When it comes to interactions between medtech companies and physicians, it’s no secret that there may be cash involved. Many doctors receive consulting fees, or other in-kind compensation like meals and lodging, from the industry representatives who are working alongside them. The surprising part is that, while this issue is widely known, it hasn’t been widely explored.
In fact, there has been very little research into device companies’ payments to physicians, even though a similar phenomenon – pharma companies’ payments to physicians – has long come under scrutiny. We don’t know exactly how these financial relationships affect which products are chosen, still less how they impact patient care.
A new study, published in the journal Health Affairs in May, sheds new light on the subject, with an eye-opening analysis of how much is actually spent. The paper, by researchers in Pennsylvania and New York, found that US medical device firms spent $3.62bn between 2014 and 2017 on physician payments, compared to $3.28bn from pharma firms.
Although the difference sounds small, the real story here is that medtech firms spent seven times more as a proportion of total revenue. Around 1.7% of total industry revenue went towards physician payments, compared to 0.24% of pharma revenue.
Their payments to doctors also skewed larger, with payments divided among 196,624 physicians compared to 331,187 for the pharma industry. As the authors wrote, ‘larger payments may indicate a higher frequency or intensity of interactions with industry’.
Although the researchers didn’t dig too deeply into the implications, they did lay the groundwork for future research, posing some big questions that need answering.
“Our paper establishes the first comprehensive set of facts about what these payment relationships look like,” says study author Dr Ashley Swanson, an assistant professor at the Colombia Business School in New York. “We use the end of our paper as a call for action for researchers to fill in some of the remaining gaps and there are some very important gaps.”
What the study tells us
As well as presenting overall totals, the paper breaks down the payments by category (are these royalty payments? Consulting fees? Travel expenses?), and by physician specialty. The paper also explores the relationship between how much physicians receive and their Medicare billing amounts. Finally, it looks at payments across firms.
“One thing that I found surprising was that a few categories of payments were much, much higher in med tech than in pharma,” says Swanson.
“These were royalties and licenses, and education payments. Another thing I found surprising is that ten medical device firms accounted for about two-thirds of payments to physicians – so very concentrated. Those were the same firms that were quite dominant in the top-selling device categories, like coronary stents and spinal cord stimulators.”
In terms of the physician specialty, doctors with surgical specialties (especially neurosurgeons and orthopaedic surgeons) were the most likely to receive payments from device companies, while dermatologists and psychiatrists were the least likely.
The median annual payment to a neurosurgeon stood at $454, with payments dipping as low as $14 for certain non-surgical specialties.
Medicare billing amounts also made a difference, at least when it came to surgeons. Although non-surgical specialists were paid quite similar amounts, irrespective of their Medicare billing, the study found a steep correlation between a surgeon’s Medicare billing and how much device companies paid them.
Those with a higher billing (in the eighth decile) were paid $5,497 more a year than those with a lower billing (in the third decile).
It is clear that medical device companies have been targeting some doctors ahead of others – specifically those who are likely to spend the most on medical devices.
Information or persuasion?
The burning question is, of course, to what extent these kinds of payments might lead to bias. If the payments reflect time spent in training then that’s one thing. But if a surgeon selects a device from the company that has been treating her to $500 lunches, as opposed to the one that makes the best products, there is clearly something amiss. Are doctors being informed or persuaded?
Swanson points out that the relationship between industry and physicians seems closer in medtech than in pharma.
“Medical device representatives in the US often provide technical assistance in the operating room and will have observed many procedures involving the devices they’re promoting,” she says.
“This means there’s greater scope for training, assistance and innovation. On the downside, there might be persuasion to choose my firm’s device, even if it’s not the best value device. So I think there’s greater scope for both the upside and the downside in medical technology than in pharma.”
As to why medical device firms spend more than pharma companies, Swanson remarks that there are a few possible stories that could explain the data.
“One story is that the marginal profit associated with payment to physicians is higher than in medtech than in pharma,” she says. “Another story is that there’s a greater need for industry interaction in order to deliver the product effectively in med tech versus pharma. Both of these stories are plausible, but our paper doesn’t answer this question.”
Questions to be answered
In terms of avenues that need exploring, one is the way that payments affect utilisation and pricing. This is something Swanson and her colleagues are pursuing in ongoing research – and it’s a tricky subject to unpick, given the number of confounding variables.
“One confounding story would be reverse causality,” says Swanson. “For instance, when a physician is planning on using more of a product, they might make a call to the device representative and say, hey, can you come show me how to use this? And when that device representative comes for a visit, they buy the physician a sandwich.
“That would be a story where utilisation is actually causing payments, rather than the other way round. Sorting through those kinds of statistical relationships is a very big challenge for researchers, and one that we’re trying to tackle in ongoing work.”
Another line of questioning is, what is the link between payments and innovation? Are we seeing more and better products in the medtech landscape because these financial relationships exist? Finally – and perhaps most importantly – what is the causal effect of payments on patient outcomes?
“To answer this question effectively, further data is needed to link payments and devices to claims data, and that is broadly just not available at this point to researchers,” says Swanson.
She believes that, until these kinds of questions have been answered, it’s difficult to know how the industry-physician relationship might be better managed. Ultimately, it will come down to whether these financial ties are mostly good or bad for patients – and determining that will require a lot more research.