A more complete list of publications is available at this NCBI PubMed profile and this Google Scholar profile.
Kanter GP, Segal AG, Groeneveld PW. Income disparities in access to critical care services. Health Affairs 2020; 39.
View full article [paywall - contact Lab if you need a copy]
The coronavirus disease 2019 (COVID-19) pandemic has highlighted the importance of intensive care unit (ICU) beds in preventing death from the severe respiratory illness associated with COVID-19. However, the availability of ICU beds is highly variable across the US, and health care resources are generally more plentiful in wealthier communities. We examined disparities in community ICU beds by US communities’ median household income. We found a large gap in access by income: 49 percent of the lowest-income communities had no ICU beds in their communities, whereas only 3 percent of the highest-income communities had no ICU beds. Income disparities in the availability of community ICU beds were more acute in rural areas than in urban areas. Policies that facilitate hospital coordination are urgently needed to address shortages in ICU hospital bed supply to mitigate the effects of the COVID-19 pandemic on mortality rates in low-income communities.
Kanter GP, Nabet B, Matone M, Rubin DM. Association of state Medicaid expansion with hospital community benefit spending. JAMA Netw Open 2020; 3:3205529.
IMPORTANCE Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities.
OBJECTIVE To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion.
DESIGN, SETTING, AND PARTICIPANTS This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019.
EXPOSURES State Medicaid expansion between 2011 and 2017.
MAIN OUTCOMES AND MEASURES Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending.
RESULTS Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%])were small hospitals with fewer than 100 beds, and nearly 70%of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (−0.68 [95%CI, −0.99 to −0.37] percentage points from a baseline mean [SD] of 3.6%[4.0%] of total hospital expenditures; P < .001) and in bad debt (−0.17 [95%CI, −0.32 to −0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95%CI, 0.60 to 1.10] percentage points; P = .04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (−0.24 [95%CI, −0.48 to 0.00] percentage points; P = .049). Direct community expenditures remained more stable in small hospitals (–0.07 [95%CI, –0.20 to 0.05] percentage
points; P =.26) compared with large hospitals (–0.37 [95%CI, –0.86 to 0.12] percentage points; P = .14) and in nonurban hospitals (0.02 [95%CI, −0.09 to 0.14] percentage points; P = .70) compared with urban hospitals (–0.36 [95%CI, –0.73 to 0.01] percentage points; P = .06).
CONCLUSIONS AND RELEVANCE In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals’ burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.
Kanter GP, Polsky D, Werner RM. Changes in Physician Consolidation with the Spread of Accountable Care Organizations. Health Affairs 2019; 38:1936-1943.
While early evidence suggests that accountable care organizations (ACOs) are associated with higher quality and lower costs, there have been simultaneous concerns that ACOs may incentivize consolidation of physician groups. This is particularly concerning as previous research has shown that consolidation is associated with lower quality and higher prices. Using a difference-in-differences strategy and data from the Medicare Shared Savings Program, which began in 2012, we examined whether physician practices consolidated after ACOs entered health care markets. We observed a 4.0-percentage-point increase in large practices (those with fifty or more physicians) in counties with the greatest ACO penetration, compared to counties with zero ACO penetration, and a 2.7-percentage-point decline in the percentage of small practices (ten or fewer physicians) from 2010 to 2015. The growth of large practices was concentrated in specialty and hospital-owned practices. These findings suggest that ACOs may contribute to the concentration of physician practices.
Kanter GP, Loewenstein G. Evaluating Open Payments. JAMA 2019; 322:401-402.
Perhaps the greatest challenge of transparency may be its potential to increase patient distrust of medicine, adversely affecting the patient-physician relationship and patient health. The extensive use that journalists have made of Open Payments in spotlighting physicians with the largest payments, as well as lapses in reporting conflicts of interest, raises the question of whether disclosure of industry payments to physicians could have a perverse effect, potentially leading patients to avoid the services of physicians, including physicians who did not receive payments, or to not follow well-informed advice.
Kanter GP, Carpenter D, Lehmann L, Mello MM. 2019. US Nationwide Disclosure of Industry Payments and Public Trust in Physicians. JAMA Netw Open 2:e191947.
