The Federal Black Lung Program (FBLP) is an administrative structure that monitors workers’ compensation claims for totally debilitating coal mine dust lung illnesses filed by coal miners. Financial conflicts of interest (COIs) may routinely bias clinicians when classifying chest X-rays (CXRs) for the absence, presence, and severity of pneumoconiosis, according to specific case reports. Researchers wanted to determine the direction and amount of the relationship between financial COIs of FBLP physicians and international standards for the classification of pneumoconiosis radiographs. To identify physician classifications of radiographs, an epidemiologic review of black lung claims filed with the FBLP from 2000 to 2013 was conducted. The financial COIs of each physician were assessed using FBLP court rulings (n = 7,656) from 2002 to 2019. Radiograph classifications for the lack of pneumoconiosis (small opacity classifications of 0/0 or 0/1), simple pneumoconiosis (small opacity classifications of 1/0 through 3/+), and progressive massive fibrosis (PMF) were the main outcome measures employed (large opacities with classifications of A, B, or C).

Out of 63,780 radiograph classifications performed by 264 clinicians, 31.4% were positive for uncomplicated pneumoconiosis, while 3.6% were positive for PMF. In 99% or more of their readings, 52 physicians assessed CXRs as having no evidence of pneumoconiosis, while 18 physicians classified CXRs as positive for simple pneumoconiosis in 99% or more of their readings. For every 10% increase in the proportion of court documents proving that a physician was employed by the company, the adjusted chances of a negative pneumoconiosis classification were 1.46 (95% CI, 1.44–1.47). The adjusted odds ratio for diagnosing simple pneumoconiosis was 1.51 (95% CI, 1.49–1.52) for every 10% increase in court records suggesting a physician was engaged by the miner/claimant, while the adjusted odds ratio for identifying PMF was 1.51 (95% CI, 1.49–1.52). There was a strong link between payment source and radiograph categorization, implying the need of removing financial COIs from what should be an objective decision of Black Lung Workers’ compensation claims eligibility.