Which medical specialties take the most industry money?

The federal Open Payments program records every consulting fee, speaking honorarium, royalty, meal, and travel reimbursement that drug and medical-device companies give to American physicians. Group the $3.31 billion in 2024 general (non-research) payments by the recipient's specialty, and the field stops looking like "medicine" in general and starts looking like a map of where industry money concentrates — overwhelmingly in the operating room.

Orthopedic surgery takes more than any other specialty

The single highest-paid specialty in 2024 was orthopedic surgery: $381.4 million across 222,891 payments — more than three times the second-place specialty. Add the orthopedic subspecialties that CMS lists separately — spine surgery ($54.8M), adult joint reconstruction ($47.8M), and sports medicine ($47.8M) — and the orthopedic family drew $531.8 million, about 16% of every general-payment dollar in the country.

Behind orthopedics, the top of the table is a list of procedure-heavy fields: neurological surgery ($83.1M), cardiovascular disease ($71.6M), hematology and oncology ($68.6M), gastroenterology ($65.5M), and ophthalmology ($60.8M). The two large outliers are internal medicine ($113.4M), which ranks second only because it is an enormous field, and endodontics ($102.3M), which ranks third because of one transaction (more below).

The eighteen-fold intensity gap

Total dollars hide the real difference. Divide each specialty's dollars by its number of payments and the structure of industry medicine appears.

Source: CMS Open Payments PY2024, general payments only, via open_payments_by_specialty_mv.

The average orthopedic payment, $1,711, is roughly eighteen times the average internal-medicine payment of $96, and forty-four times the average payment to a family nurse practitioner. The surgeon's payment is a royalty or a consulting fee; the primary-care clinician's payment is a catered lunch. They are recorded in the same file under the same statute, but they describe two different economies.

The average payment to an orthopedic surgeon was $1,711. The average payment to an internal-medicine physician was $96. Same file, same year, an eighteen-fold gap.

One deal can move a specialty

Endodontics — root-canal specialists — ranks third overall at $102.3 million, which is startling for a small dental subspecialty. The explanation is a single record: the largest general payment in the entire 2024 file, $91.1 million, an acquisition-related transfer from one dental-device company to a small group of physician-owners. Strip that one payment out and endodontics falls far down the list.

This is why specialty totals must be read alongside payment counts and the largest-payment list. A specialty can rank high because thousands of its physicians each took a moderate royalty (orthopedics), because it is simply a vast field (internal medicine), or because of one enormous transaction (endodontics). The three are not the same phenomenon, and our companion study on the kinds of payments industry makes shows why the payment-nature mix is what really distinguishes them.

Why procedural specialties dominate

The pattern is structural, not behavioral. Implantable and instrumented medicine — joints, spines, heart valves, surgical robots — generates intellectual property, and the surgeons who design or refine that hardware are owed royalties, sometimes for years. Those royalties are large and concentrated in a small number of high-volume specialists. The same device makers that dominate the list of largest industry payers — Stryker, Medtronic, Arthrex, Zimmer Biomet, Intuitive Surgical — are the ones whose business model puts orthopedic and neurological surgeons at the top of the specialty table.

Medication-driven fields look different. A drug is prescribed, not implanted, so pharmaceutical companies cannot pay prescribers royalties; their general-payment footprint is built from speaker programs and meals spread across hundreds of thousands of clinicians. That is why primary care, with millions of payments, still trails a single surgical subspecialty in total dollars.

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 primary specialty as listed in the federal provider taxonomy. The taxonomy is pipe-delimited — for example, Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine — and this study reports the most-specific segment. Because each recipient carries a single primary specialty, a clinician who works across roles is counted once, under that primary. Every figure aggregates these rows by specialty; none names a recipient.

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; aggregates are computed server-side in the open_payments_by_specialty_mv and open_payments_overview_mv materialized views. "General payments" means records with record type general, excluding research and ownership. Specialty grouping uses the CMS recipient_specialty field exactly as published; the orthopedic-family total sums the orthopedic primary specialty with the spine, adult-reconstructive, and sports-medicine subspecialty categories. The exact query is in the reproducibility block below and on the Open Payments dataset page. Methodology version: open-payments/v1.

Limitations

• Snapshot, not a trend. Figures reflect the 2026-01-23 PY2024 release; CMS publishes a new file annually and restates prior years.
• One-off transfers distort small specialties. A single acquisition or royalty (as with endodontics) can dominate a specialty's annual total. Read totals alongside payment counts.
• Primary specialty only. Each recipient carries one primary specialty; multi-role clinicians are counted once. Subspecialties are reported separately from their parent field.
• General payments only. Research ($8.49B) and ownership ($147.8M) are excluded.
• Disclosure, not influence, and aggregate-only. A specialty's total measures the scale and structure of industry money, not its effect on care. No individual physician is named 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-specialty taxonomy, payment-nature codes, and reporting rules.
• Physician Payments Sunshine Act — 42 U.S.C. §1320a-7h — the statute requiring manufacturer disclosure.
• National Uniform Claim Committee — Health Care Provider Taxonomy — the provider-specialty code set used in the recipient-specialty field.