Transparency of industry payments to physicians could engender greater public trust in physicians but might also lead to greater mistrust of physicians and the medical profession, adversely affecting the patient-physician relationship.
To examine the association between nationwide public disclosure of industry payments and Americans’ trust in their physicians and trust in the medical profession.
Design, Setting, and Participants
Survey study using difference-in-difference analyses of a national longitudinal survey comparing changes in states where industry payments were newly disclosed by Open Payments with changes in states where payments information was already available because of state sunshine laws. The US population-based surveys were conducted in September 2014—shortly before the initial public disclosure of industry payments—and again in September 2016. Final analyses were conducted September through December 2018. Participants were adults 18 years and older (n = 1388).
National public disclosure through Open Payments of payments made by pharmaceutical and medical device firms to physicians.
Main Outcomes and Measures
Wake Forest measure of trust in one’s own physician and Wake Forest measure of trust in the medical profession.
Of the 3542 original survey respondents, 2180 (61.5%) completed the second survey 2 years later, and 1388 named the same most frequently seen physician in both surveys. The mean age of respondents at the time of the first survey was 53 years, and 749 (54.0%) were women. Race/ethnicity was white in 76.6% (1063 of 1388) and non-Hispanic black in 8.0% (111 of 1388). Public disclosure of payments was associated with lower trust in one’s own physician regardless of whether respondents knew their physicians had received payments (decrease in Wake Forest measure of trust in one’s own physician of 0.56 point; 95% CI, −0.79 to −0.32 point; P < .001). Open Payments was also associated with lower trust in the medical profession (decrease in Wake Forest measure of trust in the medical profession of 0.35 point; 95% CI, −0.58 to −0.12 point; P = .004).
Conclusions and Relevance
Nationwide public disclosure of industry payments may be associated with decreased trust in physicians and in the medical profession. More judicious presentation of payments information may counteract unintended negative trust and spillover consequences of public disclosure.
Kanter GP, Carpenter D, Lehmann L, Mello MM. 2019. Effect of the Public Disclosure of Industry Payments Information on Patients: Results from a Population-Based Natural Experiment. BMJ Open 9:e024020.
To determine the effect of the public disclosure of industry payments to physicians on patients’ awareness of industry payments and knowledge about whether their physicians had accepted industry payments.
Interrupted time series with comparison group (difference-in-difference analyses of longitudinal survey).
Nationally representative US population-based surveys. Surveys were conducted in September 2014, shortly prior to the public release of Open Payments information, and again in September 2016.
Adults aged 18 and older (n=2180).
Main outcome measures
Awareness of industry payments as an issue; awareness that industry payments information was publicly available; knowledge of whether own physician had received industry payments.
Public disclosure of industry payments information through Open Payments did not significantly increase the proportion of respondents who knew whether their physician had received industry payments (p=0.918). It also did not change the proportion of respondents who became aware of the issue of industry payments (p=0.470) but did increase the proportion who knew that payments information was publicly available (9.6% points, p=0.011).
Two years after the public disclosure of industry payments information, Open Payments does not appear to have achieved its goal of increasing patient knowledge of whether their physicians have received money from pharmaceutical and medical device firms. Additional efforts will be required to improve the use and effectiveness of Open Payments for consumers.
Kanter GP, Pauly MV. 2019. Coordination of Care or Conflict of Interest? Exempting ACOs from the Stark Law. N Engl J Med 380:410-411.
Care coordination has become a central theme of new payment and delivery systems. There is, however, at least one downside to care coordination arrangements: they clash with existing regulations on financial conflicts of interest in medicine.
Kanter GP. 2018. Extending the Sunshine Act from Physicians to Patient Advocacy Organizations. Am J Public Health. 108:978-979.
Abstract (first paragraph)
In the mythical past, health care was about patients and physicians. Then, insurers and pharmaceutical companies intruded. Patient advocates interceded. Legislators intervened. The health care system became crowded and complex. We now find ourselves in a convoluted system in which pharmaceutical companies are financing the activities of patient advocacy organizations.
