The 1% of doctors who get two-thirds of industry money

The federal Open Payments program publishes, once a year, every consulting fee, speaking honorarium, royalty, meal, and travel reimbursement that drug and medical-device companies give to American physicians. The companion studies in this series ask who pays (device makers, not pharma) and which fields are paid (orthopedic surgery, by far). This one asks a different question of the same file: once the money reaches doctors, how evenly is it spread? The answer is that it is barely spread at all.

Two-thirds of the money goes to the top 1%

Group the 2024 general (non-research) payments by recipient and rank physicians from highest-paid to lowest. The top 1% of recipients — 9,792 of the 979,136 who received anything — captured 66.1% of every NPI-attributed general-payment dollar, about $1.74 billion of $2.64 billion. Narrow further: the top 0.1%, just 980 physicians, took 33.9% — a third of the entire pool flows to fewer than a thousand people. Widen out, and the curve is just as steep at the bottom: the bottom half of recipients, 489,568 physicians, split 1.2% between them.

A physician needed at least $42,735 for the year to sit in the top 1%, and at least $277,347 to reach the top 0.1%. Below the line, the numbers collapse fast: the median recipient received $164, and 363,598 recipients — more than a third of everyone in the file — received under $100 for the entire year.

Industry money to physicians is more unequally distributed than US household income — the top 1% of recipients take two-thirds of it, and the bottom half splits about one-fiftieth.

The whole distribution, band by band

The clearest way to see the concentration is the cumulative share at each cut of the ranking. Each row is the same pool of dollars, read from the top down.

Source: CMS Open Payments PY2024, general payments with a recipient NPI, via the per-recipient rollup in the reproducibility block.

By the top decile the pool is effectively exhausted: the top 10% of physicians hold 90% of the money, leaving the remaining 881,000 recipients to share the last tenth. The distance between the 90% line at the top decile and the 1.2% line at the bottom half is the whole story — industry money does not taper off toward the median, it falls off a cliff just past the top few percent.

More concentrated than income

To put the steepness on a familiar scale, compute the Gini coefficient across recipients — the standard 0-to-1 measure of inequality, where 0 is everyone receiving the same amount and 1 is a single recipient taking everything. For industry payments to physicians in 2024, the Gini is 0.927.

That is an extreme figure. US household income carries a Gini of roughly 0.41; US wealth, far more skewed than income, sits near 0.85. At 0.927, the distribution of industry money across doctors is more concentrated than the American wealth distribution — among the most unequal distributions found in any public health-finance dataset.

The mean-versus-median gap says the same thing in dollars. The average recipient received $2,694; the median received $164. Whenever a mean sits sixteen times above its median, a small set of very large values is doing the lifting — here, the 156 physicians who each received $1 million or more, and above them a single recipient tied to the $91.1 million dental-device acquisition transfer that is the largest general payment in the entire file.

Who sits in the top 1%

The concentration is not random across medicine — it tracks the specialties where industry pays royalties rather than for meals. Break the 9,792 top-1% recipients down by their primary specialty and the operating room dominates.

Source: CMS Open Payments PY2024, top 1% of NPI-identified general-payment recipients, most-specific taxonomy segment.

Orthopedic surgery alone supplies 767 of the top-1% recipients and 18.9% of their dollars; fold in the spine and adult-reconstructive subspecialties and the orthopedic family reaches 1,156 recipients and 24.9% of all top-1% money — a quarter of the most-concentrated tier in one surgical field. The pattern is structural, not behavioral: device makers owe royalties on implants and instruments, those royalties are large and accrue to a small number of high-volume surgeons, and the same firms that lead the list of largest payers — Stryker, Medtronic, Arthrex, Zimmer Biomet — are the ones putting these surgeons at the top of the recipient distribution. Endodontics is the lone outlier, third on the list almost entirely because of one acquisition-related transfer rather than a broad royalty stream.

