Unveiling the Hidden Discrepancies Between Medicare Physician Reimbursement Rates and Inflation Across Different Surgical Specialties.

OBJECTIVE: This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties. BACKGROUND: Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement. STUDY DESIGN: The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics. RESULTS: After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001). CONCLUSIONS: This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.

The hidden costs of the intercollegiate membership of the Royal College of surgeons examinations: Can trainees afford it?

BACKGROUND: The Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination is a mandatory requirement for higher specialty surgical training in the UK. However, there is a significant economic impact on trainees which raises the question of whether the costs of this exam hinder surgical career progression. This study explores the burden of these exams on trainees. METHODS: A 37-point questionnaire was distributed to all trainees who were preparing for or have sat MRCS examinations. Univariate analyses included the cost of the preparatory resources, extra hours worked to pay for these and the examinations, and the number of annual leave (AL) days taken to prepare. Pearson correlation coefficients were used to identify possible correlation between monetary expenditure and success rate. RESULTS: On average, trainees (n â€‹= â€‹145) spent £332.54, worked 31.2 â€‹h in addition to their rostered hours, and used 5.8 AL days to prepare for MRCS Part A. For MRCS Part B/ENT, trainees spent on average £682.92, worked 41.7 extra hours, and used 5 AL days. Overall, the average trainee spent 5-9% of their salary and one-fifth of their AL allowance to prepare for the exams. There was a positive correlation between number of attempts and monetary expenditure on Part A preparation (r(109)=0.536, p â€‹< â€‹0.001). CONCLUSIONS: There is a considerable financial and social toll of the MRCS examination on trainees. Reducing this is crucial to tackle workforce challenges that include trainee retention and burnout. Further studies exploring study habits can help reform study budget policies to ease this pressure on trainees.

Exploring the approach to parameter uncertainty in early economic evaluations of surgical technology - a systematic review.

INTRODUCTION: The role of early economic evaluation (EEE) in the development of medical technology has been increasingly recognized; however, data on the use of EEE in surgical technology are sparse. The objective of this review was to explore the use of EEE in the development of surgical technologies, with emphasis on how uncertainty has been addressed. AREAS COVERED: A systematic review was conducted, and original articles employing any form of EEE of surgical technology were selected for review, with 10 studies included in the analysis. These studies demonstrated significant variation in the approach to managing parameter uncertainty, specifically regarding the type of analysis used and the inclusion of effectiveness parameters in sensitivity analysis. The conclusions drawn did not appear to factor in uncertainty in the models. EXPERT OPINION: Approaches to handling parameter uncertainty in previous EEEs of surgical technology have been limited, with some studies failing to address parameter uncertainty. In addition, EEEs do not appear to follow established guidelines with respect to the use of sensitivity analyses. It is important that EEEs of surgical technology address parameter uncertainty in order to draw more robust conclusions from the analysis and allow investors to consider this uncertainty when making investment decisions.

Reducing Operating Room Cost: Comparing Attending and Surgical Trainee Perceptions About the Implementation of Supply Receipts.

BACKGROUND: As operating room (OR) expenditures increase, faculty and surgical trainees will play a key role in curbing future costs. However, supply cost utilization varies widely among providers and, despite requirements for cost education during surgical training, little is known about trainees' comfort discussing these topics. To improve OR cost transparency, our institution began delivering real-time supply "receipts" to faculty and trainees after each surgical case. This study compares faculty and surgical trainees' perceptions about supply receipts and their effect on individual practice and cultural change. STUDY DESIGN: Faculty and surgical trainees (residents and fellows) from all adult surgical specialties at a large academic center were emailed separate surveys. RESULTS: A total of 120 faculty (30.0% response rate) and 119 trainees (35.7% response rate) completed the survey. Compared with trainees, faculty are more confident discussing OR costs (p < 0.001). Two-thirds of trainees report discussing OR costs with faculty as opposed to 77.0% of faculty who acknowledge having these conversations (p = 0.08). Both groups showed a strong commitment to reduce OR expenditures, with 87.3% of faculty and 90.0% of trainees expressing a responsibility to curb OR costs (p = 0.84). After 1 year of implementation, faculty continue to have high interest levels in supply receipts (82.4%) and many surgeons review them after each case (67.7%). In addition, 74.3% of faculty are now aware of how to lower OR costs and 52.5% have changed the OR supplies they use. Trainees, in particular, desire additional cost-reducing efforts at our institution (p < 0.001). CONCLUSIONS: Supply receipts have been well received and have led to meaningful cultural changes. However, trainees are less confident discussing these issues and desire a greater emphasis on OR cost in their curriculum.

