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Comparing industry compensation of cardiothoracic surgeons and interventional cardiologists
j o u r n a l o f s u r g i c a l r e s e a r c h f e b r u a r y 2 0 1 7 ( 2 0 8 ) 5 1 e5 9
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Comparing industry compensation of cardiothoracic surgeons and interventional cardiologists Joshua Parreco, MD,a,* Elie Donath, MD,b Robert Kozol, MD,a and Cristiano Faber, MDc a
Department of General Surgery, University of Miami, Atlantis, Florida Department of Internal Medicine, University of Miami, Atlantis, Florida c Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, Florida b
article info
abstract
Article history:
Background: The purpose of this study was to compare payment trends between cardio-
Received 14 May 2016
thoracic surgeons and interventional cardiologists using the Open Payments website made
Received in revised form
available for the public by the Center for Medicare and Medicaid Services.
9 August 2016
Material and methods: Data were extracted from the second release of the Open Payments
Accepted 9 September 2016
database, which includes payments made between August 1, 2013 and December 31, 2014.
Available online 17 September 2016
Total payments to individual physicians were aggregated based on specialty, region of the country, and payment type. The Gini index was calculated for each specialty to measure
Keywords:
income disparity. A Gini index of 1 indicates all the payments went to one individual,
Payment
whereas a Gini index of 0 indicates all individuals received equal payments.
Compensation
Results: During the study period of interest, data were made available for 3587 (80%)
Sunshine act
cardiothoracic surgeons compared with 2957 (99%) interventional cardiologists. Mean total
Cardiothoracic surgery
payments to cardiothoracic surgeons were $7770 (standard deviation, $52,608) compared
Interventional cardiology
with a mean of $15,221 (standard deviation, $98,828) for interventional cardiologists. The median total payments to cardiothoracic surgeons was $1050 (interquartile range, $233-$3612) compared with $1851 (interquartile range, $607-$5462) for interventional cardiologists. The overall Gini index was 0.932, whereas the Gini index was 0.862 for interventional cardiologists and 0.860 for cardiothoracic surgeons. Conclusions: The vast majority of interventional cardiologists and cardiothoracic surgeons received payments from drug and device manufacturers. The mean total payments to interventional cardiologists were higher than any other specialty. However, like cardiothoracic surgery, they were among the most equitably distributed compared with other specialties. ª 2016 Elsevier Inc. All rights reserved.
* Corresponding author. General Surgery, University of Miami, 5301 S Congress Ave, Atlantis, FL 33462. Tel.: þ1 561 548 1711; fax: þ1 561 548 1743. E-mail address: [email protected] (J. Parreco). 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.09.022
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j o u r n a l o f s u r g i c a l r e s e a r c h f e b r u a r y 2 0 1 7 ( 2 0 8 ) 5 1 e5 9
Introduction Over the past several decades, the scope of practice and the patient populations of interventional cardiologists and cardiothoracic surgeons have begun to increasingly overlap. Yet little has been published about payments received from industry drug and device manufacturers to physicians in these specialties and how they compare to each other. Such information has been made readily available by the 2010 Patient Protection and Affordable Care Act. This law mandates the Centers for Medicare and Medicaid Services (CMS) to gather information related to payments to physicians and teaching hospitals from applicable manufacturers and group-purchasing organizations and to make these data publicly available online.1 The goal of the Open Payments website was to encourage transparency of financial relationships in the healthcare industry. Notably, users of the website are presented with definitions of conflict of interest from the Institute of Medicine (IOM), and the public is left to decide if the goals of their healthcare provider are influenced by the pursuit of financial gain or other secondary interests. While the Open Payments data can be useful when exploring bias at the individual level, it also provides some flexibility in that it can be aggregated by specialty, region, payment type, company, and product. This allows physicians in individual specialties to compare themselves to their peers within their own specialty as well as others. Several previous studies have evaluated Open Payments data for individual specialties such as ophthalmology, orthopedic surgery, and emergency medicine.2-4 The purpose of this research is twofold. First, to delve into payments made to both interventional cardiologists and cardiothoracic surgeons and to determine how different they are from each other. In addition, along those lines, to identify the dispersion of such payments via the Gini index, a commonly used indicator of income inequality. Second, to disseminate knowledge regarding how to access data from the
Open Payments website and try to convey how meaningful that these data are and how important it can be to investigate.
Material and methods This is a retrospective study of the Open Payments database made available via the CMS website (note that data collection began August 1, 2013 and subsequent years are collected in entirety and published in June of the following calendar year). All payments made to physicians between August 1, 2013 and December 31, 2014 by US medical drug or device manufacturers and group-purchasing organizations were extracted (note that the website provides users with a “Data Explorer” that enables users to perform complex aggregations; however, only advanced users will likely use this feature). The Gini index for each specialty was calculated using Microsoft Excel software (Microsoft Corporation, Redmond, WA). This index is one of the most common measures of income dispersion and has been used across a wide range of populations and compensation methods. It was first developed in 1912 by Corrado Gini as a ratio of the areas around a Lorenz curve, a graphical representation of inequality of wealth distribution.5 A Gini index of 1 reveals that all the payments were received by one individual, whereas an index of 0 means all individuals received equal payments. In 1986, McConnel and Tobias6 used the American Medical Association’s physician masterfiles to determine the Gini index and compare general practitioners with specialists by county and showed that surgical specialists were the most uniformly distributed of all physician groups. More recently, the American College of Surgeons, Health Policy Research Institute used the Gini index to compare physicians by specialty and county to calculate their relative distribution. They found that surgical subspecialty Gini indices reflect a move to greater maldistribution from 2001 to 2006.7 Samuel et al.2 calculated the Gini index by specialty using the more limited
Fig. 1 e Median total industry payments per physician by specialty in US dollars. Interquartile range shown by error bars.
parreco et al paying ct surgery versus int. cardiology
53
Denver: MT, ND, SD, WY, UT, CO; (9) San Francisco: CA, NV, AZ, HI, GU, AP; (10) Seattle: WA, OR, ID, AK. The Gini index for each region and specialty was also calculated. The mean total payments by specialty and payment type were calculated. Also, the percentage of individuals who received payments in multiple payment types was determined to help identify the subset of individuals receiving the most payments. Finally, the top five companies with the highest sum payments to each specialty were determined along with the associated product having the highest total payments.
Results Fig. 2 e Median total industry payments per physician by CMS region in US dollars. Interquartile range shown by error bars. Interventional cardiology (IC) hashed bars, cardiothoracic surgery (CT) solid bars.
compensation in the first release of the Open Payments database and found that Family Medicine/General Practice was the most equitably distributed specialty with a Gini index of 0.80. Mean total payments to each physician by physician profile ID was calculated with standard deviation (SD). Median total payments with interquartile range (IQR) were also calculated in a similar fashion. These calculations were then aggregated by specialty and CMS region. The CMS regions are numbered and defined by the location of each regional office as follows: (1) Boston: ME, NH, VT, MA, RI, CT; (2) New York: NY, NJ, PR, VI; (3) Philadelphia: PA, WV, VA, DE, MD, DC; (4) Atlanta: KY, TN, NC, SC, GA, AL, MS, FL; (5) Chicago: MN, WI, IL, IN, OH, MI; (6) Dallas: NM, OK, TX, AR, LA; (7) Kansas City: NE, IA, KS, MO; (8)
During the time period of interest, payments were made to 3587 cardiothoracic surgeons (80% of 4502 active cardiothoracic surgeons in 2014) compared with 2957 interventional cardiologists (99% of 2987 active interventional cardiologists in 2014).8,9 Total payments to cardiothoracic surgeons was $28,532,643, and total payments to interventional cardiologists was $45,311,751. Mean total payments to cardiothoracic surgeons was $7770 (SD, $52,608) compared with a mean of $15,221 (SD, $98,828) to interventional cardiologists. The median total payments to cardiothoracic surgeons were $1050 (IQR, $233-$3612) compared to $1851 (IQR, $607-$5462) for interventional cardiologists. As this is evident from Figure 1, payments made to cardiothoracic surgeons and interventional cardiologists appear to be markedly higher than most other specialties. In addition, several subgrouping approaches were undertaken to better understand what was driving any of the differences between interventional cardiologists and cardiothoracic surgeons. Figure 2 displays median total payments per physician among interventional cardiologists and cardiothoracic surgeons at a regional level. Notably, the median was higher
Fig. 3 e Gini index by specialty. (A Gini index of 1 indicates that all the payments were received by one individual within the specialty, whereas an index of 0 means all individuals received equal payments.)
