Study Finds that Physicians Receiving Remuneration Were More Likely to Give Hyaluronic Acid Injections Under Medicare Part B

Recently, JAMA Internal Medicine published “Association Between Pharmaceutical Industry Marketing Payments to Physicians and Intra-articular Hyaluronic Acid Administration to Medicare Beneficiaries,” a study on pharmaceutical industry marketing payments made to physicians that administered hyaluronic acid injections to Medicare beneficiaries for knee osteoarthritis. The study, conducted by Nishant Uppal, MD, MBA, and Timothy S. Anderson, MD, MAS, found that physicians who received $100 in remuneration were more than three times as likely to give hyaluronic acid injections under Medicare Part B than those receiving no payments. Remuneration could include not only cash, but also compensation for participating in continuing medical education programs, free meals, free travel, and free entertainment.

Additionally, the study found that the number of injections given by physicians was linked to industry payments. The study found a rate ratio of 2.15 for giving hyaluronic acid shots for physicians with “high procedural volume” among those paid more than $100 when compared to physicians who did not receive any form of remuneration. High procedural volume is defined as more than 250 large joint injections annually.

In conducting the research, Uppal and Anderson pulled Medicare Part B data from 2019 and identified physicians who gave more than 50 large joint injections per year. They then cross-referenced the data with records from the Open Payments system. Out of the 20,501 physicians identified, 41.5% were recorded as administering hyaluronic acid injections. Uppal and Anderson calculated the probability of giving hyaluronic acid injections increased by 21% for physicians who received more than $100 and 12.7% for those paid something, but less than $100. The authors also noted that Medicare spending on hyaluronic acid exceeded $440 million in 2019.

Primary care physicians were more likely to be giving hyaluronic acid injections than orthopedic surgeons (rate ratio 1.12), pain specialists (rate ratio 1.25), or rheumatologists (rate ratio 2.04). Further, DOs were more likely than MDs to give hyaluronic acid injections and females were more likely than male providers. Providers with more than a decade of practice were more likely to give the injections when compared to those practicing a decade or less and providers in an urban practice setting were more likely to give hyaluronic acid injections than those in large towns, small towns, or rural settings.

Uppal and Anderson concluded that “these results suggest industry payments are associated with increased use” of hyaluronic acid injections, which they refer to as an “invasive, high-cost procedure widely considered to have little benefit.” However, the researchers also did not analyze which particular companies made payments, such as vendors of hyaluronic acid as compared to other types of products. Therefore, using this study to conclude that physicians were paid (or rewarded in any way) specifically for their use of hyaluronic acid seems to be unfounded at this time.

Additional limitations to the study included relying on administrative data for Medicare and industry payment data.