Spot­light on physi­cian pay­ments

Modern Healthcare - - NEWS - By Jaimy Lee

Dr. Uzma Sa­madani, a New York City neu­ro­sur­geon, pub­licly dis­closes that she re­ceives 6% of her rev­enue from re­search fund­ing and has eq­uity in a startup med­i­cal tech­nol­ogy firm she founded.

Sa­madani and about 300 other doc­tors and clin­i­cians are mem­bers of “Who’s My Doc­tor?,” a new na­tional group that en­cour­ages physi­cians to not only dis­close to pa­tients their fi­nan­cial re­la­tion­ships with med­i­cal man­u­fac­tur­ers, but also re­port other de­tails about their pro­fes­sional fi­nances, such as whether they re­ceive fee-for-ser­vice pay­ments that could mo­ti­vate them to per­form more ser­vices. Even so, she has con­cerns about how pa­tients will in­ter­pret such dis­clo­sures. “It can be very mis­lead­ing for pa­tients,” she said.

Many physi­cians, hos­pi­tals, med­i­cal re­searchers and other health­care or­ga­ni­za­tions will share her wor­ries Tues­day when the fed­eral gov­ern­ment is sched­uled to launch its Open Pay­ments web­site. The site will present in­for­ma­tion to the pub­lic about pay­ments by med­i­cal de­vice and drug man­u­fac­tur­ers to doc­tors and teach­ing hos­pi­tals. The data­base is a re­quire­ment of the Physi­cian Pay­ments Sun­shine Act, a pro­vi­sion of the Pa­tient Pro­tec­tion and Af­ford­able Care Act spear­headed by Sen. Charles Grass­ley (R-Iowa).

The law re­quires dis­clo­sure of all trans­fers of value, in­clud­ing gifts, con­sult­ing and speak­ing fees, and meals worth more than $10. The first round will cover pay­ments from Au­gust 2013 to De­cem­ber 2013. The CMS, which has faced pres­sure from provider groups to de­lay the web­site, ini­tially will with­hold about one-third of the data over ac­cu­racy con­cerns.

The dis­clo­sures will shed light on the fi­nan­cial re­la­tion­ships be­tween doc­tors, teach­ing hos­pi­tals and man­u­fac­tur­ers that have the po­ten­tial to in­flu­ence clin­i­cal de­ci­sions and raise health­care costs. But since the law was passed in 2010, some hos­pi­tals and health sys­tems, such as the Henry Ford Health Sys­tem, al­ready have strength­ened their dis­clo­sure poli­cies to be more strin­gent than the law’s re­quire­ments. Even so, some or­ga­ni­za­tions have found that such poli­cies aren’t nec­es­sar­ily enough to curb in­dus­try’s in­flu­ence on doc­tors and halt some du­bi­ous prac­tices.

There are ques­tions about what groups will use the data dis­closed on the Open Pay­ments web­site. While the Sun­shine Act was in­tended to help pa­tients un­der­stand po­ten­tial con­flicts of in­ter­est, some ex­perts say the data may be used by gov­ern­ment in­ves­ti­ga­tors and in­sur­ers track­ing doc­tors’ pre­scrib­ing, sur­gi­cal and other prac­tice pat­terns. “Any­one who is pay­ing for med­i­cal ser­vices of var­i­ous types is go­ing to be in­ter­ested in this,” said Dan Kra­cov, a part­ner with law firm Arnold & Porter.

The CMS has pro­posed re­quir­ing dis­clo­sure of pay­ments by man­u­fac­tur­ers to doc­tors pro­vid­ing con­tin­u­ing med­i­cal ed­u­ca­tion, but that data will not be in­cluded in the first round.

Other or­ga­ni­za­tions that re­quire fi­nan­cial dis­clo­sures, such as med­i­cal jour­nals and med­i­cal re­search and qual­ity-im­prove­ment groups, also may study the data­base to check the com­plete­ness and ac­cu­racy of physi­cians’ re­port­ing. But rep­re­sen­ta­tives of the New Eng­land Jour­nal of Medicine and the Na­tional Qual­ity Fo­rum said their or­ga­ni­za­tions al­ready have pro­cesses to han­dle dis­clo­sures and do not plan to use the data­base.

Still, some ob­servers won­der how many con­sumers will pay at­ten­tion to the dis­clo­sures. For in­stance, after Mas­sachusetts re­quired health­care providers to publish sim­i­lar dis­clo­sures of in­dus­try pay­ments in 2010, ex­ec­u­tives at Bos­ton-based Part­ners Health Care said they re­ceived few ques­tions from pa­tients. “It did not seem to

gen­er­ate the in­ter­est and follow-up ques­tion­ing that we thought it might,” said Christo­pher Clark, di­rec­tor of the Part­ners Of­fice for In­ter­ac­tions.

Many hos­pi­tals, health­care or­ga­ni­za­tions and med­i­cal jour­nals have poli­cies that seek to pre­vent con­flicts of in­ter­est. Sev­eral widely pub­li­cized con­flicts of in­ter­est spurred the de­vel­op­ment of such poli­cies. But it’s un­clear as to how many health­care or­ga­ni­za­tions have en­forced the poli­cies and used third-party sources to val­i­date self-re­ported data pro­vided by physi­cians. “A lot of hos­pi­tals do have var­i­ous con­flict- of- in­ter­est poli­cies … and don’t pay much at­ten­tion to them,” Kra­cov said.

The Na­tional Qual­ity Fo­rum, whose clin­i­cal rec­om­men­da­tions are used by Medi­care, faced a scan­dal this year when the Jus­tice Depart­ment al­leged that a physi­cian head­ing an NQF com­mit­tee had re­ceived mil­lions of dol­lars in pay­ments from a man­u­fac­turer to in­flu­ence the NQF’s prod­uct rec­om­men­da­tions to hos­pi­tals. Fol­low­ing the scan­dal, the fo­rum’s CEO, Dr. Chris­tine Cas­sel, re­signed from two out­side boards amid ques­tions about whether they posed con­flicts.