54
j o u r n a l o f s u r g i c a l r e s e a r c h f e b r u a r y 2 0 1 7 ( 2 0 8 ) 5 1 e5 9
Fig. 4 e Gini index by CMS region for interventional cardiology (IC) hashed bars and cardiothoracic surgery (CT) solid bars. (A Gini index of 1 indicates that all the payments were received by one individual within the specialty, whereas an index of 0 means all individuals received equal payments.)
for interventional cardiology in every region with the exception of the CMS Denver region where cardiothoracic surgeons received a median payment of $1708.34 (IQR, $345.92-$3604.44) and interventional cardiologists received a median payment of $832.77 (IQR, $192.03-$3047.97). Among all specialties, the Gini index was 0.932. Figure 3 reveals the Gini index was 0.862 for interventional
cardiologists and 0.860 for cardiothoracic surgeons. The specialty with the highest Gini index was preventative medicine with 0.957, and the specialty with the lowest was vascular surgery at 0.831. Figure 4 shows the Gini index based on CMS region. The Denver region had the lowest Gini index for cardiothoracic surgeons at 0.690 with the Philadelphia region having the highest at 0.902. The regional Gini indices for interventional cardiologists ranged from 0.778 in the Boston region to 0.889 in the San Francisco region. Table 1 contains the results of aggregating by payment type and specialty with the mean payments per recipient. Interventional cardiologists were statistically significantly more likely than cardiothoracic surgeons to receive compensation for “services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program” and for “food and beverage,” whereas the opposite was true for compensation related to “education.” Tables 2 and 3 show the percentage of cardiothoracic surgeons and interventional cardiologists, respectively, receiving payments in multiple payment types. The payment types listed in rows are the denominator for total number of individuals receiving payments, whereas the payment types listed in columns are the numerator for percentage of individuals receiving payments in both payment types. Tables 4 and 5 reveal the top five companies (by sum total payments) that provide compensation to cardiothoracic surgeons and interventional cardiologists, respectively. These tables also show the product names for each company associated with the highest total payments.
Table 1 e Payment type by specialty in US dollars. Payment type
Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program Compensation for serving as faculty or a s a speaker for a nonaccredited and noncertified continuing education program Compensation for serving as faculty or as a speaker for an accredited or certified continuing education program Consulting fee Current or prospective ownership or investment interest Education Entertainment Food and beverage Gift Grant Honoraria Royalty or license Travel and lodging
Cardiothoracic surgery
Interventional cardiology
P value
Recipients
Total, $
Mean, $
Recipients
Total, $
Mean, $
369
6,913,228
18,735
650
23,668,736
36,413
0.03
9
107,271
11,919
16
44,319
2770
0.11
11
14,800
1345
6
10,245
1708
0.15
394
5,858,707
14,870
483
6,202,558
12,842
0.37
1
900,000
900,000
1
2,706,000
2,706,000
881
1,145,506
1300
1763
315,712
179
88
7433
84
196
14,414
74
3587
3,323,317
926
2957
4,954,271
1675
NA <0.001 0.32 <0.001
48
78,492
1635
58
11,084
191
0.05
9
64,495
7166
24
255,227
10,634
0.62
146
1,291,326
8845
122
1,114,716
9137
0.91
25
3,431,281
137,251
8
1,466,375
183,297
0.74
1847
5,396,787
2922
1422
4,548,094
3198
0.12
Total
28,532,643
Total
45,311,751
Table 2 e Percentage of cardiothoracic surgeons who received both payment types.
Compensation for services
100.0
2.2
0.8
44.7
0.3
36.9
5.1
98.1
3.0
0.8
18.2
2.7
85.6
88.9
100.0
0.0
77.8
0.0
55.6
22.2
100.0
0.0
0.0
66.7
0.0
88.9
27.3
0.0
100.0
9.1
0.0
36.4
0.0
100.0
9.1
0.0
0.0
0.0
81.8
other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program Compensation for serving as faculty or as a speaker for a nonaccredited and noncertified continuing education program Compensation for serving as faculty or as a speaker for an accredited or certified continuing education program Consulting fee
41.9
1.8
0.3
100.0
0.3
31.7
4.8
98.0
2.0
0.8
19.8
3.6
87.3
100.0
0.0
0.0
100.0
100.0
0.0
0.0
100.0
100.0
100.0
100.0
100.0
100.0
Education
15.4
0.6
0.5
14.2
0.0
100.0
3.7
95.0
1.6
0.2
6.5
0.6
72.0
Entertainment
21.6
2.3
0.0
21.6
0.0
37.5
100.0
98.9
0.0
1.1
9.1
1.1
71.6
Food and beverage
10.1
0.3
0.3
10.8
0.0
23.3
2.4
100.0
1.2
0.3
4.0
0.6
50.8
Gift
22.9
0.0
2.1
16.7
2.1
29.2
0.0
91.7
100.0
4.2
14.6
4.2
75.0
Grant
33.3
0.0
0.0
33.3
11.1
22.2
11.1
100.0
22.2
100.0
55.6
11.1
66.7
Honoraria
45.9
4.1
0.0
53.4
0.7
39.0
5.5
98.6
4.8
3.4
100.0
3.4
91.1
Royalty or license
40.0
0.0
0.0
56.0
4.0
20.0
4.0
80.0
8.0
4.0
20.0
100.0
60.0
Travel and lodging
17.1
0.4
0.5
18.6
0.1
34.3
3.4
98.6
1.9
0.3
7.2
0.8
100.0
Current or prospective ownership or investment interest
parreco et al paying ct surgery versus int. cardiology
Compensation Compensation for Compensation for Consulting Current or Education Enter- Food and Gift Grant Hono- Royalty Travel for services serving as faculty serving as fee (%) prospective (%) tainment beverage (%) (%) raria or and other than or as a speaker faculty or as a ownership or (%) license lodging (%) (%) consulting, for a nonaccredited speaker for investment (%) (%) including and noncertified an accredited interest serving as continuing or certified (%) faculty or as a education continuing speaker at program education a venue other (%) program than a continuing (%) education program (%)
Payment types in rows represent total number of individuals and payment types in columns represent portion of total number of individuals.
55
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Table 3 e Percentage of interventional cardiologists who received both payment types.
Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program
100.0
2.2
0.6
47.2
0.0
78.2
13.1
99.7
3.8
2.0
13.5
0.9
82.6
Compensation for serving as faculty or as a speaker for a nonaccredited and noncertified continuing education program
87.5
100.0
0.0
81.3
0.0
62.5
6.3
100.0
0.0
12.5
31.3
0.0
100.0
Compensation for serving as faculty or as a speaker for
66.7
0.0
100.0
66.7
0.0
50.0
66.7
100.0
0.0
0.0
33.3
16.7
100.0
an accredited or certified continuing education program Consulting fee Current or prospective ownership or investment interest
63.6
2.7
0.8
100.0
0.2
73.5
12.4
99.6
4.3
1.9
17.2
1.7
86.7
0.0
0.0
0.0
100.0
100.0
0.0
0.0
100.0
0.0
0.0
0.0
0.0
100.0
56.1
Education
28.8
0.6
0.2
20.1
0.0
100.0
8.3
99.2
2.6
1.0
5.0
0.3
Entertainment
43.4
0.5
2.0
30.6
0.0
74.5
100.0
99.5
3.6
0.5
13.8
0.5
76.0
Food and beverage
21.9
0.5
0.2
16.3
0.0
59.1
6.6
100.0
2.0
0.8
4.1
0.3
48.1
Gift
43.1
0.0
0.0
36.2
0.0
77.6
12.1
100.0
100.0
0.0
15.5
1.7
74.1
Grant
54.2
8.3
0.0
37.5
0.0
70.8
4.2
100.0
0.0
100.0
8.3
0.0
83.3
Honoraria
72.1
4.1
1.6
68.0
0.0
73.0
22.1
99.2
7.4
1.6
100.0
2.5
91.8
Royalty or license
75.0
0.0
12.5
100.0
0.0
75.0
12.5
100.0
12.5
0.0
37.5
100.0
87.5
Travel and lodging
37.8
1.1
0.4
29.5
0.1
69.5
10.5
99.9
3.0
1.4
7.9
0.5
100.0
Payment types in rows represent total number of individuals and payment types in columns represent portion of total number of individuals.
j o u r n a l o f s u r g i c a l r e s e a r c h f e b r u a r y 2 0 1 7 ( 2 0 8 ) 5 1 e5 9
Compensation for Compensation for Compensation for Consul- Current or Education Entertain- Food and Gift Grant Hono- Royalty Travel services other serving as faculty serving as faculty ting prospective (%) ment (%) beverage (%) (%) raria or and than consulting, or as a speaker or as a speaker fee (%) ownership or (%) (%) license lodging including serving as for a nonaccredited for an accredited investment (%) (%) faculty or as a and noncertified or certified interest speaker at a venue continuing continuing (%) other than a education education continuing program program education (%) (%) program (%)
57
parreco et al paying ct surgery versus int. cardiology
Table 4 e Top five companies by total payments in US dollars to cardiothoracic surgeons. Company
Payments
Total, $
Top product
Top product total, $
Medtronic Vascular, Inc
15,466
Edwards Lifesciences Corporation
11,489
3,491,594.10
Heart valves
2,368,204.74
3,106,323.04
Transcatheter heart valves
1,160,648.74
AtriCure, Inc
4333
St. Jude Medical, Inc
5686
2,052,136.93
Cardiovascular
2,052,136.93
1,997,360.52
Structural heart
Intuitive Surgical, Inc
3937
1,578,195.39
da Vinci Surgical System
Total payments to individuals by region have been aggregated in Table 6 for cardiothoracic surgeons and Table 7 for interventional cardiologists. These tables contain the regional mean total payments with SD and median with IQR as well as the minimum and maximum payments.
Discussion There is a belief that physicians should avoid relationships with industry as it may compromise quality of care.10 Several major pharmaceutical companies began to reduce payments to physicians in the period immediately following the passage of the Sunshine Act in 2010 and before the first reporting of the Open Payments database.11 Despite this, 99% of 2987 active interventional cardiologists and 80% of 4502 active cardiothoracic surgeons (who are listed on the Open Payments database) received industry compensation during this study period.8,9 The median industry compensation was $1851 for interventional cardiologistsdthis was 55% higher than $1050 for cardiothoracic surgeons (Fig. 1). This figure represents a small fraction of the median salary for either specialty and yet, amazingly, the difference in median industry compensation between the two specialties is much greater, percentage-wise, than their respective difference in median salaries (estimated median salary for an interventional cardiologist is $560,000 compared to $500,000 for cardiothoracic surgeonsdrepresenting a difference of only 11%).8,9 As would be expected, outliers exist mainly on the higher end of the spectrum for both specialties, and they are more commonplace among the interventional cardiologists. Mean total payments to cardiothoracic surgeons was $7770 compared with a mean of $15,221 for interventional cardiologists (a difference of 65%). This disparity is also reflected in the Gini index in which interventional cardiology has the higher value of 0.862 (relative to cardiothoracic surgery at 0.860), these values are much lower than most other
900,159.10 1,578,195.39
specialties (Fig. 3) indicating that the payments are more equitably distributed among the recipients. Notably, Figure 3 also reveals that the range of Gini indices (among all medical specialties) is relatively narrow with the highest being 0.957 for preventative medicine and the lowest being 0.831 for vascular surgery. Unfortunately, there is no statistical test (i.e., P value) available to assess the significance of these differences. Nevertheless, interpretation of the Gini index is usually done in comparative terms by highlighting different groups. For example, in 2003, Shi et al.12 used Gini coefficient in bivariate analysis with age adjusted all cause mortality to show that areas of the United States with a higher Gini coefficient have a significant increased risk of mortality. This range of 0.957-0.831 (Fig. 3) is much higher than other applications of the Gini index. For example, the World Bank estimated the primary household income Gini index for the United States was 0.411 in 2013.13 This suggests that industry payments to physicians are much more inequitable than primary household income in the United States. Figure 2, a comparison of payments at the regional level, reinforces the notion that higher median payments exist for interventional cardiologists nearly across the board. One notable exception to this is the Denver region (which had the lowest number of recipients [109], the lowest total payments [$429,488.12], the lowest maximum payments [$40,188.00], and the lowest mean payments [$3940.26] for cardiothoracic surgeons [Table 6]). The Denver region is also different from other regions in the sense that payments there were more equitably spread (the lowest Gini index for cardiothoracic surgeons at 0.690 [Fig. 4]) than in all other regions. One possible explanation for this lies in the 2005 survey by the Society of Thoracic Surgeons and the American Association for Thoracic Surgery which determined that cardiothoracic surgeons in Mountain regions seemed to have inordinately high educational debt burdens. In addition, the Southwest and Mountain regions were noted to be heavily reliant on peripheral vascular surgery.14 These explanations raise the
Table 5 e Top five companies by total payments in US dollars to interventional cardiologists. Company AstraZeneca Pharmaceuticals LP IDev Technologies, Inc St. Jude Medical, Inc Evalve Inc Medtronic Vascular, Inc
Payments
Total, $
Top product
Top product total, $
24,898
6,846,815.30
Brilinta
6,609,008.17
5
3,607,542.65
Not reported
3,607,542.65
8202
