BACKGROUND AND OBJECTIVES: Ties between physicians and pharmaceutical/medical device manufactures have received considerable attention. The Open Payments program, part of the Affordable Care Act, requires public reporting of payments to physicians from industry. We sought to describe payments from industry to physicians caring for children by (1) comparing payments to pediatricians to other medical specialties, (2) determining variation in payments among pediatric subspecialties, and (3) identifying the types of payment and the products associated with payments to pediatricians.
METHODS: We conducted a descriptive, cross-sectional analysis of Open Payments data from January 1 to December 31, 2014. The primary outcomes included percent of physicians receiving payments, median total pay per physician, the types of payments received, and the drugs and devices associated with payments.
RESULTS: There were 9 638 825 payments to physicians, totaling $1 186 217 157. There were 244 915 payments to general pediatricians and pediatric subspecialists, totaling >$32 million. The median individual payment to general pediatricians was $14.63 (interquartile range 12–20), and median total pay per general pediatrician was $89 (interquartile range 32–186). General pediatricians accounted for 1.7% of total payments, and 0.9% of the sum of payments. Developmental pediatricians had the highest percentage of pediatric physicians receiving payment, and pediatric endocrinologists received the highest median payment. Top marketed medications were for attention-deficient/hyperactivity disorder and vaccinations.
CONCLUSIONS: More than 40% of pediatricians received payments from industry in 2014, a lower percentage than family physicians or internists. There was considerable variation in physician-industry ties among the pediatric subspecialties. Most payments were associated with medications that treat attention-deficient/hyperactivity disorder and vaccinations.
- ADHD —
- attending deficient hyperactivity syndrome
- AMA —
- American Medical Association
- CME —
- continuing medical education
What’s Known on This Subject:
Conflicts of interest between physicians and pharmaceutical/medical device manufactures have received considerable attention. The Physician Payments Sunshine Act, recently enacted as part of the Affordable Care Act, requires public reporting of payments to physicians from pharmaceutical and medical device companies.
What This Study Adds:
To our knowledge, there are no national, published data on the extent of financial relationships between industry and pediatricians. We describe payments data for pediatrics to raise awareness and provide transparency on financial relationships between pharmaceutical/medical devices manufactures and physicians.
Close to 90% of the $30 billion spent on product promotion by pharmaceutical and device manufacturers (hereafter called industry) each year targets prescribing clinicians.1,2 In a 2007 national survey, 94% of physicians reported a relationship with industry, mostly involving receiving food in the workplace during “detailing” visits by pharmaceutical representatives or receiving drug samples.3 Such relationships have been shown to be associated with physician prescribing behavior and hospital formulary recommendations4 and have long been a source of debate and controversy among physicians as well as lawmakers.1,5–7 The extent of ties between industry and physicians caring for children is unknown.
The Open Payments program, enacted in 2010 as part of the Affordable Care Act, requires public reporting of payments to physicians from industry. The Open Payments program is administered by the Centers for Medicare & Medicaid Services and is the first systematic nationwide effort to collect and report financial interactions between industry and physicians and teaching hospitals. Data collection began in August of 2013, with initial data release in September of 2014.8,9
We used Open Payments data to describe pediatrician-industry ties by (1) comparing payments between pediatricians and other medical specialties, (2) examining variation in ties among pediatric subspecialties, and (3) identifying the types of payment and the drugs or devices associated with payments to pediatricians.
We conducted a descriptive, cross-sectional analysis of Open Payments data. The Open Payments program requires reporting of payments to teaching hospitals and licensed physicians (defined as doctors of medicine, osteopathy, chiropractic medicine, dentistry, optometry, and podiatry). Reportable payments include any cash, cash equivalent or in-kind items, services, or stocks worth at least $10, or an aggregate of $100 in the calendar year. Types of payments include consulting fees, speaker fees, food, paid travel, and royalties or licensing fees. Product samples and other products intended for use by or with patients are exempt. A commonly reported payment is a meal provided by a pharmaceutical representative to a physician while visiting the office or at a company-sponsored lecture. For the latter, the cost of the food provided at the lecture would be divided among the attendees.