McCoy MS, Kanter GP. 2018. Campaign Contributions From Political Action Committees to Members of Congressional Committees Responding to the Opioid Crisis. JAMA 320:1489-1491.
View full article (contact Kanter Research Lab for copy if unable to access)
Abstract (first paragraph)
Federal lawmakers have recently taken steps to ensure that the policy response to the opioid crisis is not influenced by advocacy groups with financial ties to the opioid industry. However, whether members of Congress might have relevant conflicts of interest stemming from financial ties to the opioid industry is unknown. Although advocacy groups can influence policy only indirectly, members of Congress oversee federal agencies and are directly responsible for crafting legislation to address the opioid crisis. In particular, members of the Senate Health, Education, Labor, and Pensions (HELP) Committee and the House Energy and Commerce Committee have led the Senate and House responses to the crisis.
Pham-Kanter G, Mello MM, Lehmann LS, Campbell EG, Carpenter D. 2017. Public Awareness of and Contact with Physicians Who Receive Industry Payments: A National Survey. Journal of General Internal Medicine 32:767-774.
The Physician Payments Sunshine Act, part of the Affordable Care Act, requires pharmaceutical and medical device firms to report payments they make to physicians and, through its Open Payments program, makes this information publicly available.
To establish estimates of the exposure of the American patient population to physicians who accept industry payments, to compare these population-based estimates to physician-based estimates of industry contact, and to investigate Americans’ awareness of industry payments.
Cross-sectional survey conducted in late September and early October 2014, with data linkage of respondents’ physicians to Open Payments data.
A total of 3542 adults drawn from a large, nationally representative household panel.
Respondents’ contact with physicians reported in Open Payments to have received industry payments; respondents’ awareness that physicians receive payments from industry and that payment information is publicly available; respondents’ knowledge of whether their own physician received industry payments.
Among the 1987 respondents who could be matched to a specific physician, 65% saw a physician who had received an industry payment during the previous 12 months. This population-based estimate of exposure to industry contact is much higher than physician-based estimates from the same period, which indicate that 41% of physicians received an industry payment. Across the six most frequently visited specialties, patient contact with physicians who had received an industry payment ranged from 60 to 85%; the percentage of physicians with industry contact in these specialties was much lower (35–56%). Only 12% of survey respondents knew that payment information was publicly available, and only 5% knew whether their own doctor had received payments.
Patients’ contact with physicians who receive industry payments is more prevalent than physician-based measures of industry contact would suggest. Very few Americans know whether their own doctor has received industry payments or are aware that payment information is publicly available.
Pham-Kanter G. 2014. Revisiting Financial Conflicts of Interest in FDA Advisory Committees. Milbank Quarterly 92: 446-70.
The Food and Drug Administration (FDA) Safety and Innovation Act has recently relaxed conflict-of-interest rules for FDA advisory committee members, but concerns remain about the influence of members’ financial relationships on the FDA's drug approval process. Using a large newly available data set, this study carefully examined the relationship between the financial interests of FDA Center for Drug Evaluation and Research (CDER) advisory committee members and whether members voted in a way favorable to these interests.
The study used a data set of voting behavior and reported financial interests of 1,379 FDA advisory committee members who voted in CDER committee meetings that were convened during the 15-year period of 1997–2011. Data on 1,168 questions and 15,739 question-votes from 379 meetings were used in the analyses. Multivariable logit models were used to estimate the relationship between committee members’ financial interests and their voting behavior.
Individuals with financial interests solely in the sponsoring firm were more likely to vote in favor of the sponsor than members with no financial ties (OR = 1.49, p = 0.03). Members with interests in both the sponsoring firm and its competitors were no more likely to vote in favor of the sponsor than those with no financial ties to any potentially affected firm (OR = 1.16, p = 0.48). Members who served on advisory boards solely for the sponsor were significantly more likely to vote in favor of the sponsor (OR = 4.97, p = 0.005).
There appears to be a pro-sponsor voting bias among advisory committee members who have exclusive financial relationships with the sponsoring firm but not among members who have nonexclusive financial relationships (ie, those with ties to both the sponsor and its competitors). These findings point to important heterogeneities in financial ties and suggest that policymakers will need to be nuanced in their management of financial relationships of FDA advisory committee members.