3,586,053.96
Vascular
2,939,681.21
6
3,222,920.41
Not reported
3,222,920.41
17,437
2,720,959.04
Stents
1,055,223.68
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Table 6 e Total payments to individual cardiothoracic surgeons with minimum, maximum, median, interquartile range (IQR), median, and standard deviation (SD). Region
Recipients
Total, $
Min, $
Max, $
Median, $
IQR low, $
IQR high, $
Mean, $
STD, $
01 Boston
204
850,087.79
11.70
82,141.40
750.56
164.59
2668.72
4167.10
10,190.91
02 New York
364
3,536,427.27
12.00
1,516,247.81
1037.23
288.08
3399.64
9715.46
80,810.91
03 Philadelphia
409
3,637,439.19
11.35
1,419,273.75
696.83
144.26
3200.48
8893.49
73,401.10
04 Atlanta
757
4,781,599.31
10.77
398,207.14
1299.99
303.18
4224.56
6316.51
23,164.92
05 Chicago
673
4,191,562.80
10.22
251,792.18
1069.72
236.25
3499.52
6228.18
22,120.57
06 Dallas
406
3,334,187.19
10.91
1,466,921.90
1039.88
265.92
3343.77
8212.28
74,197.26
07 Kansas City
175
762,199.44
3.30
104,227.27
749.45
134.12
3109.78
4355.43
11,977.78
08 Denver
109
429,488.12
10.60
40,188.00
1708.34
345.92
3604.44
3940.26
6877.25
09 San Francisco
446
6,004,372.82
10.80
1,216,246.45
1233.19
278.22
4552.51
13,462.72
73,843.59
10 Seattle
128
1,005,101.08
5.08
296,951.30
690.53
177.23
3138.76
7852.35
31,159.42
possibility that differences in industry payments across regions and specialties are probably specific to the nature of the particular practice. There are many potential examples of this. One in particular is the highly statistically significant divergence in mean payments for “Education” between the two specialties (Table 1) which is most likely due to specific product marketing that occurred during the study period. In particular, the development of transcatheter aortic valve procedures and the release of new antiplatelet drugs. Medtronic and Edwards were the top two contributors to cardiothoracic surgeons, while both companies were actively marketing their transcatheter aortic valve products during the study period (Table 4). Alternatively, AstraZeneca was the largest contributor to interventional cardiologists as they were marketing their new antiplatelet drug, Brilinta (Table 5). The current industry consensus on transcatheter aortic valves states that both a surgeon and an interventional cardiologist should be integrally involved with each procedure.15 Therefore, many interventional cardiologists were also likely being educated on transcatheter aortic valves during the study period. However, the top product by St. Jude was reported as “vascular” for interventional cardiologists (Table 5), while St. Jude’s top product for cardiothoracic
surgeons was reported as “structural heart” (Table 4). Similarly, Medtronic’s top product for interventional cardiologists was “stents” (Table 5), while their top product for cardiothoracic surgeons was “heart valves” (Table 4). This reveals that the differences between these specialties could be due to different proportions of physicians being educated on new transcatheter heart valve procedures. In further dividing the payment types in Tables 2 and 3, several compelling observations emerge. First, the two groups are similar when comparing the two payment types “Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program” and “Consulting Fee”. For both groups, serving as a speaker results in a sizeable portion also receiving consulting fees (44.7% for cardiothoracic surgeons and 47.2% for interventional cardiologists). Second, there is a marked difference in payments for “Education” between the two groups across the board. This is indicative of the many more interventional cardiologists who are receiving compensation in the form of education across all individuals (regardless of speaking or consulting activity). This suggests that differences between these two specialties are possibly driven by patterns in product education taking place during the study period.
Table 7 e Total payments to individual interventional cardiologists with minimum, maximum, median, interquartile range (IQR), median, and standard deviation (SD). Region Recipients Total, $ Min, $ Max, $ Median, $ IQR low, $ IQR high, $ Mean, $ STD, $ 01 Boston
96
861,151.48
12.66
136,632.97
1324.99
329.28
9351.00
8970.33
20,068.59
02 New York
209
3,091,109.58
10.94
272,882.00
2357.79
781.64
9870.79
14,790.00
33,776.61
03 Philadelphia
293
2,971,656.17
14.25
376,099.62
1634.47
560.11
4978.27
10,142.17
33,196.04
04 Atlanta
711
12,574,439.09
8.36
2,737,256.71
1996.81
689.23
5950.58
17,685.57
121,646.97
05 Chicago
506
6,245,953.77
10.06
1,204,115.67
1557.57
529.66
4812.77
12,343.78
65,460.56
06 Dallas
411
7,750,168.27
10.37
1,896,897.44
2242.81
773.95
6179.26
18,856.86
108,489.10
07 Kansas City
163
2,167,170.30
13.26
319,488.36
1905.23
633.96
5351.01
13,295.52
39,060.84
08 Denver
103
742,361.28
12.88
175,277.85
832.77
192.03
3047.97
7207.39
21,882.71
09 San Francisco
400
8,266,862.86
10.47
3,174,519.40
1926.74
535.36
5948.47
20,667.16
162,648.54
83
640,727.61
7.76
244,055.61
1342.22
409.92
3051.56
7719.61
29,622.71
10 Seattle
parreco et al paying ct surgery versus int. cardiology
There are a variety of limitations to this study. First, there have been inaccuracies in how payments are recorded. In the first year, 1347 companies reported data and 1228 of them submitted at least one payment record with inconsistent physician identifiers.1 During that first release, only 4.8% of physicians in the database reviewed the data before release and $2.2 billion was unpublished due to inaccuracies.16 For the second year, CMS implemented algorithms to validate physician information with other sources and 98.8% of submitted payment records were successfully validated.17 Second, it does seem that there are several extreme outliers in this data set that could be skewing some of the means provided previously (which is why medians were presented as well). Notably, these outliers were balanced among the two specialties and consisted among payments mainly for “Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program” and “Current or prospective ownership or investment interest”. Third, these data were all retrospectively derived. Fourth, it is limited to the years 2013 and 2014 only. Finally, the data are restricted to Americanbased physicians only.
Conclusions This study reveals that while the mean payments to interventional cardiologists and cardiothoracic surgeons are among the highest of any specialty, payments are more equitably distributed than most other specialties. It is also the intention of these authors to educate other physicians as to the potential of the Open Payments website. It is imperative for physicians to review their data on the Open Payments website annually during the review period (particularly physicians with a common name or with multiple or ambiguous specialties). They should compare their reported payment totals to their peers to avoid any implication of bias that may be perceived by patients. Industry compensation to physicians is a necessity for the growth and development of the industry. It is up to individual physicians to educate the public to this fact.