Con­flict-of-in­ter­est poli­cies at the Univer­sity of Illi­nois Hos­pi­tal and Health Sciences Sys­tem in Chicago came un­der scru­tiny this year when In­tu­itive Sur­gi­cal ran an ad for its da Vinci ro­botic surgery sys­tem fea­tur­ing the hos­pi­tal’s name, logo and physi­cians.

About a third of med­i­cal schools had strict con­flict-of-in­ter­est poli­cies in 2011, up from 10% in 2008, ac­cord­ing to a 2013 re­port by the Pew Char­i­ta­ble Trusts. In 2006, only 38% of med­i­cal schools had any such poli­cies. Beyond the Open Pay­ments web­site, there are other trans­parency ef­forts un­der­way. In May, Con­necti­cut be­came the first state to re­quire man­u­fac­tur­ers to dis­close pay­ments or trans­fers of value made to ad­vanced prac­tice regis­tered nurses.

The Henry Ford Health Sys­tem re­cently ex­panded its con­flict-of-in­ter­est pol­icy beyond em­ployed physi- cians, trus­tees and ven­dors to its af­fil­i­ated physi­cian groups. The pol­icy is more com­pre­hen­sive than the Sun­shine Act re­quire­ments, said Dou­glas Clark, Henry Ford’s chief com­pli­ance of­fi­cer. Henry Ford is con­sid­er­ing post­ing in­for­ma­tion about fi­nan­cial re­la­tion­ships with in­dus­try on the on­line biog­ra­phy pages of ev­ery physi­cian em­ployed at the sys­tem’s four hos­pi­tals. Clark said the Detroit­based sys­tem is still work­ing out what re­la­tion­ships would merit dis­clo­sure in that for­mat.

“We re­quire dis­clo­sure of all re­la­tion­ships, in­clud­ing those that are more of a civic ac­tiv­ity, along with those that in­volve in­dus­try or re­search,” he said.

Be­fore the Open Pay­ments dis­clo­sures, some med­i­cal-in­dus­try pay­ment data were made pub­lic through a patch­work of state laws, vol­un­tary re­port­ing by man­u­fac­tur­ers and cor­po­rate-in­tegrity agree­ments re­quir­ing drug or de­vice com­pa­nies to dis­close pay­ments made to physi­cians. Pro-Pub­lica, an in­ves­tiga­tive news site, in 2010 launched an on­line tool that com­piles pay­ment in­for­ma­tion dis­closed by 15 com­pa­nies.

Ad­vo­cates of the Sun­shine Act hope the dis­clo­sure of in­dus­try pay­ments will foster a new era of trans­parency that cur­tails in­ap­pro­pri­ate use of drugs, prod­ucts and other ser­vices aris­ing from doc­tors’ fi­nan­cial self-in­ter­est.

But physi­cian and hos­pi­tal groups and other in­dus­try or­ga­ni­za­tions, which have been crit­i­cal of the CMS’ han­dling of the data and the web­site, are ap­pre­hen­sive about how the me­dia will cover the Open Pay­ments data, and whether the in­for­ma­tion will be ac­cu­rately un­der­stood by the pub­lic. Those fears were ex­ac­er­bated by me­dia cov­er­age of Medi­care’s re­lease of in­for­ma­tion on pay­ments to in­di­vid­ual physi­cians this year.

There are likely to be me­dia sto­ries about which doc­tors and which med­i­cal spe­cial­ties re­ceive the most money from man­u­fac­tur­ers. Hos­pi­tals and physi­cians may have to field ques­tions about po­ten­tial con­flicts from re­porters, pa­tients, re­searchers, in­sur­ers, reg­u­la­tors and fraud in­ves­ti­ga­tors, and may be forced to ex­plain, de­fend and put into con­text the so­ci­etal ben­e­fits of re­ceiv­ing fund­ing. “A lot of pa­tients don’t un­der­stand the role that

DR. LEANA WEN, FOUNDER “WHO’S MY DOC­TOR?” “This will be­gin the di­a­logue be­tween pa­tients and doc­tors about fi­nan­cial dis­clo­sure.”

in­di­vid­ual doc­tors may have in sup­port­ing a clin­i­cal trial,” said Mark Se­nak, a part­ner with pub­lic-re­la­tions agency Fleish­man Hil­lard.

To pre­pare for the data re­lease on Tues­day, the Univer­sity of Iowa Hos­pi­tals and Clin­ics, a 685-bed aca­demic med­i­cal cen­ter in Iowa City, has de­vel­oped a list of fre­quently asked ques­tions for the me­dia and pa­tients who ask about dis­closed pay­ments, said Deb­bie Thoman, the hos­pi­tal’s as­sis­tant vice pres­i­dent for com­pli­ance and ac­cred­i­ta­tion. The univer­sity plans to use the data­base to con­firm pay­ment data pro­vided by its physi­cians. The univer­sity has re­quired dis­clo­sures from its physi­cians since it es­tab­lished its con­flict-of-in­ter­est pol­icy in 2009.

Dr. Leana Wen, an emer­gency room physi­cian who last year founded the “Who’s My Doc­tor?” group, said physi­cians should be proac­tive about dis­cussing what pay­ments they re­ceived with their pa­tients. Send­ing a let­ter to pa­tients or post­ing an ex­pla­na­tion in the wait­ing room are ways that physi­cians can do this. “This will be­gin the di­a­logue be­tween pa­tients and doc­tors about fi­nan­cial dis­clo­sure,” she said.

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