Which specialties do device manufacturers actually invest in?

Every device manufacturer reports what it pays physicians, and CMS publishes all of it. The 2025 program year holds 16,131,856 payment records from drug and device companies to physicians, non-physician practitioners and teaching hospitals, each tagged with the recipient’s specialty and the product the payment relates to.

That file answers a question most device marketing teams guess at: which clinical specialties does the industry actually spend money reaching? The answer depends on one decision about what counts as spend, and most readings of this data get that decision wrong.

Which specialties receive the most device-related money?

Orthopaedic surgery, by a wide margin, on the raw totals. Of $1,226.1 million in 2025 payments tied to a device or medical supply, orthopaedic surgeons received $434.3 million, or 35.4 percent. Cardiology is a distant second at $92.9 million. On that reading orthopaedics receives 4.7 times what cardiology does.

That is the number most summaries of Open Payments report, and it describes a real flow of money. It does not describe where manufacturers spend to win business. Of the $434.3 million going to orthopaedic surgeons, $327.1 million is royalty or licence income. That is 75.3 percent of the specialty’s total.

Royalties are payments for intellectual property. A surgeon who co-designed an implant system receives a share of its sales for years, and the manufacturer has no choice about paying it. That is a contractual obligation. A VP of marketing deciding where to put next year’s field budget does not control it.

Neurological surgery shows the same pattern. Its $75.1 million total includes $50.5 million in royalties and licences, 67.2 percent of the specialty’s receipts. The two surgical specialties that design the most implanted hardware are the two where headline totals mislead most.

What changes when royalties and acquisitions are taken out?

The ranking compresses. Remove royalties and licences, acquisitions, and debt forgiveness, and $703.9 million of engagement spend remains. Orthopaedic surgery still leads at $104.1 million, but cardiology is close behind at $86.1 million. The gap shrinks from 4.7 times to 1.2 times.

Engagement spend here means consulting fees, food and beverage, travel, speaker and faculty fees, education, grants, honoraria, device loans and the smaller categories. These are the payments a commercial organisation chooses to make. The excluded categories total $522.2 million, or 42.6 percent of all device-related payments, and royalties alone are 37.7 percent.

Cardiology behaves almost the opposite way to orthopaedics. Only 7.3 percent of the money cardiologists receive falls in the excluded categories. Nearly all of it is engagement: consulting, meals, travel and training around the procedures and devices they use.

Below the top two, teaching hospitals receive $71.7 million of engagement payments, general and other surgery $51.4 million, and dentists $46.6 million. Radiology follows at $31.6 million. Neurological surgery drops to $24.5 million once its royalties come out, sliding from fourth on the raw totals to seventh.

The concentration is real but not extreme. The ten largest groups hold 67.6 percent of engagement spend. The remaining third is spread across 75 smaller groups, several of which matter a great deal to the specific manufacturers that sell into them.

Which specialties get the most individual payments?

Cardiology, and then nurse practitioners. Cardiologists received 411,187 device-related payment records in 2025. Nurse practitioners received 404,034, more than orthopaedic surgeons. Counting payments rather than dollars measures how often a manufacturer touches a clinician, and it tells a different story from the dollar ranking.

Most of those touches are small. Food and beverage accounts for 2,830,088 of the 3,329,664 device-related payment records in the file. A meal at an in-service, a lunch at a practice, a dinner program: this is the texture of field-level engagement, and it shows up as volume rather than value.

The average engagement payment makes the difference plain. An orthopaedic surgeon’s average engagement payment is $415.21. A cardiologist’s is $209.39. A nurse practitioner’s is $53.41, and a physician assistant’s $61.49. The two advanced-practice groups together account for 645,865 payment records, 19.4 percent of all device-related records, but only 3.0 percent of device-related dollars.

That gap says something about how the industry works, even if the data cannot say why. Manufacturers reach advanced-practice clinicians often and cheaply, typically through practice-level engagement. They reach surgeons less often and at greater cost per contact, typically through consulting and faculty relationships. Those are two different commercial motions sitting inside one dataset.

What does the payment mix tell you about how each specialty is reached?

The mix is a fingerprint of the commercial model. Consulting fees are the largest engagement category at 17.6 percent of all device-related dollars, followed by food and beverage at 10.7 percent and speaker and faculty fees at 7.7 percent. Which of those dominates a specialty shows whether it is reached through advisers or through the field.

Orthopaedic surgeons received $57.3 million in consulting fees, 55.0 percent of their engagement total. Neurological surgeons look similar, with consulting at 51.8 percent of engagement. Cardiologists received $32.6 million in consulting and $16.1 million in food and beverage, a more even split. Nurse practitioners received $2.0 million in consulting and $13.3 million in food and beverage.

Dentists sit in between. Their consulting and food and beverage lines are almost identical, $7.2 million and $7.3 million, which fits a category where manufacturers run both advisory relationships with a small number of clinicians and routine contact with a large number of practices. Radiology leans toward consulting, at 34.8 percent of engagement, with food and beverage well behind at $4.6 million.

Read across the CSV, most specialties lean toward one of two patterns. In one, the money flows mostly through consulting, faculty and royalty relationships with a smaller number of surgeons. In the other, it flows through a very large number of small, practice-level interactions. Most device categories sell into one group far more than the other, and the specialty mix in this file makes that visible at a glance.