Association of Surgeon Representation on NIH Study Sections With Receipt of Funding by Surgeon-scientists.

OBJECTIVE: Our goal was to evaluate the relationship between surgeon representation on NIH study sections and success in grant funding. SUMMARY OF BACKGROUND DATA: NIH funding for surgeon-scientists is declining. Prior work has called for increased surgeon participation in the grant review process as a strategy to increase receipt of funding by surgeon-scientists. METHODS: A retrospective review of surgeon (primary department: General, Urology, Orthopedic, Ophthalmology, Otolaryngology, Neurosurgery) representation on NIH study sections and receipt of funding was performed using NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) and 2019 Blue Ridge Institute for Medical Research data. NIH chartered study section panels and ad hoc reviewers for each 2019 review date were also obtained. RESULTS: In 2019, 9239 individuals reviewed in at least 1 of the 168 study sections [190 (2.1%) surgeons, 64 (0.7%) standing members, 126 (1.4%) ad-hoc]. Most surgeons on study sections were male (65%) professors (63%). Surgeons most commonly served on bioengineering, technology, and surgical sciences (29.6% surgeons), diseases and pathophysiology of the visual system (28.3%), and surgery, anesthesiology and trauma (21%). In 2019, 773 surgeons received 1235 NIH grants (>$580 M) out of a total of 55,012 awards (2.2%). Funded surgeons were predominantly male (79%), White (68%), non-Hispanic (97%), full professors (50%), and 43% had additional advanced degrees (MPH/PhD/MBA). surgery, anesthesiology and trauma, diseases and pathophysiology of the visual system, and bioengineering, technology, and surgical sciences were the most common study sections that reviewed funded grants to surgeon-scientists. Ninety-two surgeons both received grant funding and served on study section. Study sections with higher surgeon representation were more likely to fund surgeon-scientists (P < 0.001). CONCLUSIONS: Surgeon representation on NIH study sections is strongly associated with receipt of funding by surgeon-scientists. Increasing NIH study section representation by surgeons may help to preserve the surgeon-scientist phenotype.

NIH Funding for Surgeon-Scientists in the US: What Is the Current Status?

BACKGROUND: Recent literature suggests that the future of surgeon-scientists in the US has been threatened for the past several decades. However, we documented an overall increase in NIH funding for surgeon-scientists, as well as the number of NIH-funded surgeons, from 2010 to 2020. STUDY DESIGN: NIH-funded principal investigators (PIs) were identified for June 2010 and June 2020 using the NIH internal data platform iSearch Grants (version 2.4). Biographical sketches were searched for key terms to identify surgeon-scientists. Grant research types and total grant costs were collected. American Association of Medical Colleges data were used to determine total surgeon and physician populations. Bivariate chi-square analyses were performed using population totals and were corroborated using z-tests of population proportions using JMP (version 13.0.0). A 2-tailed p value <0.05 was considered significant. RESULTS: In June of 2020, a total of 1,031 surgeon-scientists held $872,456,710 in NIH funding. The percentage of funded surgeons significantly increased from 2010 (0.5%) to 2020 (0.7%) (p < 0.05), and the percentage of funded other physicians significantly decreased from 2.2% in 2010 to 1.6% in 2020 (p < 0.05). All surgeons sustained R grant funding at both time points (58% in 2020 and 60% in 2010), and specifically maintained basic science-focused R grants (73% in 2020 and 78% in 2010). CONCLUSIONS: Our study found surgeon-scientists are increasing in number and NIH funding and are becoming more diverse in their research efforts, while maintaining a focus on basic science.

Surgical Residents' Perceptions of the Impact of Productivity-Based Faculty Compensation at an Academic Medical Center.