Pham-Kanter G. 2014. Act II of the Sunshine Act. PLoS Medicine 11: e1001754
The Sunshine Act will lead firms to be more forthcoming about physician payments but will also create incentives for firms to underreport and target nonphysician prescribers. Whether transparency leads to diminished firm influence on doctors depends crucially on whether physicians who accept payments will be penalized by the public or other parties for accepting. Many preconditions must be met before patients can effectively sanction doctors for receiving payments.
Pham-Kanter G, Zinner DE, Campbell EG. 2014. Codifying Collegiality: Recent Developments in Data Sharing Policy in the Life Sciences. PLoS One 9:e108451.
Over the last decade, there have been significant changes in data sharing policies and in the data sharing environment faced by life science researchers. Using data from a 2013 survey of over 1600 life science researchers, we analyze the effects of sharing policies of funding agencies and journals. We also examine the effects of new sharing infrastructure and tools (i.e., third party repositories and online supplements). We find that recently enacted data sharing policies and new sharing infrastructure and tools have had a sizable effect on encouraging data sharing. In particular, third party repositories and online supplements as well as data sharing requirements of funding agencies, particularly the NIH and the National Human Genome Research Institute, were perceived by scientists to have had a large effect on facilitating data sharing. In addition, we found a high degree of compliance with these new policies, although noncompliance resulted in few formal or informal sanctions. Despite the overall effectiveness of data sharing policies, some significant gaps remain: about one third of grant reviewers placed no weight on data sharing plans in their reviews, and a similar percentage ignored the requirements of material transfer agreements. These patterns suggest that although most of these new policies have been effective, there is still room for policy improvement.
Gorlach I, Pham-Kanter G. 2013. Brightening Up: The Effect of the Physician Payment Sunshine Act on Existing Regulation of Pharmaceutical Marketing. Journal of Law, Medicine and Ethics 41:315-322.
View full article (contact Kanter Research Lab for copy if unable to access)
Abstract (first paragraph)
In 2008 pharmaceutical companies spent over $12 billion on product promotion and detailing aimed at U.S. health care practitioners. Drug and device manufacturers rely on a workforce of detailers and physician speakers to reach health care practitioners and nudge their prescribing habits. To prevent undue influence and protect the public fisc, a number of states began regulating these marketing practices, requiring companies to disclose all gifts to practitioners, prohibiting the commercialized sale of prescription data, and prohibiting certain gifts altogether. The 2010 enactment of the Physician Payment Sunshine Act (PPSA) marks the first Congressional involvement in the regulation of disclosure related to pharmaceutical marketing. Overall, the Act improves transparency in pharmaceutical marketing to physicians and expands the regulation of disclosure of pharmaceutical marketing activities in important substantive ways.
Campbell EG, Pham-Kanter G, Vogeli C, Iezzoni LI. 2013. Physician Acquiescence to Patient Demands for Brand-Name Drugs: Results of a National Survey of Physicians. JAMA Internal Medicine 173:237-239.
Abstract (first paragraph)
Prescribing brand-name drugs when generic drugs are available generates unnecessary medical expenditures, the costs of which are borne by the public in the form of higher copayments, increased health insurance costs, and higher Medicare and Medicaid expenses. Pharmaceutical companies aim to stimulate patients' requests for brand-name medications and increase the likelihood physicians will honor such requests. Presently, little is known about how frequently physicians comply with such a request or the factors predicting this behavior.
Pham-Kanter G, Alexander GC, Nair K. 2012. Effect of Physician Payment Disclosure Laws on Prescribing. Archives of Internal Medicine 172:819-821.
Abstract (first paragraph)
With the enactment of the Physician Payments Sunshine Provision of the Affordable Care Act, pharmaceutical manufacturers are now required to disclose certain payments made to physicians—for example, payments for consulting, honoraria, gifts, or travel. This law is based on the premise that transparency in these transactions is of public importance and that disclosure acts as a deterrent against quid pro quo exchanges; physicians may be reluctant to accept large payments if these payments are publicly known and perceived as compensation for prescribing certain therapies.