Abstract
BACKGROUND AND PURPOSE: Physician-industry relationships can be useful for driving innovation and technologic progress, though little is known about the scale or impact of industry involvement in neuroradiology. The purpose of this study was to assess the trends and distributions of industry payments to neuroradiologists.
MATERIALS AND METHODS: Neuroradiologists were identified using a previously-validated method based on Work Relative Value Units and Neiman Imaging Types of Service classification. Data on payments from industry were obtained from the Open Payments database from the Centers for Medicare & Medicaid Services, from 2016 to 2021. Payments were grouped into 7 categories, including consulting fees, education, gifts, medical supplies, research, royalties/ownership, and speaker fees. Descriptive statistics were calculated.
RESULTS: A total of 3019 neuroradiologists were identified in this study. Between 2016 and 2021, 48% (1440/3019) received at least 1 payment from industry, amounting to a total number of 21,967 payments. Each year, among those receiving payments from industry, each unique neuroradiologist received between a mean of 5.49–7.42 payments and a median of 2 payments, indicating a strong rightward skew to the distribution of payments. Gifts were the most frequent payment type made (60%, 13,285/21,967) but accounted for only 4.1% ($689,859/$17,010,546) of payment value. The greatest aggregate payment value came from speaker fees, which made up 36% ($6,127,484/$17,010,546) of the total payment value. The top 5% highest paid neuroradiologists received 42% (9133/21,967) of payments, which accounted for 84% ($14,284,120/$17,010,546) of the total dollar value. Since the start of the coronavirus 2019 (COVID-19) pandemic, the number of neuroradiologists receiving industry payments decreased from a mean of 671 neuroradiologists per year prepandemic (2016−2019) to 411 in the postpandemic (2020−2021) era (P = .030). The total number of payments to neuroradiologists decreased from 4177 per year prepandemic versus 2631 per year postpandemic (P = .011).
CONCLUSIONS: Industry payments to neuroradiologists are highly concentrated among top earners, particularly among the top 5% of payment recipients. The number of payments decreased during the COVID-19 pandemic, though the dollar value of payments was offset by coincidental increases in royalty payments. Further investigation is needed in subsequent years to determine if the postpandemic changes in industry payment trends continue.
ABBREVIATIONS:
- CMS
- Centers for Medicare & Medicaid Services
- IQR
- interquartile range
- NITOS
- Neiman Imaging Types of Service
- OPD
- Open Payments database
- SE
- standard error
Financial relationships with industry are frequent among radiologists and physicians in general.1,2 Although industry payments for activities such as consulting and research may help promote research and medical breakthroughs, industry relationships are also ethically relevant to clinical practice because they could develop into potential conflicts of interest.3 In 2010, the Physician Payments Sunshine Act was passed by Congress (https://www.cms.gov/sites/default/files/repo-new/68/11709P-Open-Payments-Physicians.pdf) as a part of the Affordable Care Act to help increase the transparency of industry-physician relationships. Industry payment data are publicly available in the Open Payments database (OPD; https://openpaymentsdata.cms.gov/), collected and published by the Centers for Medicare & Medicaid Services (CMS).4 Previous studies analyzing the database have shown the frequency and magnitude of industry payments under different categories. However, there is a paucity of evidence focusing on neuroradiologists. This study aimed to characterize the industry payments to neuroradiologists during a 6-year period (2016−2021) and assess the frequency, trends, and distribution of industry payments.
MATERIALS AND METHODS
This study was deemed exempt from human subject research guidelines because it involved secondary analysis of existing, publicly available data. The study followed the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) reporting guidelines.