Acknowledgment The authors would like to thank Samantha Parreco for providing help with proofreading. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author’s contributions: J.P. and E.D. contributed the study design, statistical analysis, and drafted the manuscript. R.K. and C.F. contributed to the study design and critical review.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
59
references
1. Agrawal S, Brennan N, Budetti P. The Sunshine Actdeffects on physicians. N Engl J Med. 2013;368:2054e2057. 2. Samuel AM, Webb ML, Lukasiewicz AM, et al. Orthopaedic surgeons receive the most industry payments to physicians but large disparities are seen in Sunshine Act data. Clin Orthop Relat Res. 2015;473:3297e3306. 3. Chang JS. The Physician Payments Sunshine Act: data evaluation regarding payments to ophthalmologists. Ophthalmology. 2015;122:656e661. 4. Fleischman W, Ross JS, Melnick ER, Newman DH, Venkatesh AK. Financial ties between emergency physicians and industry: insights from open payments data. Ann Emerg Med. 2016;68:153e158.e4. 5. Bellu` LG, Liberati P. The gini index. Food and Agriculture Organization of the United Nations; 2006. Rome, Italy. Available at: http://www.fao.org/docs/up/easypol/329/gini_ index_040EN.pdf. Accessed June 23, 2016. 6. McConnel CE, Tobias LA. Distributional change in physician manpower, United States, 1963-80. Am J Public Health. 1986;76:638e642. 7. Neuwahl S, Ricketts TC, Thompson K. Geographic distribution of general surgeons: comparisons across time and specialties. Bull Am Coll Surg. 2011;96:38e41. 8. Thoracic Surgery - Medical Specialties - Medical Specialties Choose Your Specialty - Careers In Medicine. AAMC Careers Med. Available at: https://www.aamc.org/cim/specialty/list/ us/341818/thoracic_surgery.html. Accessed June 30, 2016. 9. Interventional Cardiology, Internal Medicine - Medical Specialties - Medical Specialties - Choose Your Specialty Careers In Medicine. AAMC Careers in Medicine. Available at: https://www.aamc.org/cim/specialty/list/us/341680/ interventional_cardiology_-internal_medicine.html. Accessed June 30, 2016. 10. Licurse A, Barber E, Joffe S, Gross C. The impact of disclosing financial ties in research and clinical care: a systematic review. Arch Intern Med. 2010;170:675e682. 11. Ornstein C, Sagara E, Grochowski Jones R. As full disclosure nears, doctors’ pay for drug talks plummets. ProPublica; 2014. New York, NY. Available at: http://www.propublica.org/ article/as-full-disclosure-nears-doctors-pay-for-drug-talksplummets. Accessed July 1, 2016. 12. Shi L, Macinko J, Starfield B, Wulu J, Regan J, Politzer R. The relationship between primary care, income inequality, and mortality in US states, 1980e1995. No. 2003;16. Available at: http://www.jhsph.edu/research/centers-and-institutes/ johns-hopkins-primary-care-policy-center/Publications_ PDFs/2003%20JABFP.pdf. Accessed August 8, 2016. 13. GINI index (World Bank estimate) j Data. Available at: http:// data.worldbank.org/indicator/SI.POV.GINI?locations¼US. Accessed August 8, 2016. 14. Shemin RJ, Ikonomidis JS. Thoracic surgery workforce: report of STS/AATS Thoracic Surgery Practice and Access Task Forcedsnapshot. Ann Thorac Surg. 2012;93:348e355, 355.e1-6. 15. Holmes Jr DR, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/ STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;59:1200e1254. 16. Santhakumar S, Adashi EY. The physician payment Sunshine Act: testing the value of transparency. JAMA. 2015;313:23e24. 17. Agrawal S, Brown D. The Physician Payments Sunshine ActeTwo Years of the Open Payments Program. N Engl J Med. 2016;374:906e909.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Comparing industry compensation of cardiothoracic surgeons and interventional cardiologists Joshua Parreco, MD,a,* Elie Donath, MD,b Robert Kozol, MD,a and Cristiano Faber, MDc a
Department of General Surgery, University of Miami, Atlantis, Florida Department of Internal Medicine, University of Miami, Atlantis, Florida c Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, Florida b
article info
abstract
Article history:
Background: The purpose of this study was to compare payment trends between cardio-
Received 14 May 2016
thoracic surgeons and interventional cardiologists using the Open Payments website made
Received in revised form
available for the public by the Center for Medicare and Medicaid Services.
9 August 2016
Material and methods: Data were extracted from the second release of the Open Payments
Accepted 9 September 2016
database, which includes payments made between August 1, 2013 and December 31, 2014.
Available online 17 September 2016
Total payments to individual physicians were aggregated based on specialty, region of the country, and payment type. The Gini index was calculated for each specialty to measure
Keywords:
income disparity. A Gini index of 1 indicates all the payments went to one individual,
Payment
whereas a Gini index of 0 indicates all individuals received equal payments.
Compensation
Results: During the study period of interest, data were made available for 3587 (80%)
Sunshine act
cardiothoracic surgeons compared with 2957 (99%) interventional cardiologists. Mean total
Cardiothoracic surgery
payments to cardiothoracic surgeons were $7770 (standard deviation, $52,608) compared
Interventional cardiology
with a mean of $15,221 (standard deviation, $98,828) for interventional cardiologists. The median total payments to cardiothoracic surgeons was $1050 (interquartile range, $233-$3612) compared with $1851 (interquartile range, $607-$5462) for interventional cardiologists. The overall Gini index was 0.932, whereas the Gini index was 0.862 for interventional cardiologists and 0.860 for cardiothoracic surgeons. Conclusions: The vast majority of interventional cardiologists and cardiothoracic surgeons received payments from drug and device manufacturers. The mean total payments to interventional cardiologists were higher than any other specialty. However, like cardiothoracic surgery, they were among the most equitably distributed compared with other specialties. ª 2016 Elsevier Inc. All rights reserved.
* Corresponding author. General Surgery, University of Miami, 5301 S Congress Ave, Atlantis, FL 33462. Tel.: þ1 561 548 1711; fax: þ1 561 548 1743. E-mail address: [email protected] (J. Parreco). 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.09.022
52
j o u r n a l o f s u r g i c a l r e s e a r c h f e b r u a r y 2 0 1 7 ( 2 0 8 ) 5 1 e5 9
Introduction Over the past several decades, the scope of practice and the patient populations of interventional cardiologists and cardiothoracic surgeons have begun to increasingly overlap. Yet little has been published about payments received from industry drug and device manufacturers to physicians in these specialties and how they compare to each other. Such information has been made readily available by the 2010 Patient Protection and Affordable Care Act. This law mandates the Centers for Medicare and Medicaid Services (CMS) to gather information related to payments to physicians and teaching hospitals from applicable manufacturers and group-purchasing organizations and to make these data publicly available online.1 The goal of the Open Payments website was to encourage transparency of financial relationships in the healthcare industry. Notably, users of the website are presented with definitions of conflict of interest from the Institute of Medicine (IOM), and the public is left to decide if the goals of their healthcare provider are influenced by the pursuit of financial gain or other secondary interests. While the Open Payments data can be useful when exploring bias at the individual level, it also provides some flexibility in that it can be aggregated by specialty, region, payment type, company, and product. This allows physicians in individual specialties to compare themselves to their peers within their own specialty as well as others. Several previous studies have evaluated Open Payments data for individual specialties such as ophthalmology, orthopedic surgery, and emergency medicine.2-4 The purpose of this research is twofold. First, to delve into payments made to both interventional cardiologists and cardiothoracic surgeons and to determine how different they are from each other. In addition, along those lines, to identify the dispersion of such payments via the Gini index, a commonly used indicator of income inequality. Second, to disseminate knowledge regarding how to access data from the
Open Payments website and try to convey how meaningful that these data are and how important it can be to investigate.
Material and methods This is a retrospective study of the Open Payments database made available via the CMS website (note that data collection began August 1, 2013 and subsequent years are collected in entirety and published in June of the following calendar year). All payments made to physicians between August 1, 2013 and December 31, 2014 by US medical drug or device manufacturers and group-purchasing organizations were extracted (note that the website provides users with a “Data Explorer” that enables users to perform complex aggregations; however, only advanced users will likely use this feature). The Gini index for each specialty was calculated using Microsoft Excel software (Microsoft Corporation, Redmond, WA). This index is one of the most common measures of income dispersion and has been used across a wide range of populations and compensation methods. It was first developed in 1912 by Corrado Gini as a ratio of the areas around a Lorenz curve, a graphical representation of inequality of wealth distribution.5 A Gini index of 1 reveals that all the payments were received by one individual, whereas an index of 0 means all individuals received equal payments. In 1986, McConnel and Tobias6 used the American Medical Association’s physician masterfiles to determine the Gini index and compare general practitioners with specialists by county and showed that surgical specialists were the most uniformly distributed of all physician groups. More recently, the American College of Surgeons, Health Policy Research Institute used the Gini index to compare physicians by specialty and county to calculate their relative distribution. They found that surgical subspecialty Gini indices reflect a move to greater maldistribution from 2001 to 2006.7 Samuel et al.2 calculated the Gini index by specialty using the more limited
Fig. 1 e Median total industry payments per physician by specialty in US dollars. Interquartile range shown by error bars.
parreco et al paying ct surgery versus int. cardiology
53
Denver: MT, ND, SD, WY, UT, CO; (9) San Francisco: CA, NV, AZ, HI, GU, AP; (10) Seattle: WA, OR, ID, AK. The Gini index for each region and specialty was also calculated. The mean total payments by specialty and payment type were calculated. Also, the percentage of individuals who received payments in multiple payment types was determined to help identify the subset of individuals receiving the most payments. Finally, the top five companies with the highest sum payments to each specialty were determined along with the associated product having the highest total payments.