Data are collected by pharmaceutical and medical device manufactures and submitted to Centers for Medicare & Medicaid Services annually and include details about the payment, the physician or teaching hospital receiving the payment, and the drug or device associated with the payment. The physician’s specialty is also identified in the data and is based on information from the National Plan & Provider Enumeration System and the official Medicare enrollment record where available. Physicians and hospitals were able to review and dispute data before the public release of the data on an online portal.10
We included data from January 1, 2014, to December 31, 2014. We excluded research and royalty payments. We also excluded 208 payments that were reported as speaker fees but the dollar value of which indicated that they were likely royalties or ownership payments. An example of such a payment was a $41 million payment categorized as speaking fees. We identified likely miscategorized payments by calculating the average dollar value of royalty payments ($59 888) and removed payments listed as speaker fees that were at or above this value.
The primary outcomes were the percent of physicians receiving payments by specialty, total pay per physician by specialty, the types of payments received by pediatricians, and the drugs and devices associated with payments. We used data from the American Medical Association (AMA) Physician Master File11 to determine the number of active physicians during 2013 for the studied specialties and calculated the percentage of physicians receiving payments for each specialty. Manufacturers and distributors were required to report what drug or device was associated with each payment, and up to 5 drug and/or devices could be associated with each payment. We calculated the most common products associated with payments to pediatricians by summing drug and device associations.
Statistical analysis was performed with Stata (version 13.1, StataCorp LP, College Station TX). The study was deemed to be exempt from review by the Yale University institutional review board.
There were 9 638 825 payments to 463 470 physicians in the studied specialties, totaling $1 186 217,157. General pediatricians represented 5.6% of studied physicians and accounted for 1.7% of all payments and for 0.9% of the sum value of all payments. Among active general pediatricians, 43% received a payment in 2014, lower than the percentage in family medicine (72%) and internal medicine (58%, Table 1).
There were 244 915 payments to 36 000 pediatricians and pediatric subspecialists, totaling >$32 million. The median individual payment was $14.63 (interquartile range 12–20), similar to other specialties. The median total pay per general pediatrician was $89 (interquartile range 32–186), lower than medians in most other specialties. Developmental pediatricians had the highest percentage of pediatricians within a specialty receiving payment at 90%, with radiologists lowest at 13% (Table 2 and Fig 1).
Among pediatric subspecialties, the per-payment medians ranged from $15 for general pediatricians to $93 for infectious disease physicians, whereas the median total paid per physician ranged from $40 for anesthesiologists to $350 for dermatologists. The differences in the total pay per physician were largely driven by variation in the number of payments per physician, rather than by differences in the average dollar value of payments (Table 2).
The most common payments were for food and beverage (87%, Table 3). The most common products associated with payments to general pediatricians and pediatric subspecialists (Table 4) were medications considered treatment of attention-deficient/hyperactivity disorder (ADHD) including Vyvanse (lisdexamfetamine), Quillivant Xr (methylphenidate HCl), and Intuniv (guanfacine). Vaccines were the second most common product and included Menactra (meningococcal polysaccharide diphtheria toxoid conjugate vaccine), Pentacel (diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactive poliovirus and Haemophilus b conjugate vaccine), Fluzone Qiv (influenza vaccine), and Adacel (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed). Qvar (beclomethasone dipropionate HFA) used for control of asthma symptoms is also in the top 10 list.
The top 10 drugs associated with payments to pediatricians and pediatric specialists accounted for 51% of the number payments to pediatricians, with 3 ADHD drugs accounting for nearly 25% of payments. The pharmaceutical companies Pfizer, Shire and Sanofi Pasteur were the most common payers to pediatricians. A complete list of drugs and devices associated with payments to pediatric physicians is available in the Supplemental Information.
In this cross-sectional analysis of Open Payments data, 43% of pediatricians received payment from Industry in 2014. Although substantial, this was lower than in other specialties such as cardiologists (97%), gastroenterologists (83%), and family practitioners (72%, Table 1). Notably, just 3% (1085) of the studied pediatric physicians accounted for 78% of the sum value of payments. Also notable is that lower percentages of physicians in hospital-based specialties such as radiology, critical care, or emergency medicine received payment compared with general pediatricians (Fig 1). These hospital-based physicians may be less marketed to by industry because hospital-wide committees usually establish formularies and guide purchasing of equipment.