Neuroradiologists were identified using the Medicare Physician & Other Practitioners-by Provider and Service database (https://catalog.data.gov/dataset/medicare-physician-other-practitioners-by-provider-and-service-b156e) obtained from the CMS for calendar years 2016−2021.5 The Work Relative Value Units associated with each radiologist’s claims were categorized by imaging modalities and body regions, according to the Neiman Imaging Types of Service (NITOS; https://www.neimanhpi.org/policy-briefs/nitos/), which classifies radiology services as invasive or noninvasive, as well as by technique, body region, and focus area. Neuroradiologists were identified on the basis of the condition that the fraction of the total Work Relative Value Units dedicated to neuroradiology services (NITOS-defined codes with body region of brain, head/neck, or spine) exceeded a threshold of 50%. The threshold and method were based on results from previous sensitivity analyses aiming to identify radiologist subspecialties in academic and private practice settings.6⇓-8 The remainder were excluded from the data and subsequent analysis. Sex, state, and years of practice were obtained from this data set. Regions (Northeast, Midwest, South, and West) were defined using the US Census Bureau system (https://www.commerce.gov/bureaus-and-offices/census).9
Payments made by industry payers to physicians between 2016 and 2021 were obtained from the CMS Open Payments database.4 Payments were categorized into 7 main categories, in a fashion similar to that in prior studies,10 using the following categories: consulting fees, educational funding, gifts (including food and beverages, entertainment, and charitable contributions), medical supplies, research funding, speaker fees (including honoraria and travel expenses), and royalties/ownership. Payments were aggregated for each unique neuroradiologist receiving payments for analysis on the basis of national provider identification numbers. Data were analyzed for trends between 2016 and 2021 and at the aggregate levels. Additionally, attention was placed on data trends before and after the coronavirus 2019 (COVID-19) pandemic (2016−2019 versus 2020−2021) to assess the impact of the pandemic on industry payments to neuroradiologists.
Data analysis was performed using R Version 4.2.2 (https://www.r-project.org/) with R Studio (http://rstudio.org/download/desktop).11 Wilcoxon tests, t tests, and χ2 were used to compare medians, means, and proportions, respectively.
RESULTS
Recipient Demographics
Among a total of 3019 unique neuroradiologists, 48% (1440/3019) received payments from industry during the study period (Table 1). Women were 20.2% (610/3019) of the neuroradiology workforce but constituted 16.5% (238/1440) of neuroradiologists who received industry payments. The industry-paid group had higher median years in practice of 21 (interquartile range [IQR], 15−30) years, compared with a median of 17 (IQR, 10−25) years in practice for the nonpaid group. The highest-represented geographic regions among neuroradiologists paid by industry were the Northeast (n = 361) and the South (n = 502). Proportions of regional representation were different for neuroradiologists who were paid versus not paid (Table 1). There was no statistically significant difference in the median aggregate industry payment per year between male and female neuroradiologists (P = .591).
Demographics of neuroradiologists paid and not paid by industry
Characterization of Industry Payments
Between 2016 and 2021, a total of 21,967 payments were made to neuroradiologists, totaling $17,010,546. Payments were made to a total of 1440 unique neuroradiologists during the study period. Each year, each unique neuroradiologist received between a mean of 6 payments and a median of 2 payments, indicating a strong rightward skew to the distribution of payments. The mean (standard error [SE]) value of individual payments was $774 ($28) with a median value of $69 (IQR, $20 to $221) (Table 2). Payments of >$10,000 represented 1% (197/21,967) of all payments, while 12% (2657/21,967) of all payments were between $1000 and $10,000. Eighty-seven percent (19,113/21,967) of payments were <$1000.
Number and value of payments from 2016 to 2021
The Online Supplemental Data provide the number and value of payments by payment category. Gifts were the most frequent payment type made (60%, 13,285/21,967) but accounted for 4.1% ($689,859/$17,010,546) of payment value. The second and third most frequent payment types were speaker fees (25%, 5556/21,967) and consulting fees (11%, 2447/21,967), respectively. The greatest aggregate payment value came from speaker fees, consulting fees, and research fees, which made up 36% ($6,127,484/$17,010,546), 36% ($6,041,361/$17,010,546), and 18% ($3,029,316/$17,010,546) of total payment value, respectively (Online Supplemental Data).
Top 5% and Bottom 95% of Recipients
Among neuroradiologists who received industry payments, 72 neuroradiologists had their total industry payment value in the top 5% of recipients, earning a median of $97,481 (IQR, $66,731–$197,635) ($16,247 per year) during the 6-year period. The minimum threshold needed to join this group was $36,580 during the 6-year period. In comparison, the rest of the recipients, the bottom 95%, received a median of $177 (IQR, $60–$1187) ($30 per year) during the same period. The top 5% group received a median of 67 (IQR, 28−115) separate payments (11 payments per year), while the bottom 95% group received a median of 3 (IQR, 1−8) payments (0.5 payments per year). The number of neuroradiologists receiving payments by value of payment categories in each year is provided in the Online Supplemental Data.