BACKGROUND: Academic medical centers have increasingly adopted productivity-based compensation models for faculty. The potential exists for conflict between financial incentives and the quality of surgical resident education. This study aims to examine surgical residents' perceptions regarding the impact of productivity-based compensation on education. METHODS: Following implementation of a productivity-based compensation plan, a survey of surgical residents (general surgery, plastic surgery, otolaryngology, urology, orthopedic surgery, and neurosurgery) was conducted to examine perceptions of its impact on didactics, patient care, surgical technique, teaching in the operating room, and financial considerations. Survey data were prospectively collected and analyzed. A retrospective analysis of relative value units (RVUs) was also performed. RESULTS: Following implementation of the productivity-based compensation plan, annual work RVUs increased by 8.9% in surgery as a whole, with increases observed within all surgical subspecialties. A total of 100 surveys were sent and 35 were completed (35% response rate and at least 30% within each surgical subspecialty). Forty-nine percent of participants perceived an increased focus on clinical productivity by faculty. Thirty-seven percent reported learning more about RVUs and Current Procedural Terminology coding. Most residents reported that the compensation plan did not have an impact on their education with respect to didactics (77%), patient care (94%), surgical technique (97%), and teaching in the operating room (83%). CONCLUSIONS: Increased clinical productivity in the setting of an RVU-based compensation plan was not perceived by most surgical residents to have impacted their education. In some cases, this model may enhance education in relation to RVUs, Current Procedural Terminology coding, and the financial aspects of surgery.

The Changing Face of Academic Surgery: Overrepresentation of Women among Surgeon-Scientists with R01 Funding.

BACKGROUND: There has been a recent focus on sex-based disparities within the field of academic surgery. However, the proportion of female surgeons conducting NIH-funded research is unknown. STUDY DESIGN: The NIH RePORTER (Research Portfolio Online Reporting Tools Expenditures and Results) was queried for R01 grants from surgery departments for which the principal investigator (PI) had a primary medical degree, as of October 2018. Characteristics of the PI and their respective grants were collected. Institutional faculty profiles were reviewed for PI and departmental characteristics. PIs were stratified by sex and compared using standard univariate statistics. RESULTS: There were a total of 212 R01 grants in surgery departments held by 159 PIs. Of these, 26.4% (n = 42) of R01-funded surgeons were female compared with the reported 19% of academic surgery female faculty (as reported by the Association of American Medical Colleges; p = 0.02). Women with R01 grants were more likely to be first-time grant recipients with no concurrent or previous NIH funding (21.4% vs 8.6%; p = 0.03) and less likely to have a previous R01 or equivalent grant (54.8% vs 73.5%; p = 0.03). Women were more likely to be from departments with a female surgery chair (31.0% vs 13.7%; p = 0.01) or a department with > 30% female surgeons (35.0% vs 18.2%; p = 0.03). CONCLUSIONS: Although female surgeons remain a minority in academic surgery, they hold a greater than anticipated proportion of NIH funding, with a high number of first-time grants, forming a crucial component of the next generation of surgeon-scientists.

Measuring the migration of surgical specialists.

BACKGROUND: The lack of access to essential surgical care in low-income countries is aggravated by emigration of locally-trained surgical specialists to more affluent regions. Yet, the global diaspora of surgeons, obstetricians, and anesthesiologists from low-income and middle-income countries has never been fully described and compared with those who have remained in their country of origin. It is also unclear whether the surgical workforce is more affected by international migration than other medical specialists. In this study, we aimed to quantify the proportion of surgical specialists originating from low-income and middle-income countries that currently work in high-income countries. METHODS: We retrieved surgical workforce data from 48 high-income countries and 102 low-income and middle-income countries using the database of the World Health Organization Global Surgical Workforce. We then compared this domestic workforce with more granular data on the country of initial medical qualification of all surgeons, anesthesiologists, and obstetricians made available for 14 selected high-income countries to calculate the proportion of surgical specialists working abroad. RESULTS: We identified 1,118,804 specialist surgeons, anesthesiologists, or obstetricians from 102 low-income and middle-income countries, of whom 33,021 (3.0%) worked in the 14 included high-income countries. The proportion of surgical specialists abroad was greatest for the African and South East Asian regions (12.8% and 12.1%). The proportion of specialists abroad was not greater for surgeons, anesthesiologists, or obstetricians than for physicians and other medical specialists (P = .465). Overall, the countries with the lowest remaining density of surgical specialists were also the countries from which the largest proportion of graduates were now working in high-income countries (P = .011). CONCLUSION: A substantial proportion of all surgeons, anesthesiologists, and obstetricians from low-income and middle-income countries currently work in high-income countries. In addition to decreasing migration from areas of surgical need, innovative strategies to retain and strengthen the surgical workforce could involve engaging this large international pool of surgical specialists and instructors.

Assessment of the Contribution of the Work Relative Value Unit Scale to Differences in Physician Compensation Across Medical and Surgical Specialties.

