Truth, Trust, and Transparency—The Highly Complex Nature of Patients’ Perceptions of Conflicts of Interest in Medicine

Abstract

Half of all US physicians receive payments from the biomedical industry, totaling $2.4 billion in 2015. 1 While this phenomenon reflects critical physician-industry collaboration, we cannot ignore the conflicts of interest (COIs) that these financial relationships introduce into medical practice.Motivated by the notion that patients should have access to this payment information to make more informed medical decisions, the Physician Payments Sunshine Act was implemented in 2013.Under the 2010 Patient Protection and Affordable Care Act, pharmaceutical and medical device manufacturers are required to report all gifts and payments they make to physicians.Run by the Centers for Medicare & Medicaid Services, this information is publicly available, with the aim of increased transparency to engender patient trust and (ideally) improve care. 2 To this end, Kanter et al 3 attempted to ask: did it work?Do patients trust their physicians (and the medical field) more now that they can access information on industry payments?In their national study of 1388 US adults, Kanter et al 3 performed a difference-in-difference analysis comparing the longitudinal change in trust among respondents in states where industry payments were newly disclosed via Open Payments with states where industry payment information was already available due to state disclosure laws.After controlling for demographic variables, they concluded that there was an "unintended consequence" of Open Payments: the authors found a greater decline in trust among states with newly available Open Payments information compared with states with preexisting publicly available financial disclosure data.Is it possible that increased payment transparency actually undermined patient trust in physicians?Several major assumptions must be made to attribute this nationwide decline in patient trust to Open Payments.First, we would have to assume that respondents even know that Open Payments exists; however, prior research shows that only 12% of US adults are aware of the data.4 Second, we would have to assume that patients care about these payments.A study 5 interviewing patients in cancer research trials specifically about their attitudes toward financial COIs revealed that they did not care much about whether their physicians were involved with industry, and most actually classified speaker and consulting fees as "ethical."Another study 6 found that some patients viewed physicians without payments as inexperienced or professionally isolated, and they alternatively viewed physicians with consulting payments as experts and better informed.Third, the biggest assumption is that we can attribute the nation's trust in health care from 2014 to 2016 specifically to Open Payments as opposed to the myriad of other variables surfacing during this time.Health care is dynamic, and important factors like rising health care costs, frustrations with insurance coverage, availability of physicians, access to care, media coverage of health care, and publicized physician scandals (to name a few) can all potentially influence patients' perceptions of trust.While Kanter et al 3 attempted to account for confounding variables by comparing states, this approach cannot control for possible state-specific factors (ie, managed health care groups and state-run insurance programs).7 Nevertheless, if we make these assumptions and thus conclude that increased transparency of payments is associated with decreased trust, should we be that surprised?Is it so clear-cut that increased transparency should automatically engender trust?Research in nonmedical fields tells us otherwise.In government, transparency was historically thought to improve decision making, impede corruption, enhance accountability, and lead to a more informed citizenry; yet, evidence +