Drug companies and medical device manufacturers have long cultivated ties with physicians and hospitals in an effort to promote their wares. This has led to some suspicion that patients may end up with prescriptions for drugs they don't need or devices they don't want.
So the federal Centers for Medicare & Medicaid Services established the Open Payments database -- required under the Affordable Care Act -- which allows patients to look up whether their physicians or hospitals have any financial ties with drug or device companies.
"'Transparency' has become a very vogue strategy in U.S. health policy," Stanford Health Policy's Michelle Mello, JD, PhD, told me. "Information disclosure requirements are being used to do everything from curbing overeating [such as with calorie counts] to helping patients decide where to have their heart surgery."
Mello, a professor of health research and policy at the School of Medicine and professor of law at Stanford Law School, and her colleagues wanted to understand whether the Open Payments system is achieving its goal of helping patients make more informed decisions.
In a study published by JAMA Network Open, the researchers found an unintended consequence of the public disclosure system: It may have diminished trust in even those physicians who never received payments from drug or medical device firms.
The authors' survey of 3,500 respondents found that public disclosure of payments was associated with a 2.7 percent decline in trust in one's own physician regardless of whether the respondents knew their physicians had received payments. In fact, the authors note, fewer than 5 percent of U.S. adults report knowing about their physicians' industry payments or using the Open Payment website.
"Doctors might consider that unfair because people reported diminished trust even though most of them had no idea whether their doctor took industry payments or not," Mello said. "About two-thirds of physicians receive industry payments, so what we're seeing is a kind of spillover reputational damage to the one-third who don't."
Mello said she and her co-authors -- Genevieve Kanter, PhD, of the University of Pennsylvania; Daniel Carpenter, PhD, of Harvard University; and Lisa Lehmann, MD, PhD, of the National Center for Ethics in Health Care in the Department of Veterans Affairs -- were surprised by their findings.
"Why would trust go down if few people are using the Open Payments data?" Mello asked. "We think that the large amount of media publicity about the Open Payments law -- which has described drug companies' financial influence as pervasive and highlighted extreme cases of physicians taking very large payments -- may have changed how people think about the trustworthiness of the medical profession as a whole."
Pharmaceutical companies for decades have engaged physicians through a variety of kinds of financial relationships. Grants for company-sponsored research constitute the largest expenditure, but consulting fees, honoraria for giving lectures, providing meals, covering travel expenses, and giving small gifts are also common activities. Physicians may also have investment interests in drug and device companies.
"However, the nature of these relationships and the magnitude of the dollars flowing from companies to physicians have largely been opaque to the public," the authors wrote.
Trust is a crucial element of the physician-patient relationship affecting many aspects of patient behavior and sentiment that ultimately affect health, the authors said. For example, trust in one's physician is associated with "whether patients follow treatment recommendations, how well they self-manage chronic conditions, and whether they seek preventive care."
Further, the authors said, trust in the medical profession may affect the public's views of scientific authority and medical research, which may influence patient adherence and health-promoting behaviors.
The researchers suggested institutional policies should be implemented by hospitals and physicians to help patients understand what these payments represent. Some kinds of payments, such as an honorarium for serving as a paid speaker for a drug company, are more concerning than, say, research grants. But many patients may not be able to distinguish between the two.
"Pharma-free physicians might consider advertising that status to current and prospective patients, or health plans could include a marker for that on their 'find a physician' websites," Mello said.
Finally, she said, patients should look up their doctor and if they see any payments they find concerning, ask their doctors about them.
"Seeing whether the payments pass the 'red-faced test' in these conversations should be illuminating," Mello said.
Photo by Aidan Bartos