Importance: The work relative value units (wRVUs) for a physician service can be conceptualized as the amount of time spent by the physician multiplied by a compensation rate (wRVUs/min). Disproportionately high compensation rates assigned to procedures have been blamed for pay differences across specialties, but to our knowledge, a comprehensive assessment is lacking. Objective: To assess how compensation rates built into work RVUs contribute to differences in physician compensation across specialties. Design, Setting, and Participants: This cross-sectional analysis examined 2017 Part B fee-for-service Medicare data. The data were analyzed from May 1 to May 30, 2019. Main Outcomes and Measures: A specialty-wide compensation rate (wRVUs/min) was generated for 42 medical and surgical specialties defined as the sum of wRVUs for all billed current procedural terminology codes divided by the presumed time to perform those services. This measure accounted for the volume and diversity of services each specialty provides. Sensitivity analyses were performed to assess the association of errors in wRVU time estimates with average compensation rates. Results: The final sample included 42 specialties and 6587 distinct Current Procedual Terminology (CPT) codes. The number of CPT codes attributed to a specialty ranged from 575 (medical oncology) to 4346 (general surgery). Compensation rates ranged from 0.029 wRVUs/min (pathology) to 0.057 wRVUs/min (emergency medicine). Most specialties (34/42 [81.0%]) had compensation rates between 0.035 and 0.045 wRVUs/min. The mean compensation rate for surgical specialties was 7.2% higher than for medical specialties, a difference that was not statistically significant. This narrow range reflects the fact that most specialties had more than 60% of time allocated to activities outside the intraservice period. Assuming that time values for surgical procedures are significantly overestimated increased the difference in average compensation between surgical and medical specialties to 23.4%. Conclusions and Relevance: Compensation rates assumed in wRVU valuations are small contributors to differences in physician compensation. Factors outside of the wRVU system, such as payer mix and work hours, could be targeted if narrowing the difference in compensation across specialties is desired.

Gender disparities in academic vascular surgeons.

OBJECTIVE: Previous studies have identified significant gender discrepancies in grant funding, leadership positions, and publication impact in surgical subspecialties. We investigated whether these discrepancies were also present in academic vascular surgery. METHODS: Academic websites from institutions with vascular surgery training programs were queried to identify academic faculty, and leadership positions were noted. H-index, number of citations, and total number of publications were obtained from Scopus and PubMed. Grant funding amounts and awards data were obtained from the National Institutes of Health (NIH) and Society for Vascular Surgery websites. Industry funding amount was obtained from the Centers for Medicare and Medicaid Services website. Nonsurgical physicians and support staff were excluded from this analysis. RESULTS: We identified 177 female faculty (18.6%) and 774 male faculty (81.4%). A total of 41 (23.2%) female surgeons held leadership positions within their institutions compared with 254 (32.9%) male surgeons (P = .009). Female surgeons held the rank of assistant professor 50.3% of the time in contrast to 33.9% of men (P < .001). The rank of associate professor was held at similar rates, 25.4% vs 20.7% (P = .187), respectively. Fewer women than men held the full professor rank, 10.7% compared with 26.2% (P < .001). Similarly, women held leadership positions less often than men, including division chief (6.8% vs 13.7%; P < .012) and vice chair of surgery (0% vs 2.2%; P < .047), but held more positions as vice dean of surgery (0.6% vs 0%; P < .037) and chief executive officer (0.6% vs 0%; P < .037). Scientific contributions based on the number of each surgeon's publications were found to be statistically different between men and women. Women had an average of 42.3 publications compared with 64.8 for men (P < .001). Female vascular surgeons were cited an average of 655.2 times, less than half the average citations of their male counterparts with 1387 citations (P < .001). The average H-index was 9.5 for female vascular surgeons compared with 13.7 for male vascular surgeons (P < .001). Correcting for years since initial board certification, women had a higher H-index per year in practice (1.32 vs 1.02; P = .005). Female vascular surgeons were more likely to have received NIH grants than their male colleagues (9.6% vs 4.0%; P = .017). Although substantial, the average value of NIH grants awarded was not statistically significant between men and women, with men on average receiving $915,590.74 ($199,119.00-$2,910,600.00) and women receiving $707,205.35 ($61,612.00-$4,857,220.00; P = .416). There was no difference in the distribution of Society for Vascular Surgery seed grants to women and men since 2007. Industry payments made publicly available according to the Sunshine Act for the year 2018 were also compared, and female vascular surgeons received an average of $2155.28 compared with their male counterparts, who received almost four times as much at $8452.43 (P < .001). CONCLUSIONS: Although there is certainly improved representation of women in vascular surgery compared with several decades ago, a discrepancy still persists. Women tend to have more grants than men and receive less in industry payments, but they hold fewer leadership positions, do not publish as frequently, and are cited less than their male counterparts. Further investigation should be aimed at identifying the causes of gender disparity and systemic barriers to gender equity in academic vascular surgery.