Results Fig. 2 e Median total industry payments per physician by CMS region in US dollars. Interquartile range shown by error bars. Interventional cardiology (IC) hashed bars, cardiothoracic surgery (CT) solid bars.
compensation in the first release of the Open Payments database and found that Family Medicine/General Practice was the most equitably distributed specialty with a Gini index of 0.80. Mean total payments to each physician by physician profile ID was calculated with standard deviation (SD). Median total payments with interquartile range (IQR) were also calculated in a similar fashion. These calculations were then aggregated by specialty and CMS region. The CMS regions are numbered and defined by the location of each regional office as follows: (1) Boston: ME, NH, VT, MA, RI, CT; (2) New York: NY, NJ, PR, VI; (3) Philadelphia: PA, WV, VA, DE, MD, DC; (4) Atlanta: KY, TN, NC, SC, GA, AL, MS, FL; (5) Chicago: MN, WI, IL, IN, OH, MI; (6) Dallas: NM, OK, TX, AR, LA; (7) Kansas City: NE, IA, KS, MO; (8)
During the time period of interest, payments were made to 3587 cardiothoracic surgeons (80% of 4502 active cardiothoracic surgeons in 2014) compared with 2957 interventional cardiologists (99% of 2987 active interventional cardiologists in 2014).8,9 Total payments to cardiothoracic surgeons was $28,532,643, and total payments to interventional cardiologists was $45,311,751. Mean total payments to cardiothoracic surgeons was $7770 (SD, $52,608) compared with a mean of $15,221 (SD, $98,828) to interventional cardiologists. The median total payments to cardiothoracic surgeons were $1050 (IQR, $233-$3612) compared to $1851 (IQR, $607-$5462) for interventional cardiologists. As this is evident from Figure 1, payments made to cardiothoracic surgeons and interventional cardiologists appear to be markedly higher than most other specialties. In addition, several subgrouping approaches were undertaken to better understand what was driving any of the differences between interventional cardiologists and cardiothoracic surgeons. Figure 2 displays median total payments per physician among interventional cardiologists and cardiothoracic surgeons at a regional level. Notably, the median was higher
Fig. 3 e Gini index by specialty. (A Gini index of 1 indicates that all the payments were received by one individual within the specialty, whereas an index of 0 means all individuals received equal payments.)
54
j o u r n a l o f s u r g i c a l r e s e a r c h f e b r u a r y 2 0 1 7 ( 2 0 8 ) 5 1 e5 9
Fig. 4 e Gini index by CMS region for interventional cardiology (IC) hashed bars and cardiothoracic surgery (CT) solid bars. (A Gini index of 1 indicates that all the payments were received by one individual within the specialty, whereas an index of 0 means all individuals received equal payments.)
for interventional cardiology in every region with the exception of the CMS Denver region where cardiothoracic surgeons received a median payment of $1708.34 (IQR, $345.92-$3604.44) and interventional cardiologists received a median payment of $832.77 (IQR, $192.03-$3047.97). Among all specialties, the Gini index was 0.932. Figure 3 reveals the Gini index was 0.862 for interventional
cardiologists and 0.860 for cardiothoracic surgeons. The specialty with the highest Gini index was preventative medicine with 0.957, and the specialty with the lowest was vascular surgery at 0.831. Figure 4 shows the Gini index based on CMS region. The Denver region had the lowest Gini index for cardiothoracic surgeons at 0.690 with the Philadelphia region having the highest at 0.902. The regional Gini indices for interventional cardiologists ranged from 0.778 in the Boston region to 0.889 in the San Francisco region. Table 1 contains the results of aggregating by payment type and specialty with the mean payments per recipient. Interventional cardiologists were statistically significantly more likely than cardiothoracic surgeons to receive compensation for “services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program” and for “food and beverage,” whereas the opposite was true for compensation related to “education.” Tables 2 and 3 show the percentage of cardiothoracic surgeons and interventional cardiologists, respectively, receiving payments in multiple payment types. The payment types listed in rows are the denominator for total number of individuals receiving payments, whereas the payment types listed in columns are the numerator for percentage of individuals receiving payments in both payment types. Tables 4 and 5 reveal the top five companies (by sum total payments) that provide compensation to cardiothoracic surgeons and interventional cardiologists, respectively. These tables also show the product names for each company associated with the highest total payments.
Table 1 e Payment type by specialty in US dollars. Payment type
Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program Compensation for serving as faculty or a s a speaker for a nonaccredited and noncertified continuing education program Compensation for serving as faculty or as a speaker for an accredited or certified continuing education program Consulting fee Current or prospective ownership or investment interest Education Entertainment Food and beverage Gift Grant Honoraria Royalty or license Travel and lodging
Cardiothoracic surgery
Interventional cardiology
P value
Recipients
Total, $
Mean, $
Recipients
Total, $
Mean, $
369
6,913,228
18,735
650
23,668,736
36,413
0.03
9
107,271
11,919
16
44,319
2770
0.11
11
14,800
1345
6
10,245
1708
0.15
394
5,858,707
14,870
483
6,202,558
12,842
0.37
1
900,000
900,000
1
2,706,000
2,706,000
881
1,145,506
1300
1763
315,712
179
88
7433
84
196
14,414
74
3587
3,323,317
926
2957
4,954,271
1675
NA <0.001 0.32 <0.001
48
78,492
1635
58
11,084
191
0.05
9
64,495
7166
24
255,227
10,634
0.62
146
1,291,326
8845
122
1,114,716
9137
0.91
25
3,431,281
137,251
8
1,466,375
183,297
0.74
1847
5,396,787
2922
1422
4,548,094
3198
0.12
Total
28,532,643
Total
45,311,751
Table 2 e Percentage of cardiothoracic surgeons who received both payment types.
Compensation for services
100.0
2.2
0.8
44.7
0.3
36.9
5.1
98.1
3.0
0.8
18.2
2.7
85.6
88.9
100.0
0.0
77.8
0.0
55.6
22.2
100.0
0.0
0.0
66.7
0.0
88.9
27.3
0.0
100.0
9.1
0.0
36.4
0.0
100.0
9.1
0.0
0.0
0.0
81.8
other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program Compensation for serving as faculty or as a speaker for a nonaccredited and noncertified continuing education program Compensation for serving as faculty or as a speaker for an accredited or certified continuing education program Consulting fee
41.9
1.8
0.3
100.0
0.3
31.7
4.8
98.0
2.0
0.8
19.8
3.6
87.3
100.0
0.0
0.0
100.0
100.0
0.0
0.0
100.0
100.0
100.0
100.0
100.0
100.0
Education
15.4
0.6
0.5
14.2
0.0
100.0
3.7
95.0
1.6
0.2
6.5
0.6
72.0
Entertainment
21.6
2.3
0.0
21.6
0.0
37.5
100.0
98.9
0.0
1.1
9.1
1.1
71.6
Food and beverage
10.1
0.3
0.3
10.8
0.0
23.3
2.4
100.0
1.2
0.3
4.0
0.6
50.8
Gift
22.9
0.0
2.1
16.7
2.1
29.2
0.0
91.7
100.0
4.2
14.6
4.2
75.0
Grant
33.3
0.0
0.0
33.3
11.1
22.2
11.1
100.0
22.2
100.0
55.6
11.1
66.7
Honoraria
45.9
4.1
0.0
53.4
0.7
39.0
5.5
98.6
4.8
3.4
100.0
3.4
91.1
Royalty or license
40.0
0.0
0.0
56.0
4.0
20.0
4.0
80.0
8.0
4.0
20.0
100.0
60.0
Travel and lodging
17.1
0.4
0.5
18.6
0.1
34.3
3.4
98.6
1.9
0.3
7.2
0.8
100.0
Current or prospective ownership or investment interest
parreco et al paying ct surgery versus int. cardiology
Compensation Compensation for Compensation for Consulting Current or Education Enter- Food and Gift Grant Hono- Royalty Travel for services serving as faculty serving as fee (%) prospective (%) tainment beverage (%) (%) raria or and other than or as a speaker faculty or as a ownership or (%) license lodging (%) (%) consulting, for a nonaccredited speaker for investment (%) (%) including and noncertified an accredited interest serving as continuing or certified (%) faculty or as a education continuing speaker at program education a venue other (%) program than a continuing (%) education program (%)
Payment types in rows represent total number of individuals and payment types in columns represent portion of total number of individuals.
