Pushing from one side, pulling from the other

The main thrust of this blog is prescription data-mining: the way pharmaceutical companies can buy the prescribing habits of any doctor, and know exactly how many prescriptions she's written for every drug.

One of the reasons this is problematic is that drug reps can then ply doctors with various incentives, like food and entertainment, and monitor see if it's having an effect on how many prescriptions they write. Doctors who are susceptible get more goodies. Doctors who aren't get kicked off the gravy train. An unspoken quid pro quo develops between doctor and drug rep.

Banning the prescription data-mining that lets drug companies profile doctors in this way is an important part of fixing the problem. But a devoted group of advocates is working from the other side. And by the other side, I mean the "goodies" side.

Last week's New England Journal of Medicine perspective discussed the movement toward online disclosure of payments, gifts and consulting fees to physicians.

They appropriately lauded the bills at the state and federal level that would bring transparency to physician-industry relationships.

One problem is that most of these regulations are targeted at big-time payments, in the range of thousands. Gifts in the smaller range (less than $100 in the federal law, and less than $50 in the Massachusetts law) don't have to be reported at all.

This means that a drug rep can buy you dinner three times a week, and it won't have to appear on any online disclosure website.

Obviously, disclosure of big consulting fees is essential. But let's find a way to report the small gifts too. Pressure can be applied with a hundred tiny pushes as well as one giant shove.

More research on prescription costs

There's a recent NYT article on the issue of prescription drug costs. The article discusses a recent study by the Center for Studying Health System Change, which showed that over the past 5 years the number of people who couldn't afford their drugs jumped by 30%.

The increase in affordability problems likely stemmed from higher prescribing rates, drug prices that are rising faster than workers’ earnings, higher patient cost sharing in private insurance and the introduction of expensive new medications.

So there are all these new expensive medications, and doctors are prescribing them a lot, and people can't afford them. But hmm....maybe some of these medications aren't really necessary. Maybe some of them have cheaper generic alternatives that work just as well.

So people aren't taking all their medicines, but those medications aren't necessarily ones they need. They do need SOME kind of medicine for that hypertension or high cholesterol, but it doesn't have to be the fancy new model, all shiny and fresh from the show room.

The problem is, patients don't always know when they can switch to a generic drug. So if they can't afford the fancy new medicine, they just take nothing. Which is a real tragedy, because for just about every real medical problem that exists, there's at least one cheap medicine out there.

Let it not be said that this is an anti-Pharma blog. It's just as much an anti-physician blog. I myself am a physician, and I too find those catchy brand names popping into my head when I'm considering which statin to prescribe, or how to treat neuropathic pain. On a busy day in the clinic, it's easy to prescribe the drug that pops into your head, rather than taking the time to think about whether the patient can afford it.

Which is why doctors need to give ourselves space from Pharma, so we have the room to make the right decisions for the right reasons.

Hello

Well, I guess a few people may start reading this, so I should start to write things that are interesting to others and not just myself. Really, I've been using this blog as a storage space for the many websites about prescription privacy that I want to follow.

If you are reading this, and you know of a resource that I don't have listed somewhere in the columns to the right, please let me know. Like in a comments section someplace I guess.

Bill Maher on Pharma

He doesn't say it directly, but I don't think Bill would have warm fuzzies about prescription data-mining....

Drug Rep Toy Blog

It's pretty self-explanatory: photos of interesting drug rep toys. He puts the best toy at the top of the blog.

I was going to write something like "let's just think a little about the costs, and who they get passed on to." But ugh, I hate being a wet blanket.

She Doth Protest Too Much

Here's a fascinatingly transparent display of spin-doctoring from Pharma. This comes from one of the senior vice-presidents who was asked during a recent press conference about the new industry code prohibiting trinkets with logos on them:

“We have never said and would never say that a pharmaceutical pen or notebook has influenced any prescription,” Ms. Bieri said.

Really? You spent $6 billion on these trinkets without thinking they would influence ANY prescription?

I think she goes too far. Everyone knows that drug companies want doctors to prescribe their products, and that's no secret. The ultimate goal of the tens of billions spent on marketing every year is, despite what Ms. Bieri says, to in some way 'influence prescriptions'.

The point of marketing, in any business, is to increase sales. And in the pharmaceutical business, sales can only be increased by way of doctors' prescriptions. So yes, all those pens were meant to influence prescriptions. But that's not such a surprise.

I'm more surprised, in fact, that PhRMA felt the need to so strenuously deny this somewhat ordinary truth.

The drug companies will market to us in every way we let them. So let's choose how we let them do it, and not just allow them to decide.

No Free Pens

There's a great article in the last NYT of 2008 about the new "restrictions" that the pharmaceutical industry is imposing on itself. No mugs, no pens, no trinkety free goodies.

Sounds great, right? Pharma is policing itself.

Well, first of all, these restrictions are all voluntary, which means no penalty for breaking the rules. Which is one reason we have laws.

Then, if we read a little further, the fine print comes, down in grafs eleven and fourteen:

The guidelines, for example, still permit drug makers to underwrite free lunches for doctors and their staffs or to sponsor dinners for doctors at restaurants, as long as the meals are accompanied by educational presentations.

The industry code also permits drug makers to pay doctors as consultants “based on fair market value” — which critics say means that companies can continue to pay individual doctors tens of thousands of dollars or more a year.

Cutting out the pens but leaving the rest is like going on a diet where you only eat Big Macs. They've cut out the cheapest and least effective part of their marketing campaigns, while doing nothing about the most expensive and deviously influential elements.

Drug reps can still buy lunches for doctors in their offices; they can still take docs out to dinners, as long as there is some educational component. (I went on one of these "educational dinners" long ago... the talk lasted 5 minutes and then we ate for two hours...) Also, the companies can still pay "consulting fees" that generally run in the tens of thousands.

Some of these consultancies are real. But do you think most of the doctors who receive these consulting payments would continue to get them if those doctors banned drug reps from their offices, banned all lunches and dinners, and stopped prescribing the manufacturer's drug?

Which leads me to the main point of this blog: drug companies should not be allowed to track in precise detail exactly which doctors are prescribing their medicines. They can know the rough outlines --- by zip code, for example --- but allowing them to buy databases with the exact number of prescriptions each doctor has given out for each medicine. . . . there's too much potential for an unspoken quid pro quo to exist between doctors and drug reps.

I am heartened by one aspect of this: the fact that Pharma is imposing these restrictions voluntarily means that they see the writing on the wall. They are trying desperately to prevent the kinds of laws that New Hampshire passed from spreading across the country. They want to give opponents of reform some ammunition, something to let them point to and say "See? The drug companies have cleaned up their act! Everything is fine now!"

Except in four or five years, when we're paying attention to something else, the pens and mugs will come creeping back. They'll come back slowly, a trickle at a time, without the big press release and glowing article in the New York Times.

The time has come to reject the hidden intrusion of Pharma into our lives. Prescriptions belong to doctors and patients, no one else.