Development and Validation of the Data Instrument for Surgical Global Outreach.

Countless efforts have been made by global surgery outreach organizations to provide care to individuals in low- and middle-income countries; however, there is a paucity of data on these interventions. The authors created the Data Instrument for Surgical Global Outreach to collect basic program, cost, and clinical data on surgical outreach efforts using the literature and the experience of our team. The authors performed a two-round modified Delphi technique to build content validity on the instrument and establish consensus. Experts engaged in global health or global surgery as a health care provider, researcher, or policymaker participated in the validation. In addition, the authors calculated Cronbach's alpha to determine the degree of agreement among experts. A total of 22 experts in global health participated in the validation of the data tool. Changes were made to reword, combine, remove, add, clarify, and simplify data points. There was a unanimous decision to accept the revised data collection instrument among the experts after the second Delphi round. Cronbach's alpha was 0.86 for the first round and 0.95 for the second round, indicating a high degree of internal consistency. The global surgery outreach community must define a set of strategies to collect more robust data on surgical outreach efforts to low- and middle-income countries. Such data will permit policymakers to identify shortfalls in programs and researchers to pursue sustainable treatment modalities and processes of care. Quality collaboratives for surgical outreach organizations may serve as a tool to overcome variation, reduce cost, and improve the quality of care for patients.

Gender and compensation among surgical specialties in the Veterans Health Administration.

BACKGROUND: A gender pay gap has been reported across many professions, including medicine. METHODS: Surgeons employed at complex Veterans Affairs Medical Centers (VAMC) nationwide in 2016 were identified. Data on salary, gender, years since medical school graduation, professorship status, h-index, and geographic location were collected. RESULTS: Of 1993 surgeons nationwide, 23% were female. On average, female surgeons had significantly lower salaries compared to male surgeons ($268,429 ± 41,339 versus $287,717 ± 45,379, respectively; p < 0.001). Among each surgical specialty, there were no significant differences in salary on univariate analysis. Women were underrepresented in higher paying specialties and more heavily represented in lower paying specialties. On multivariate analysis, gender (p < 0.001), time since medical school graduation (p < 0.001), surgical specialty (p = 0.031), h-index (p < 0.001), and geographic location (p < 0.001) were significant predictors of salary. CONCLUSION: Female gender significantly predicted lower salary among VAMC surgeons, however within each surgical specialty, there was no significant gender pay gap. SENTENCE SUMMARY: Independent predictors of salary included gender, surgical specialty, experience, h-index, and geographic location. Although female surgeons had lower overall salaries compared to male surgeons in the Veterans Health Administration (VHA), there were no significant gender differences in salary among each surgical specialty. Pay transparency, unique to the VHA, along with the use of rational and objective criteria to establish and adjust salaries, may play a role in reducing the gender pay gap among VHA surgeons.

Industry Payments for Otolaryngology Research: A Four-Year Analysis of the Open Payments Database.

OBJECTIVE: To characterize industry research payments to otolaryngologists. STUDY DESIGN: Cross-sectional retrospective analysis. METHODS: We examined research payments made to otolaryngologists 2014 through 2017 included in the Open Payments Database. Trends in payment values over time were characterized and compared to other surgical specialties. Geographical and temporal trends in payments to specific principal investigators, along with the ties to specific companies, were analyzed. RESULTS: Among surgical specialties, otolaryngology was the second lowest paid in terms of total compensation from industry for research per active U.S. physician. The median (mean) payment to otolaryngologists was $819 ($5,514), $548 ($3,083), $771 ($3,484), and $1,000 ($5,768) in 2014, 2015, 2016, and 2017, respectively. There was typically a higher mean and median payment per otolaryngologists in the Northeast, although significant differences between each region varied by year. The 40 most highly funded recipients had total compensation that was on average spread over 3.35 years of the database, 2.975 different companies, and 7.35 distinct scientific studies-all significantly higher compared to otolaryngologists with less funding. CONCLUSION: Research payments to otolaryngologists are concentrated in a small number of otolaryngologists; however, many of the most highly funded principal investigators worked on numerous studies with a variety of different companies over many years. Our characterization of the Open Payments Database over 4 years illustrates the depth of relationship between otolaryngology research and industry as well as raises awareness regarding the ease of connecting otolaryngologists to research payments. LEVEL OF EVIDENCE: NA Laryngoscope, 130:314-320, 2020.