55
56
Table 3 e Percentage of interventional cardiologists who received both payment types.
Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program
100.0
2.2
0.6
47.2
0.0
78.2
13.1
99.7
3.8
2.0
13.5
0.9
82.6
Compensation for serving as faculty or as a speaker for a nonaccredited and noncertified continuing education program
87.5
100.0
0.0
81.3
0.0
62.5
6.3
100.0
0.0
12.5
31.3
0.0
100.0
Compensation for serving as faculty or as a speaker for
66.7
0.0
100.0
66.7
0.0
50.0
66.7
100.0
0.0
0.0
33.3
16.7
100.0
an accredited or certified continuing education program Consulting fee Current or prospective ownership or investment interest
63.6
2.7
0.8
100.0
0.2
73.5
12.4
99.6
4.3
1.9
17.2
1.7
86.7
0.0
0.0
0.0
100.0
100.0
0.0
0.0
100.0
0.0
0.0
0.0
0.0
100.0
56.1
Education
28.8
0.6
0.2
20.1
0.0
100.0
8.3
99.2
2.6
1.0
5.0
0.3
Entertainment
43.4
0.5
2.0
30.6
0.0
74.5
100.0
99.5
3.6
0.5
13.8
0.5
76.0
Food and beverage
21.9
0.5
0.2
16.3
0.0
59.1
6.6
100.0
2.0
0.8
4.1
0.3
48.1
Gift
43.1
0.0
0.0
36.2
0.0
77.6
12.1
100.0
100.0
0.0
15.5
1.7
74.1
Grant
54.2
8.3
0.0
37.5
0.0
70.8
4.2
100.0
0.0
100.0
8.3
0.0
83.3
Honoraria
72.1
4.1
1.6
68.0
0.0
73.0
22.1
99.2
7.4
1.6
100.0
2.5
91.8
Royalty or license
75.0
0.0
12.5
100.0
0.0
75.0
12.5
100.0
12.5
0.0
37.5
100.0
87.5
Travel and lodging
37.8
1.1
0.4
29.5
0.1
69.5
10.5
99.9
3.0
1.4
7.9
0.5
100.0
Payment types in rows represent total number of individuals and payment types in columns represent portion of total number of individuals.
j o u r n a l o f s u r g i c a l r e s e a r c h f e b r u a r y 2 0 1 7 ( 2 0 8 ) 5 1 e5 9
Compensation for Compensation for Compensation for Consul- Current or Education Entertain- Food and Gift Grant Hono- Royalty Travel services other serving as faculty serving as faculty ting prospective (%) ment (%) beverage (%) (%) raria or and than consulting, or as a speaker or as a speaker fee (%) ownership or (%) (%) license lodging including serving as for a nonaccredited for an accredited investment (%) (%) faculty or as a and noncertified or certified interest speaker at a venue continuing continuing (%) other than a education education continuing program program education (%) (%) program (%)
57
parreco et al paying ct surgery versus int. cardiology
Table 4 e Top five companies by total payments in US dollars to cardiothoracic surgeons. Company
Payments
Total, $
Top product
Top product total, $
Medtronic Vascular, Inc
15,466
Edwards Lifesciences Corporation
11,489
3,491,594.10
Heart valves
2,368,204.74
3,106,323.04
Transcatheter heart valves
1,160,648.74
AtriCure, Inc
4333
St. Jude Medical, Inc
5686
2,052,136.93
Cardiovascular
2,052,136.93
1,997,360.52
Structural heart
Intuitive Surgical, Inc
3937
1,578,195.39
da Vinci Surgical System
Total payments to individuals by region have been aggregated in Table 6 for cardiothoracic surgeons and Table 7 for interventional cardiologists. These tables contain the regional mean total payments with SD and median with IQR as well as the minimum and maximum payments.
Discussion There is a belief that physicians should avoid relationships with industry as it may compromise quality of care.10 Several major pharmaceutical companies began to reduce payments to physicians in the period immediately following the passage of the Sunshine Act in 2010 and before the first reporting of the Open Payments database.11 Despite this, 99% of 2987 active interventional cardiologists and 80% of 4502 active cardiothoracic surgeons (who are listed on the Open Payments database) received industry compensation during this study period.8,9 The median industry compensation was $1851 for interventional cardiologistsdthis was 55% higher than $1050 for cardiothoracic surgeons (Fig. 1). This figure represents a small fraction of the median salary for either specialty and yet, amazingly, the difference in median industry compensation between the two specialties is much greater, percentage-wise, than their respective difference in median salaries (estimated median salary for an interventional cardiologist is $560,000 compared to $500,000 for cardiothoracic surgeonsdrepresenting a difference of only 11%).8,9 As would be expected, outliers exist mainly on the higher end of the spectrum for both specialties, and they are more commonplace among the interventional cardiologists. Mean total payments to cardiothoracic surgeons was $7770 compared with a mean of $15,221 for interventional cardiologists (a difference of 65%). This disparity is also reflected in the Gini index in which interventional cardiology has the higher value of 0.862 (relative to cardiothoracic surgery at 0.860), these values are much lower than most other
900,159.10 1,578,195.39
specialties (Fig. 3) indicating that the payments are more equitably distributed among the recipients. Notably, Figure 3 also reveals that the range of Gini indices (among all medical specialties) is relatively narrow with the highest being 0.957 for preventative medicine and the lowest being 0.831 for vascular surgery. Unfortunately, there is no statistical test (i.e., P value) available to assess the significance of these differences. Nevertheless, interpretation of the Gini index is usually done in comparative terms by highlighting different groups. For example, in 2003, Shi et al.12 used Gini coefficient in bivariate analysis with age adjusted all cause mortality to show that areas of the United States with a higher Gini coefficient have a significant increased risk of mortality. This range of 0.957-0.831 (Fig. 3) is much higher than other applications of the Gini index. For example, the World Bank estimated the primary household income Gini index for the United States was 0.411 in 2013.13 This suggests that industry payments to physicians are much more inequitable than primary household income in the United States. Figure 2, a comparison of payments at the regional level, reinforces the notion that higher median payments exist for interventional cardiologists nearly across the board. One notable exception to this is the Denver region (which had the lowest number of recipients [109], the lowest total payments [$429,488.12], the lowest maximum payments [$40,188.00], and the lowest mean payments [$3940.26] for cardiothoracic surgeons [Table 6]). The Denver region is also different from other regions in the sense that payments there were more equitably spread (the lowest Gini index for cardiothoracic surgeons at 0.690 [Fig. 4]) than in all other regions. One possible explanation for this lies in the 2005 survey by the Society of Thoracic Surgeons and the American Association for Thoracic Surgery which determined that cardiothoracic surgeons in Mountain regions seemed to have inordinately high educational debt burdens. In addition, the Southwest and Mountain regions were noted to be heavily reliant on peripheral vascular surgery.14 These explanations raise the
Table 5 e Top five companies by total payments in US dollars to interventional cardiologists. Company AstraZeneca Pharmaceuticals LP IDev Technologies, Inc St. Jude Medical, Inc Evalve Inc Medtronic Vascular, Inc
Payments
Total, $
Top product
Top product total, $
24,898
6,846,815.30
Brilinta
6,609,008.17
5
3,607,542.65
Not reported
3,607,542.65
8202
3,586,053.96
Vascular
2,939,681.21
6
3,222,920.41
Not reported
3,222,920.41
17,437
2,720,959.04
Stents
1,055,223.68
58
j o u r n a l o f s u r g i c a l r e s e a r c h f e b r u a r y 2 0 1 7 ( 2 0 8 ) 5 1 e5 9