Two economies in one file

The concentration resolves the file into two activities that share a statute but little else. At the top, a few thousand surgeons receive device royalties — large, recurring, individually negotiated transfers that account for two-thirds of the money. At the bottom, hundreds of thousands of clinicians receive food, beverage, and speaker payments — the broad, shallow footprint of pharmaceutical marketing, averaging tens of dollars and summing, across the entire bottom half, to barely one-fiftieth of the total. The companion study on the kinds of payments industry makes takes that split apart by payment nature; the recipient distribution is the same divide seen from the doctor's side of the ledger.

This is why a single number like "$2.64 billion to 979,136 physicians" misleads. It implies an average of roughly $2,700 a doctor, when the typical doctor sees $164 and a few see eight figures. The aggregate is real; the average is a fiction that no individual recipient experiences.

What one record actually is

Each row in cms_open_payments is one reported transfer of value to one covered recipient, carrying the recipient's NPI and primary specialty. Rolling those rows up by recipient_npi gives one total per physician — the unit of this study. A recipient who took 200 catered lunches and one who took a single $1 million royalty each become one observation; the concentration figures rank those observations and measure how the dollars distribute across them. Because the unit is the recipient, no count or share in this study names, ranks, or surfaces an individual physician.

Methodology

All figures are aggregations over the cms_open_payments table, populated from the CMS Open Payments program-year-2024 release (PGYR2024, published 2026-01-23, RLS Pattern B — public read). The table holds 16,146,544 records. "General payments" means records with record type general, excluding research ($8.49B) and ownership ($147.8M). The concentration universe is general payments carrying a recipient NPI: 979,136 recipients holding $2,638,034,613, which is 79.6% of the all-recipient general total of $3.31 billion; the remainder has no NPI and is about 98.5% teaching-hospital payments, excluded because a concentration measure needs an individual-recipient identity.

Per-recipient totals are computed as sum(total_amount_usd) GROUP BY recipient_npi — one recipient, one observation. Cumulative shares rank recipients descending and sum each top band as a fraction of the NPI-attributed total. The Gini coefficient uses the rank formula 2·Σ(i·amount)/(n·Σamount) − (n+1)/n over ascending ranks. Because a count-distinct plus percentile over the 15.4-million-row general slice exceeds PostgREST's statement timeout, the figures are point-in-time to the frozen 2026-01-23 snapshot; the exact SQL is in the reproducibility block below and on the Open Payments dataset page. Methodology version: open-payments/v1.

Limitations

• Recipient-NPI universe only. Concentration is measured across the 979,136 general-payment recipients with an NPI ($2.64B). Teaching-hospital and other non-NPI payments ($675.8M) are excluded because they have no individual recipient; the all-recipient general total is $3.31 billion.
• Snapshot, not a trend. Figures reflect the 2026-01-23 PY2024 release. CMS restates prior years and publishes a new file annually, so the bands shift between releases.
• One-off transfers steepen the top. A single acquisition or large royalty (as with endodontics, or the $91.1 million top recipient) lifts the very top of the distribution. The concentration is real either way, but the extreme tail is sensitive to a handful of records.
• Primary specialty only. Each recipient carries one primary specialty; multi-role clinicians are counted once. Subspecialties are reported separately from their parent field.
• Reported identity, not resolved. Recipients are grouped by the NPI as reported; no cross-NPI entity resolution is applied, so a clinician reported under two NPIs would appear as two recipients.
• Disclosure, not influence, and aggregate-only. Concentration measures how industry money is distributed, never its effect on care. No individual physician is named, ranked, or surfaced.

Sources

• CMS — Open Payments (openpaymentsdata.cms.gov) — the federal disclosure database behind every figure in this study.
• CMS — Open Payments data dictionary and methodology — recipient-NPI, recipient-type, payment-nature codes, and reporting rules.
• Physician Payments Sunshine Act — 42 U.S.C. §1320a-7h — the statute requiring manufacturer disclosure.
• U.S. Census Bureau — Gini index of income inequality — the reference definition and US household-income benchmark used for comparison.

The companion dataset page for CMS Open Payments lists the full schema and refresh cadence; the payer-side counterpart sits in which companies pay U.S. doctors the most, and the specialty cut in which specialties take the most industry money.