Stanford's Biodesign Innovation program: Teaching opportunities for value-driven innovation in surgery.

The Stanford Biodesign Innovation process, which identifies meaningful clinical needs, develops solutions to meet those needs, and plans for subsequent implementation in clinical practice, is an effective training approach for new generations of healthcare innovators. Continued success of this process hinges on its evolution in response to changes in healthcare delivery and an ever-increasing demand for economically viable solutions. In this article, we provide perspective on opportunities for value-driven innovation in surgery and relate these to value-related teaching elements currently integrated in the Stanford Biodesign process.

Is Global Pediatric Surgery a Good Investment?

Investing in surgery has been highlighted as integral to strengthening overall health systems and increasing economic prosperity in low-income and middle-income countries (LMICs). The provision of surgical care in LMICs not only affects economies on a macro-level, but also impacts individual families within communities at a microeconomic level. Given that children represent 50% of the population in LMICs and the burden of unmet surgical needs in these areas is high, investing pediatric-specific components of surgical and anesthesia care is needed. Implementation efforts for pediatric surgical care include incorporating surgery-specific priorities into the global child health initiatives, improving global health financing for scale-up activities for children, increasing financial risk protection mechanisms for families of children with surgical needs, and including comprehensive pediatric surgical models of care into country-level plans.

The Sunshine Act and Surgeons: A Nation-Wide Analysis of Industry Payments to Physicians.

BACKGROUND: The Physician Payments Sunshine Act mandates the submission of payment records between medical providers and industry. We used the Open Payments Program database to compare industry payments to surgeons and nonsurgeons, as well as among surgical specialties, and to identify geographic distribution of payments. MATERIALS AND METHODS: We included all reported industry payments in the Centers for Medicare and Medicaid Services' Open Payments Program in the United States, 2014-2015. Multivariable regression fixed effects panel analysis of total payments was conducted among surgeons, adjusting for surgeon specialty, payor type, payment category, and state. A geographic heat map was created. RESULTS: Of 2,097,150 subjects meeting criteria, 1,957,528 (45.66%) were physicians. The mean standard deviation (SD) payment overall was $232.64 ($6262.00), and the state with the highest mean (SD) payment was Vermont at $2691.61 ($11,508.40). Surgeons numbered 153,916 (7.86%). The specialty with the highest mean (SD) payment was orthopedic surgery at $2811.50 ($33,632.71, P < 0.001). Among 2,097,150 subjects meeting criteria, in multivariable regression fixed effects panel analysis, orthopedic compared to general surgeons were significantly likely to receive more industry payments (beta $1065.34 [95% CI $279.00-1851.00, P = 0.008), even controlling for payor, payment type, and state. Significant geographic disparities in payment were noted as 12 states received the top mean ($24.52-$500,000.00), leaving seven states with the lowest ($0.00-$12.56). CONCLUSIONS: There are significant differences in industry payments to surgeons versus nonsurgeons and among surgical specialties, as well geographic distribution of payments. These data may prompt further investigation into trends and their causality and effects on research and practice.

Assessing the domino effect: Female physician industry payments fall short, parallel gender inequalities in medicine.

BACKGROUND: Physician-industry relationships have been complex in modern medicine. Since large proportions of research, education and consulting are industry-backed, this is an important area to consider when examining gender inequality in medicine. METHODS: The Open Payments Program (OPP) database from August 2013 to December 2016 was analyzed. In order to identify physicians' genders, the OPP was matched with the National Provider Index dataset. Descriptive statistics of payments to female compared to male surgeons were obtained and stratified by payment type, subspecialty, geographic location and year. RESULTS: 3,925,707 transactions to 136,845 physicians were analyzed. Of them, 31,297 physicians were surgeons with an average payment per provider of $131,252 to male surgeons compared to $62,101 to female surgeons. Significantly fewer women received consultant, royalty/licensure, ownership and speaker payments. However, women received a higher average amount per surgeon compared to their male counterparts within research payments. Overall payments to women trended upwards over time. CONCLUSION: Gender inequality still exists in medicine, and in industry-physician payments. Industry should increasingly consider engaging women in consultancies, speaking engagements, and research.