Healthy Skepticism Library item: 11355

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Publication type: news

Olson J.
Minnesota / Lilly link to state program questioned
Pioneer Press 2007 Aug 20
http://www.twincities.com/ci_6665989?IADID&nclick_check=1

Full text:

Critics see a conflict of interest in drugmaker’s health plan role

One of the nation’s largest drug companies is helping Minnesota cut costs and reduce questionable prescriptions of psychiatric drugs to poor and disabled residents.

While Eli Lilly provides this guidance without charge, critics believe it’s the “fox watching the henhouse,” because the company has a financial interest in encouraging state policies that increase drug sales.

If the state “asks Eli Lilly to help decide how to buy prescription drugs, or even General Motors to help decide how to buy a car, I guess I’m going to be concerned about that,” said Ronald Hadsall, assistant dean of the University of Minnesota College of Pharmacy. “That just smacks of conflict to me.”

Officials with the Minnesota Department of Human Services defended the program, which is funded by Lilly but run by an independent contractor, Comprehensive NeuroScience. State officials believe CNS has saved money for Minnesota’s fee-for-service health plans, but more important, it has corrected some questionable prescriptions of expensive and powerful psychiatric drugs.

“Cost is an issue, certainly, but what is most important is that we get the right health care for patients,” said Brian Osberg, assistant commissioner of the human services department.

Twenty states have contracts with CNS, which identifies doctors who are prescribing psychiatric drugs outside of recommended guidelines for safety and effectiveness. A common problem is patients taking two or three antipsychotic drugs at once, despite an increased risk of side effects and no evidence that patients benefit by taking multiple drugs.

The states then send warning letters to doctors, who can decide whether to alter their prescriptions.

Opponents believe states are paying Lilly back for this help by keeping its drugs off prior-authorization lists. Such lists prohibit doctors from prescribing drugs without first gaining permission from the state.

Lilly is the manufacturer of Zyprexa, a top-selling antipsychotic drug. Minnesota’s fee-for-service health plans spent more than $28 million on Zyprexa in 2005, and $103 million on antipsychotics in general. That more than doubled the 2000 total of $43 million for the plans, which cover 200,000 poor and disabled Minnesotans.

While other states have used prior authorization to curb these soaring costs, Minnesota has not. In fact, none of the states with Lilly partnerships use prior authorization to manage antipsychotic drugs.

Wisconsin had a contract with Lilly until last year, when the state’s Medicaid agency placed antipsychotic drugs, including Zyprexa, on the prior authorization list. State officials were informed shortly thereafter that Lilly was canceling the program.

A Lilly spokeswoman acknowledged that the company is trying to discourage states from using prior authorization. “We just feel the doctor should be in the driver’s seat as far as picking the best medication, especially an antipsychotic,” said Janice Chavers. “It’s not like taking a cold medication.”

In opposing prior authorization, Lilly has a long list of allies, including doctors and patients who feel it disrupts their relationship. Mental health advocates also argue that prior authorization cuts off drugs from needy patients, who then end up needing more expensive hospital care.

There is little question prior authorization reduces drug costs, though. Wisconsin saved $4 million after placing restrictions on antipsychotics, despite losing its contract with Lilly.

Some states have reported savings with the Lilly partnership as well. Michigan’s spending on mental health drugs dropped 21 percent in six months.

Even if states benefit, there is little question Lilly has a profit motive, said Tom Croghan, a former Lilly executive who conducts health policy research for Mathematica Inc. Drug companies are happy to prevent excessive prescribing of pills to some people, he said, if they can encourage state policies that keep the drugs widely available to others.

“Drug companies are interested in selling their pills and selling as many as they can,” he said.

The Lilly program targets what one Minnesota psychiatrist referred to as “lazy” prescribing.

When a patient is hospitalized, the inpatient psychiatrist might prescribe a new antipsychotic but won’t take the patient off the old one, said Dr. David Adson of the University of Minnesota. Then the outpatient doctor simply leaves the patient on multiple drugs.

As the clinical lead of the CNS project, Adson signs each letter sent by the state to doctors with questionable prescriptions, including unusually high or low doses, or hasty switches from one drug to another.

The number of patients on three or more antipsychotics dropped from 76 in November 2005 to 27 in August 2006, according to a state review of the program.

A state study of the program suggests doctors change questionable prescriptions more quickly when they receive the warning letters. However, the doctors still change the prescriptions over time without the letters. The study also found only modest cost savings.

A Michigan critic believes Lilly is profiting from its partnership with Minnesota. In February, Minnesota encouraged patients to split cheaper double-strength pills instead of taking multiple smaller-dose pills, which can save money for the state at the expense of drugmakers.

The “dose optimization” strategy was required for Abilify, Geodon and Seroquel – which are competing antipsychotic drugs – but not for Zyprexa.

“Pure coincidence that dose optimization and tablet splitting are utilized exclusively for Eli Lilly’s competitors?” asked Ben Hansen, who has sued to expose Michigan’s partnership with Lilly. “I don’t think so.”

Human services officials replied that there was no financial benefit to placing Zyprexa on the pill-splitting list.

The Lilly contract ends in February, but may be renewed. While the program hasn’t cut drug costs, state officials are studying whether it saved administrative costs and reduced spending on mental health services.