he Physician Payment Sunshine Act has been a valuable tool for revealing industry payments to our nation’s physicians. Nearly $17 billion in payments from drug and device companies have been recorded since the act was passed as part of the Affordable Care Act. The publicly available data it has created lets consumers and other interested parties judge for themselves whether their doctors have important conflicts of interest that might affect their treatment decisions.
Because the Sunshine Act was passed as part of the ACA, efforts to undo Obamacare may catch the Sunshine Act in its net. This would be a tremendous public disservice. By making public the payments that industry makes to physicians, the Sunshine Act helps mitigate the tendency of physicians to underreport important conflicts of interest.
This is indisputably important to patients and other interested parties because, like everyone else, physicians’ behavior can be swayed by conflicts of interest. What’s more, doctors often fail to disclose such conflicts — even in circumstances in which we have agreed to do so.
Physician lack of disclosure is well-documented. A landmark study published about the time the Sunshine Act was passed looked at disclosure rates among physicians who had received at least $1 million in industry payments during the preceding year. Fewer than half of articles published by these physicians disclosed industry payments, despite journal policies requiring such disclosure.
Other researchers have examined conflicts of interest among panel members writing clinical practice guidelines for the management of common diseases such as diabetes — guidelines with the potential to broadly sway treatment decisions across the country. “The prevalence of financial conflicts of interest and their under-reporting by members of panels producing clinical practice guidelines … was high,” they concluded.
The Sunshine Act has also made it possible for researchers to study connections between conflicts of interest and physician behavior. A report published last year in JAMA Internal Medicine, for example, evaluated data from 2013 Medicare Part D and data from the federal Open Payments program — the searchable database created under the Sunshine Act. It showed a correlation between receipt of industry-sponsored meals, even those valued at less than $20, and increased rates of prescribing the drugs promoted during these meals. Of note, some of the drugs found to be associated with increased prescription frequency were among the most expensive ones in the Medicare program, costing taxpayers billions of dollars a year.
ProPublica has published a detailed analysis of this same dataset for the year 2014. The news organization found that doctors practicing in five common specialties who received industry payments were between two and three times more likely to have high brand-name prescribing rates than those who did not receive such payments. Furthermore, when dividing physicians by size of industry payments, doctors receiving larger payments had higher average brand-name prescribing rates than those receiving smaller payments. (ProPublica’s Dollars for Docs website offers another searchable database of industry payments to physicians and teaching hospitals.)
These associations between prescribing patterns and industry payments would have remained hidden without data available through the Sunshine Act.
Despite the success of the act, it remains under attack. The House of Representatives, for example, included in the 21st Century Cures Act legislation a broad exclusion from reporting payments made to doctors for industry-sponsored educational purposes. Fortunately, it was stripped by the Senate before the act was passed.
Financial conflicts other than payments from pharmaceutical companies and medical device manufacturers can also alter physician behavior. The Government Accountability Office has released several reports on physician self-referral for diagnostic and therapeutic services. That means referring patients for testing or treatment to medical facilities in which the provider, or the provider’s family, has a financial interest.
GAO auditors found that the growth rate of self-referred services outpaced non-self-referred services by a margin of up to 7 to 1 for imaging studies such as MRI scans.
The auditors also found that financial conflicts of interest swayed physicians’ decisions regarding treatment, even for therapies such as radiation therapy, which have the possibility of serious and even life-threatening side effects. Between 2004 and 2010, the use of radiation therapy by urologists who owned radiation therapy centers grew by as much as 356 percent, while its use by urologists with no ownership interests declined by 5 percent, as most doctors began switching to less toxic treatments.
Because of these findings, the GAO recommended that the Centers for Medicare and Medicaid Services improve its ability to identify and monitor physician self-referral of services such as both advanced imaging and radiation therapy.
No current law or regulation provides a mechanism for following the GAO’s recommendations about self-referral. Expanding the Sunshine Act to include financial data about physician self-referral could allow it to capture this useful information.
When looking at all available data regarding physician financial conflicts of interest, it’s clear that more transparency, not less, would help consumers attempting to make informed choices regarding their health care and researchers investigating the effect of prescribers’ conflicts of interest.
Instead of weakening the Sunshine Act, Congress should strengthen it to include physician self-referral. With such available information, patients could make the most clear-eyed assessments of their doctors’ recommendations and the motivations behind them. This would be invaluable to consumers, since a rollback of the ACA could potentially eliminate the public reporting of quality performance data for hospitals and doctors.
While changes to the ACA appear inevitable, we should protect and even expand those provisions of the law that bring light to the dark world of physician conflicts of interest.
James Rickert, MD, is president of the Society for Patient Centered Orthopedics.