Our finding of ADHD drugs as the most marketed products to pediatricians fits with our finding that developmental pediatricians were most likely to receive a payment compared with other pediatricians. This likely reflects marketing by industry targeting the pediatricians most likely to treat patients with ADHD. Other medications associated with the most frequent payments in pediatrics included vaccines and asthma medications. Pediatric pulmonologists were also in the top 4 pediatric subspecialists to receive payments, likely related to marketing of asthma medications.
Particularly germane to the findings of this descriptive analysis, ADHD drug use has increasingly become an area of concern for pediatricians, patients, and families.12 Indeed, a study found that children with ADHD managed by general pediatricians were more likely to be prescribed medications for ADHD treatment than children with ADHD seen by psychiatrists.13 In addition to the potential of physician-industry relationships affecting prescribing behavior, some have also suggested a link between physician-industry financial interactions and overdiagnosis of disease by way of industry influence on members of guideline panels that widen diagnostic parameters.14 According to 2 analyses, 5 of 9 members on the most recent guidelines panel expanding the ADHD definition each had ties to at least 2 manufacturers of ADHD medications.15
The risks and benefits of physician-industry financial relationships have long been hotly debated.16,17 Proponents argue that physicians and patients benefit from interaction with industry that can educate physicians on newer treatment options, allow physicians to be more involved in the creation of beneficial drugs and devices, and has not been definitively linked to patient harm.16,18 Opponents point to social science literature showing influence of even small financial transactions such as a provided meal19 and to studies showing that these interactions are associated with lower quality prescribing.20 In recent years, academic institutions and professional organizations have issued restrictions and guidelines on managing conflicts of interest and Industry influence,21 and these, along with the advent of the Open Payments program, may have led to reduced physician-industry relationships and decreased industry-funded Continuing Medical Education (CME).22 In 2007, industry funded >60% of CME expenses, but this had declined by ∼40% by 2014.23
A leading pediatric society has published formal conflict of interest policy24 for internal corporate guidance and for society sponsored CME, but to our knowledge, no major national pediatrics society has adopted a formal policy or issued guidance on individual physician-industry financial relationships. Given the potential of individual interactions to influence patient care,4,20 clinicians could benefit from society policy guidance that extends to these interactions as well. Furthermore, the availability of Open Payments data should spur societies and organizations to use the data to vet guideline panelists and authors for potential conflicts of interest, instead of relying solely on unreliable self-reports.25,26
There are several limitations to this work. First, data integrity issues may be of concern and have been noted by others.22 As noted earlier, some payments may have been categorized incorrectly. We excluded suspected miscategorized payments as detailed earlier. Second, we based our calculations of physician subspecialties on how physicians self-reported their field of medicine to the AMA, which may under- or overestimate the actual number of active physicians within a specialty. Related to this issue, some subspecialties did not have separate AMA categories and are included with similar subspecialties but may differ significantly when it comes to industry relationships. For example, the category of general pediatrics includes both outpatient and inpatient pediatricians. However, hospitalists likely receive payments at a lower rate than outpatient clinicians, based on the trend we noted for other hospital-based subspecialties such as emergency medicine and intensive care. Finally, because we excluded research and royalty payments, our results reflect only a subset of ties between pediatricians and industry.
In summary, we found that 43% of pediatricians received payments from Industry in 2014. Pediatricians accounted for a small portion of the overall number and value of payments, and payments were most commonly associated with medications targeted for ADHD treatment and vaccines. Future work should evaluate whether and how industry ties influence patient care because it is reasonable to believe that these payments influence physician prescribing.
- Accepted March 8, 2016.
- Address correspondence to Kavita Parikh, MD MSHS, Division of Hospitalist Medicine, Department of Pediatrics, Children’s National Medical Center and George Washington School of Medicine, 111 Michigan Ave NW, Washington DC 20010. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2016 by the American Academy of Pediatrics