The top 5% highest paid neuroradiologists received 42% (9133/21,967) of payments, which accounted for 84% ($14,284,120/$17,010,546) of the total dollar value. The largest contributor by value was the consulting fees category, contributing 38% ($5,400,818). This was followed by speaker fees (34%), research (20%), royalties and ownership (7%), gifts (1%), education (0.2%), and medical supplies (0.07%). In contrast, speaker fees (46%, $1,264,081) accounted for the largest share of payments by value for the bottom 95% of recipients. They were followed by consulting fees (23%), gifts (17%), research (8%), royalties and ownership (2%), education (0.5%), and medical supplies (0.05%).
Payment value was most heavily concentrated in the top 5% of earners within the speaker fee category with the group taking 76% ($4,655,168/$6,127,484) in total payment value. The top 5% took most of the payment value in research (56%, $1,690,928/$3,029,316) and education (53%, $21,240/$39,879) as well. These categories were followed by gifts (45%, $312,781/$689,859) and consulting fees (45%, $2,699,204/$6,041,361) in terms of concentration. Medical supplies and royalties and ownership categories did not have enough recipients (n = 2 and n = 12, respectively) to isolate the top 5%.
The top 5% of recipients comprised 14 (19%) female and 58 (81%) male neuroradiologists. These proportions were not statistically significantly different from the rest of the earners: The bottom 95% comprised 224 (16%) female and 1144 (84%) male neuroradiologists (P = .6). The top 5% had a statistically significantly higher median number of years in practice (top 5% median, 26.5 [IQR, 19−34] years versus the bottom 95%, median, 21 [IQR, 15−30] years; P = .003).
Influence of COVID-19 Pandemic
Since the start of the COVID-19 pandemic, the total number of payments to neuroradiologists decreased from a mean of 4177 per year prepandemic (IQR, 2016−2019) to a mean of 2631 per year postpandemic (2020−2021) (P = .011). A mapping of the cumulative number of payments across time shows a stark decrease in slope from March 2020, around the time of the wide-scale COVID shutdown throughout the United States (Fig 1). There was no statistically significant change in total annual payment value to neuroradiologists before and after the pandemic (mean, $2,962,910 [SE, $226,506] before pandemic versus $2,579,454 [SE, $74,073] after the pandemic; P = .1917). The number of neuroradiologists receiving payments decreased from a mean of 671 neuroradiologists per year prepandemic to 411 in the postpandemic era (P = .030) (Table 2). Particularly for research, COVID-19 resulted in a sharp decrease in the number of neuroradiologists receiving payments for research activities (P = .014) (Fig 2).
Cumulative number of payments across time, 2016–2021.
Number of neuroradiologists receiving payments for research by year.
Although the number of payments and recipients has decreased postpandemic, there has been an increase in the median value per payment. The median value payment was $60 (IQR, $19 to $190) before 2020, and the median increased to $100 (IQR, $24 to $400) during 2020−2021 (P < .001).
Speaker Fees
The top 50 earners in speaker fees collected a mean of $105,552 (SE, $42,101) from 2016 to 2021, or approximately $17,592 per year. There were 42 and 15 instances of a neuroradiologist earning >$20,000 and $100,000, respectively, in a calendar year. Among the 42 instances of earnings exceeding $20,000, only 1 involved a female radiologist. Notably, none of the 15 instances of a neuroradiologist earning >$100,000 involved a female radiologist. The median years in practice were significantly lower for the 15 cases of neuroradiologists earning >$100,000 (median, 16 [IQR, 16–17] years) than those earning >$20,000 (median, 22 [IQR, 17–27] years) (P = .002).
DISCUSSION
The characterization of our study of industry payments to neuroradiologists suggests that nearly one-half of neuroradiologists received industry payments during the study period, with gifts being the most frequent payment type made (60%), but most constituting small amounts and overall accounting for only 4.1% of total payment value. This characterization is similar to the payment distribution previously described for all radiologists in which gifts constituted 76.4% of all payments by number and 4.8% of payment value.10
Accurate disclosures have been emphasized to mitigate the risk of bias and ethical concerns. However, high rates of nondisclosures have been shown in presenters at national radiology society meetings and by authors of radiology journals.12⇓-14 One possible reason for the high rates of nondisclosures may be the lack of awareness of reporting requirements. The CMS required any payment in 2023 of >$12.69 to be reported, and if the amount was lower, it needed to be disclosed if the aggregate amount exceeded 10 times that amount ($126.89) in the calendar year.15 Although the industry payments in the gifts category (including food and beverages, entertainment, and charitable contributions) are often small, awareness of the relatively low threshold of reporting requirements is important.