Teaching hospitals are a third pattern of their own. They receive few payments, 15,434 engagement records, but at an average of $4,645.56 each. The largest pieces are long-term loans of devices and supplies, at $25.6 million, and grants, at $19.4 million. That money reaches an institution rather than a clinician, and a device loan puts a product into clinical use before any purchase decision. Grants connect to the question of who produces the evidence in a category, which the clinical evidence ledger covers from the trial registry side.

How was this calculated?

Two aggregation queries against the CMS Open Payments datastore, run on 30 September 2026, over the 2025 General Payment Data file. The first totals every payment by the type of its first related product. The second totals device and medical-supply payments by recipient type, specialty and nature of payment. Both queries are recorded verbatim in the sources file.

Separating device money from drug money needs a stated rule, because the file does not classify the company making the payment. Many manufacturers sell both. What the file does classify is the product each payment relates to, in up to five slots. This analysis uses the first slot and counts a payment as device-related when that product is a device or a medical supply.

On that rule, device-related payments are $1,226.1 million of the $3,923.6 million total, or 31.3 percent. A further $1,522.7 million, 38.8 percent of all general payments, lists no related product at all and is excluded from this analysis rather than guessed at.

Specialty is the recipient’s first listed specialty, from the provider taxonomy CMS uses. It is rolled up to the classification level, so that foot and ankle surgeons count as podiatrists and spine specialists count within their parent specialty. Three classifications are board umbrellas rather than specialties, and are split: cardiology is separated from internal medicine, neurology from psychiatry, and vascular surgery from general surgery. The rule is written out in the dataset module, and the raw grain is published so the roll-up can be undone.

The datastore accepts aggregate queries directly, so the whole calculation runs server-side without downloading sixteen million rows. A grouped query takes several minutes and needs no key and no account.

What can this data not tell you?

It cannot tell you what a payment achieved, and it cannot fully separate device money from drug money. It records transfers of value to named clinicians, as the manufacturer reported them. CMS says so directly: it “does not comment on what relationships may be beneficial or potential conflicts of interest.”

The product rule is the biggest limit. A payment listing a drug first and a device second counts as drug money here. A meal at which a representative discussed three products is attributed to whichever the manufacturer listed first. And the 38.8 percent of payments listing no product at all includes some device money that cannot be identified.

The file covers payments to clinicians and teaching hospitals only. Spend on hospital purchasing committees, distributors, trade shows, advertising, digital programs and the salaries of the field force itself appears nowhere. Open Payments measures one channel of commercial investment, the one that touches a licensed clinician directly, and says nothing about the rest.

Specialty is self-reported and one clinician can hold several. Using the first listed specialty is a simplification. An interventional radiologist who also lists vascular surgery is counted once, in whichever comes first.

Totals describe the whole industry. A specialty that receives little in aggregate may be the only specialty that matters to a manufacturer in a niche category, and a large total can be driven by a handful of companies. The recipient and manufacturer detail is in the public file for anyone who needs it, but this analysis deliberately stays at the level of the market.

These are payment totals. They do not count clinicians. A specialty with many payments may reflect many clinicians reached once, or few clinicians reached often. The aggregate queries used here do not separate those.

What should a VP of marketing do with this?

Use the engagement view, not the headline totals, when benchmarking where the industry spends. Then pull the same query for your own product category and compare your field activity by specialty against the market. The gap between where peers engage and where your team engages is a planning input you can check in an afternoon.

Running it for one category takes a single extra condition. Each payment also carries the manufacturer’s own product category or therapeutic area, in free text, beside the product type. Filter on the values that match your products, group by specialty, and the result is the specialty mix for your competitive set rather than for the whole industry. The category text is not standardised, so read the distinct values once before choosing which to include, and record the list you used so next year’s run compares like with like.

Start with the royalty adjustment. If a board deck or an agency proposal cites orthopaedics as the dominant destination for device money, ask whether royalties were removed. With them in, orthopaedics looks several times larger than any other specialty. With them out, it is one of two comparable destinations, and cardiology receives more individual contact than any other specialty.

Read the payment counts as a map of commercial motion. Specialties with high counts and low averages are reached at practice level, through meals, in-services and routine field contact. Specialties with low counts and high averages are reached through consulting, faculty and advisory relationships. A marketing plan built for one motion does not transfer to the other, and many device companies sell into both.

Nurse practitioners and physician assistants receive about one in five device-related payment records and only a small share of the dollars. If they influence product choice in your category, they are being reached cheaply and at scale by competitors. If your attribution model only credits physicians, it will miss them entirely. The pillar on attribution covers how to build influence roles into the model, and the channel lead-source schema shows one way to record who actually shaped a purchase when a distributor sits in the middle.

Pair this file with the clearance data. Open Payments shows where the industry is already spending to reach clinicians. The review-panel analysis in where new device competitors are entering shows where new products are arriving. A specialty where both are rising is one where the cost of a clinician’s attention is about to go up.

Carmine’s view is that Open Payments is the most underused commercial dataset in medtech. It is public, specialty-level and annual, and it describes the one part of a competitor’s commercial model that competitor is legally required to disclose.