Spotlight on physician payments

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.