinion, is that many physicians, perhaps even the majority, believe that physician-industry collaboration is a net benefit to patients and society. I don’t necessarily share that view; however, I don’t believe there is strong, objective evidence to support one side or the other.

I think what our paper does do is provide some numbers, which some may find shocking, and hopefully it renews interest in having conversations about physician-industry payments and conflicts of interest and perhaps facilitates more research. At this moment in time, the profession seems only interested in transparency. “As long as everyone is transparent, then everything is fine.” As if someone cannot be transparent about their conflicts and highly biased at the same time. I worry a lot about how COI’s directly related to physician-industry payments may manifest as overly enthusiastic recommendations or guidelines from medical organizations to use new products when they have not been sufficiently tested, or where the evidence is not strong enough, to recommend them over old standards or nothing at all (in some cases). I can provide specifics if you’re interested. (In a follow up email I offered Entresto, Repatha, Vascepa, Impella, LifeVest, Watchman, Mitra-Clip.)

The other major problem I see with physician-industry payments is that they have a way of tilting physicians sympathy toward industry and the “medical advancements” that come from industry so that they (the physicians) more willingly adopt new products just for the sake of “industry advancement” even if they don’t have a direct COI with that particular product – in a way, they become cheerleaders for industry and more open to adopting new products simply due to this attachment. To me, this attachment or enthusiasm, is best exemplified at major medical meetings when attendees stand up and cheer after results are presented for “late-breaking” research studies. I never understood it. I imagine they would say they are cheering because they’re happy how this new product will improve the health of their patients (or something like that) but in all honesty, the benefits are very rarely ever more than marginal, tiny, or “teensy-weensy” at best.

Obviously, I think about the role industry plays in medicine a lot and have touched on it in other writings (see piece from myself, Dr. Mandrola and others on Medical Conservatism).

One challenging aspect to all of this for me, is that I feel as if I need to tread lightly. For one, I have several friends and mentors in my career, who have significant financial relationships with industry. I would imagine, if we talked about this directly, they would feel attacked and I don’t want to do that. I also feel like there genuinely are some physicians and individuals who can remain unbiased despite their conflicts. However, the biggest issue is what I underlined in the first paragraph which is, whatever you think of physician-industry payments there is very limited evidence to draw conclusions about the overall benefit or harms of the practice.

I am happy to answer other questions or talk more in person about this. All the best, Drew