Table 6 e Total payments to individual cardiothoracic surgeons with minimum, maximum, median, interquartile range (IQR), median, and standard deviation (SD). Region
Recipients
Total, $
Min, $
Max, $
Median, $
IQR low, $
IQR high, $
Mean, $
STD, $
01 Boston
204
850,087.79
11.70
82,141.40
750.56
164.59
2668.72
4167.10
10,190.91
02 New York
364
3,536,427.27
12.00
1,516,247.81
1037.23
288.08
3399.64
9715.46
80,810.91
03 Philadelphia
409
3,637,439.19
11.35
1,419,273.75
696.83
144.26
3200.48
8893.49
73,401.10
04 Atlanta
757
4,781,599.31
10.77
398,207.14
1299.99
303.18
4224.56
6316.51
23,164.92
05 Chicago
673
4,191,562.80
10.22
251,792.18
1069.72
236.25
3499.52
6228.18
22,120.57
06 Dallas
406
3,334,187.19
10.91
1,466,921.90
1039.88
265.92
3343.77
8212.28
74,197.26
07 Kansas City
175
762,199.44
3.30
104,227.27
749.45
134.12
3109.78
4355.43
11,977.78
08 Denver
109
429,488.12
10.60
40,188.00
1708.34
345.92
3604.44
3940.26
6877.25
09 San Francisco
446
6,004,372.82
10.80
1,216,246.45
1233.19
278.22
4552.51
13,462.72
73,843.59
10 Seattle
128
1,005,101.08
5.08
296,951.30
690.53
177.23
3138.76
7852.35
31,159.42
possibility that differences in industry payments across regions and specialties are probably specific to the nature of the particular practice. There are many potential examples of this. One in particular is the highly statistically significant divergence in mean payments for “Education” between the two specialties (Table 1) which is most likely due to specific product marketing that occurred during the study period. In particular, the development of transcatheter aortic valve procedures and the release of new antiplatelet drugs. Medtronic and Edwards were the top two contributors to cardiothoracic surgeons, while both companies were actively marketing their transcatheter aortic valve products during the study period (Table 4). Alternatively, AstraZeneca was the largest contributor to interventional cardiologists as they were marketing their new antiplatelet drug, Brilinta (Table 5). The current industry consensus on transcatheter aortic valves states that both a surgeon and an interventional cardiologist should be integrally involved with each procedure.15 Therefore, many interventional cardiologists were also likely being educated on transcatheter aortic valves during the study period. However, the top product by St. Jude was reported as “vascular” for interventional cardiologists (Table 5), while St. Jude’s top product for cardiothoracic
surgeons was reported as “structural heart” (Table 4). Similarly, Medtronic’s top product for interventional cardiologists was “stents” (Table 5), while their top product for cardiothoracic surgeons was “heart valves” (Table 4). This reveals that the differences between these specialties could be due to different proportions of physicians being educated on new transcatheter heart valve procedures. In further dividing the payment types in Tables 2 and 3, several compelling observations emerge. First, the two groups are similar when comparing the two payment types “Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program” and “Consulting Fee”. For both groups, serving as a speaker results in a sizeable portion also receiving consulting fees (44.7% for cardiothoracic surgeons and 47.2% for interventional cardiologists). Second, there is a marked difference in payments for “Education” between the two groups across the board. This is indicative of the many more interventional cardiologists who are receiving compensation in the form of education across all individuals (regardless of speaking or consulting activity). This suggests that differences between these two specialties are possibly driven by patterns in product education taking place during the study period.
Table 7 e Total payments to individual interventional cardiologists with minimum, maximum, median, interquartile range (IQR), median, and standard deviation (SD). Region Recipients Total, $ Min, $ Max, $ Median, $ IQR low, $ IQR high, $ Mean, $ STD, $ 01 Boston
96
861,151.48
12.66
136,632.97
1324.99
329.28
9351.00
8970.33
20,068.59
02 New York
209
3,091,109.58
10.94
272,882.00
2357.79
781.64
9870.79
14,790.00
33,776.61
03 Philadelphia
293
2,971,656.17
14.25
376,099.62
1634.47
560.11
4978.27
10,142.17
33,196.04
04 Atlanta
711
12,574,439.09
8.36
2,737,256.71
1996.81
689.23
5950.58
17,685.57
121,646.97
05 Chicago
506
6,245,953.77
10.06
1,204,115.67
1557.57
529.66
4812.77
12,343.78
65,460.56
06 Dallas
411
7,750,168.27
10.37
1,896,897.44
2242.81
773.95
6179.26
18,856.86
108,489.10
07 Kansas City
163
2,167,170.30
13.26
319,488.36
1905.23
633.96
5351.01
13,295.52
39,060.84
08 Denver
103
742,361.28
12.88
175,277.85
832.77
192.03
3047.97
7207.39
21,882.71
09 San Francisco
400
8,266,862.86
10.47
3,174,519.40
1926.74
535.36
5948.47
20,667.16
162,648.54
83
640,727.61
7.76
244,055.61
1342.22
409.92
3051.56
7719.61
29,622.71
10 Seattle
parreco et al paying ct surgery versus int. cardiology
There are a variety of limitations to this study. First, there have been inaccuracies in how payments are recorded. In the first year, 1347 companies reported data and 1228 of them submitted at least one payment record with inconsistent physician identifiers.1 During that first release, only 4.8% of physicians in the database reviewed the data before release and $2.2 billion was unpublished due to inaccuracies.16 For the second year, CMS implemented algorithms to validate physician information with other sources and 98.8% of submitted payment records were successfully validated.17 Second, it does seem that there are several extreme outliers in this data set that could be skewing some of the means provided previously (which is why medians were presented as well). Notably, these outliers were balanced among the two specialties and consisted among payments mainly for “Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program” and “Current or prospective ownership or investment interest”. Third, these data were all retrospectively derived. Fourth, it is limited to the years 2013 and 2014 only. Finally, the data are restricted to Americanbased physicians only.
Conclusions This study reveals that while the mean payments to interventional cardiologists and cardiothoracic surgeons are among the highest of any specialty, payments are more equitably distributed than most other specialties. It is also the intention of these authors to educate other physicians as to the potential of the Open Payments website. It is imperative for physicians to review their data on the Open Payments website annually during the review period (particularly physicians with a common name or with multiple or ambiguous specialties). They should compare their reported payment totals to their peers to avoid any implication of bias that may be perceived by patients. Industry compensation to physicians is a necessity for the growth and development of the industry. It is up to individual physicians to educate the public to this fact.
Acknowledgment The authors would like to thank Samantha Parreco for providing help with proofreading. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author’s contributions: J.P. and E.D. contributed the study design, statistical analysis, and drafted the manuscript. R.K. and C.F. contributed to the study design and critical review.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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