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Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. My name is Ruchika Talwar and I'm joined today by Dr. Parth Modi. Dr. Modi is an Assistant Professor at the University of Chicago and we'll be discussing some of his work centered around industry payments to urologists and advanced practice providers. Dr. Modi, thanks for being with us today.

Parth Modi: Yeah, thanks for having me.

Ruchika Talwar: You recently published a paper in The Gold Journal, which I thought was really thought-provoking and brought up some interesting points around the idea of industry payments in our field. Tell me a bit about that paper.

Parth Modi: Sure. So this paper was largely a descriptive analysis of industry marketing payments to urologists and advanced practice providers who work in urology. And the background for this paper is the open payments or also known as the Sunshine Act data, which is a national database that's administered by CMS and it records all payments from industry sources to physicians historically and has been publicly available since 2014. And there have been numerous papers over the last nine years about those payments to physicians of all different specialties and the associations between those payments and a variety of things including prescribing habits, medical or surgical device selection, editorial opinions, guideline authorship groups, things like that. For the first time in 2021, data regarding payments to non-physician healthcare providers like nurse practitioners and physician assistants became available. So these payments weren't required to be reported until recently. So that the first year of that data was published June of 2022.

And so for the first time, we had data about industry marketing payments to nurse practitioners and physician assistants. And this was of interest to me in my research. And so a couple of the studies that we've done have looked at describing those payments to advanced practice providers. And one of the unique things about advanced practice providers, one of the challenges in studying them is that their clinical specialty or field in which they're working is not readily apparent from administrative claims or other data sets like that, which can make it challenging to try to really compare apples to apples if looking at urologists and urologic APPs in particular. And so to address that, we used a second database provided by Medicare called the Medicare Data on Provider Practice and Specialty. And that database essentially groups providers into practices, into groups, and that allowed us to use groupings to identify advanced practice providers who were working in urology. And so we use that to focus on urology specifically and look at payments from industry to both urologists and advanced practice providers in urology.

Ruchika Talwar: Yeah. And a couple of points I want to just highlight there. First, the industry payments you looked at were for marketing purposes, not compensation for investigator initiated trials, things like that. So that's an important point. And I think what you're bringing up about APPs is so important as well because a lot of times APPs, depending on how you integrate them into your practice, they're often the ones making the decisions on which medication to use for a specific condition. If you're in a primarily surgical practice and you utilize your APPs, for example, in the BPH space to medically manage some of those patients, these industry payments I think certainly can have an effect on the kinds of prescriptions that are given. So kudos to you for looking at this topic. Let's talk a little bit about the results. What did you find?

Parth Modi: Yeah. So due to the limitations of the data, we could only identify, with confidence, advanced practice providers who were working in single specialty urology practices. So those groups that had predominantly urologists. And so by necessity had to focus on those. And in that we found about almost 1,100 advanced practice providers who we could classify as urologic in their practice and compared them to about 4,500 urologists to look at the distribution of payments.

And what we found interestingly, was that about the same proportion, almost 90% of both urologists and APPs received at least one industry payment in 2021. And so the first main finding was that the proportion of providers within both groups who have at least some interaction with industry for marketing is very high and similar in both physicians and APPs. Beyond that, we looked at the amount and the types and distribution of those payments. And essentially we found that the majority of payments to APPs were either monetary or in terms of food, whereas payments to physicians also included often stocks, ownership and speaking fees and things like that.

So there were some differences in the types of payments that were made. And as a result of some of those higher value payments, especially related to ownership or intellectual property presumably, the average payment for physicians was a little bit higher than that for APPs, but it wasn't as different as you might think. And probably more importantly, the number of payments, which is a proxy for the number of interactions between industry marketing efforts and the providers, were very similar between the two groups. And some earlier work suggests that it may be more than even the value of payments, the number of unique individual interactions that might have more of an impact on behavior.

Ruchika Talwar: Yeah. Again, you bring up really interesting points. Now, I think industry payments can be a sensitive topic for a lot of people, but I think data is important and understanding the state of the situation is even more important. What is your advice to the urologic community regarding disclosures and then alternatively your advice to patients, things they should keep in mind when they are thinking about this from obtaining care perspective?

Parth Modi: Yeah. I think you're right, it's often a controversial topic whenever we talk about payments of any kind, but in particular when thinking about conflicts of interest or potential conflicts of interest. And ultimately, these payments don't necessarily make up a significant proportion of the income of most urologists or urologic APPs. And I don't think that there's necessarily any negative intention for anybody in this space. I think ultimately, and much of the research, both in biomedical ethics and in social psychology, bears this out. The association or the potential impact of receiving payments like this is in terms of forming a relationship. And relationships with marketing professionals on the industry side can change behavior. We've seen that over and over again in multiple studies using data on conflicts of interest. And some of this is due to deeply seated psychological norms.

We have a norm of reciprocity in our society where if somebody gives you something, you feel the need to give them something back. This is normal, common, healthy, I would argue, but it can be used for marketing, for influencing medical decisions. And I think so for urologists, for APPs, for healthcare providers of all types, I think it's important to keep this in mind. We don't have the option of being completely unbiased and completely uninfluenced in our lives, that's not really possible. But I think trying to limit some of the bias and influence where it's easy to do so is a good idea. And I think one of the ways that's potentially pretty easy to do is to try to minimize interactions with industry marketing efforts if you can. And ultimately, we want to make decisions based on the best data and what's best for our patients, keeping in mind our own experience and our patients' preferences. I think anything beyond that in terms of marketing, if we can avoid that influence on our decision making, I think it's for the best.

Ruchika Talwar: And what is your advice to patients? Is this something they should be aware of when they're seeing a urologist or an APP?

Parth Modi: I don't think that this specifically is something that they should be focused on, honestly. I mean, it's out there, it's available, there's no harm in looking up information. I mean, I do it sometimes to see what's out there about myself and et cetera. And so it's good to know. But I think more importantly, it's important to talk to your healthcare provider about alternatives. If you're prescribed a medication, are there other options, other medications that are similar? Especially if the medications that you're being prescribed are very expensive. It certainly is reasonable to talk to your healthcare provider about alternative options and other strategies that might be available.

Ruchika Talwar: I couldn't agree more. And I think an empowered patient, somebody who understands why a certain medication was chosen, whether it's in terms of specific side effects, contraindications, maybe financial toxicity, one is cheaper, one is covered, one is not. I think that is all good information for the patient to have and understand so that they can take ownership of their care. I couldn't agree more with you. And I think, editorializing a bit here, industry payments in a lot of ways, they help us learn about new drugs in the market. But I think you hit the nail on the head when you said, "Being aware of how those relationships may influence your behavior and your bias is going to be very important for all healthcare providers."

Parth Modi: Yeah. And broadly speaking, people have described two main strategies. Disclosure, which is being done quite effectively, I think with the open payments program data. And the second strategy is divestment or trying to eliminate some of these conflicts or potential conflicts when possible. And ultimately being aware of them is one thing, I think actively trying to minimize some of those conflicts of interest is the next step for all of us.

Ruchika Talwar: Absolutely. Well, thank you, Dr. Modi for taking time to chat with us on this really important topic today.

Parth Modi: Thank you.

Ruchika Talwar: And to our UroToday audience, we'll see you next time.