There is a high concentration of industry payments to the top 5% of payment recipients, accounting for 42% of payment instances and more than three-fourths (82%) of the total value of payments. The concentration was greatest in the speaker fees, research, and education categories, in which the top 5% of earners took more than one-half of the payment value in each category (76%, 56%, and 53%, respectively). For gifts and consulting fees, the earnings of the top 5% of earners approached 50% (45% in both categories). The top 50 earners in speaker fees collected approximately $18,000 per year, and there were 42 and 15 instances of a neuroradiologist earning >$20,000 and $100,000, respectively, in a calendar year. Previous studies have raised concerns that if high-value industry payments mostly reflect gratuitous interactions with industry, it raises concerns about quid pro quo relationships and conflicts of interests, which can lead to negative outcomes for health care spending and resource use.16
Furthermore, demographic analysis revealed key insights about sex inequality and years of experience. Female neuroradiologists were disproportionately less represented in industry payments. Previous studies repeated similar results, showing that male sex was associated with not just greater representation in industry payments but also significantly higher payment values.17,18 However, within neuroradiology, we did not find a statistically significant difference in the annual payment value between the 2 sexes. We also found that the median years of experience were higher among those paid by industry, perhaps insinuating a favorable industry bias toward experienced physicians, who may command more authority in hospitals and organizations.
Data from a previous study examining industry payments to radiologists showed that neuroradiologists received a higher median value of industry payments in 2015 compared with diagnostic radiologists, interventional radiologists, as well as radiation oncologists.19 A recent study showed a median payment value of $27 (IQR, $15 to $120) for all radiologists who received industry payments from 2016 to 2020.10 Our results corroborate the previous 2015 results, with a median value of $69 (IQR, $20 to $221) for neuroradiologists.
In our temporal analysis, the effect of COVID-19 was evident. The beginning of the pandemic marked a new era of decreased payments to neuroradiologists as well as a decrease in the number of neuroradiologists receiving payments. This trend was also visible in a previous study examining the impact of COVID-19 on industry payments to radiologists.1 The decrease in industry payments during the pandemic reverses a previously studied trend of increasing industry payments to physicians across time.19,20 It remains to be seen whether industry payments to neuroradiologists will rebound after the pandemic. COVID-19 also had a novel effect on the dollar value of payments. Although the total dollar amount of payments decreased in 2021, the median payment value paradoxically increased. Our study found that COVID-19 resulted in a sharp decrease in the number of neuroradiologists receiving payments from industry for speaker fees and research. Speaker fees constituted 48.6% of all industry payments by value in 2020 but dropped to 27.6% in 2021. The decrease in speaker fees is not surprising given that in-person events were canceled during the pandemic. The financial impact on national society meetings needs further study. Consulting fees constituted 39% of all industry payments by value in 2021. Effort to amplify industry-led research may be necessary to continue financially supporting innovation and novel breakthroughs in the field of radiology.
There are limitations to this study, many of which are inherent to using the OPD database. The database relies on accurate reporting from the industry. It also does not include payments for products or services not covered by the US FDA. This study focused on payments made to physicians and does not capture payments made to organizations or academic institutions. This issue may be especially relevant to payments made by industry for research.
CONCLUSIONS
This study highlights the prevalence of industry payments to US neuroradiologists, their trends and distribution. Industry payments to neuroradiologists are highly concentrated among top earners but are common, with nearly one-half of the neuroradiologists having received at least 1 payment from industry. Greater awareness is important given the publicly available nature of data and for accurate disclosures to increase transparency and trustworthiness of research.
Footnotes
Disclosure forms provided by the authors are available with the full text and PDF of this article at www.ajnr.org.
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- Received April 10, 2024.
- Accepted after revision June 4, 2024.
- © 2024 by American Journal of Neuroradiology