Chapter 1 Introduction

The Affordable Care Act (ACA) of 2010 transformed the American healthcare system. The bill put into place new regulations meant to improve the quality of treatment for all Americans, while expanding healthcare coverage to millions of previously uninsured Americans.

A critical section of the ACA was the Physician Payments Sunshine Act. The Sunshine Act requires pharmaceutical and medical equipment companies to disclose to the Centers for Medicare and Medicaid Services (CMS) all payments, transfers of goods, or other incentives given to any physician in the United States (Richardson (2014)). As part of the Sunshine Act, CMS makes this data publicly available via a system called Open Payments. One line of thinking proposes that publicly available information on payments from the pharmaceutical industry to physicians will increase transparency and expose corruption, which will in turn decrease these practices and the industry’s influence on healthcare practices.

Nevertheless, The ACA expanded healthcare coverage to 20 million Americans, provided protections for individuals with pre-existing conditions, and expanded Medicaid to millions of low-income Americans (Rapfogel, Gee, & Calsyn (2020)). For the first time, millions of Americans were able to access critical treatments but also establish relationships with primary care physicians.

The American Academy of Family Physicians (AAFP) defines primary care as “the provision of integrated, accessible health care services by physicians and their health care teams who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (Family Physicians (2021)). Thus, primary care physicians are the point of access to healthcare for most Americans. Therefore, understanding their role is critical to observing trends within the American healthcare system.

Recognizing this, CMS has put concerted effort into addressing and supporting effective methods for increasing the quality of care. One such method is shifting healthcare from fee-for-service practices to value-based care. While fee-for-service incentivizes using the most resources, potentially indifferent to the real needs of the patient, value-based care reimburses physicians a set amount for a designated time period for treatment or care (Miller (2022)). However, these considerations focus on the physician-patient interaction.

Considering the Sunshine Act, there can be a step back to look at the broader picture of industry-physician interactions. As noted, primary care physicians are the first line of healthcare. If pharmaceutical companies are looking for ways to promote their products and reach the most patients, then targeting primary care physicians is a natural conclusion.

Therefore, before evaluating the quality of care given by primary care physicians, one must first consider these physicians’ interactions with pharmaceutical companies. This study aims to analyze exchanges happening prior to the delivery of care: where they are happening, between whom they are happening, and how these trends have changed over the time period of data available via the Open Payments system. Insights generated from this analysis will advance the field’s understanding of physician-level conflict-of-interest, providing needed awareness about the impacts of pharmaceutical industry financial practices on primary care.