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Healthy Skepticism Library item: 1951

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

 

Publication type: news

Rubenstein S.
How Lilly Influences What Prescribers Learn About Cymbalta
THE WALL STREET JOURNAL 2005 Aug 5
http://online.wsj.com/article/0,,SB112320233298905661,00.html

Keywords:
Eli Lilly cymbalta DUR antidepressant counterdetailing


Notes:

Ralph Faggotter’s Comment: This article exposes a worrying development whereby a particular drug company appears to be attempting to contractually control the dissemination of accurate pharmaceutical information to doctors. They want to prevent what they call ‘counterdetailing’- also known as ‘telling the truth’.


Full text:

http://online.wsj.com/article/0,,SB112320233298905661,00.html

How Lilly Influences What Prescribers Learn About Cymbalta

By SARAH RUBENSTEIN
THE WALL STREET JOURNAL ONLINE
August 5, 2005; Page B1

>From TV commercials to pitches in doctors’ offices, drug companies try to
cast their products in the best possible light. Some use a far less visible
approach: contractual restrictions on what insurers, hospitals and other
health facilities can tell doctors about certain drugs.

Drug makers commonly offer price breaks to insurers, hospitals and other
medical facilities. In exchange, they often get favorable placement on drug
formularies, the lists these entities use to encourage prescriptions of
certain products. Some of the contracts go further, restricting insurers and
medical organizations from making unflattering statements about the costs
and risks of drugs when they communicate with health practitioners.

A case in point is the discount contract Eli Lilly & Co. has offered health
facilities in connection with Cymbalta, an antidepressant that the Food and
Drug Administration approved last year and that faces competition in some
cases from cheaper generics. The contract illustrates tactics that some
insurers and prescribers say they find troubling.

http://online.wsj.com/public/resources/documents/Cymbalta_contract2005.pdf

The Cymbalta discount contract offers large purchasers of antidepressants a
5% discount, but specifies that they could lose most of that discount if
they engage in, among other things, “negative D.U.R. correspondence to
physicians.”

While not defined in the contract, D.U.R. is industry shorthand for “drug
utilization review,” a kind of analysis of prescription patterns that
insurers often use to identify inappropriate or risky practices and often
also to cut costs. Prime Therapeutics LLC, an Eagan, Minn.,
pharmacy-benefits manager owned by nine Blue Cross Blue Shield plans, used
drug utilization reviews to try to reduce what it determined was
overprescribing of Vioxx and Bextra, painkillers that were later pulled from
the market because of safety concerns.

Some insurers worry that contracts such as Cymbalta’s could have a chilling
effect, discouraging insurers and other groups from disseminating medically
relevant information about the drugs on their formularies — or discouraging
them from pursuing D.U.R.s altogether.

Dale Kramer, director of pharmacy contracting at Kaiser Permanente, the big
health-maintenance organization based in Oakland, Calif., says his
organization doesn’t agree to such restrictive terms.

“If I signed something like that, I think our clinicians … would be very
upset,” he says. “Someone on the business side should not have the authority
to make clinical commitments for the company they represent.”

Nancy Stalker, vice president of pharmacy services at Blue Shield of
California, based in San Francisco, says she doesn’t think her company would
sign a contract with broad language that could permit such interference by a
drug maker. “We just don’t want the manufacturer to drive what we do,” she
says. “We want to be able to make the best clinical decision.”

Eli Lilly, based in Indianapolis, says it has a legitimate interest in
controlling negative D.U.R. communications. Drug-industry executives say
many of these types of communications, while ostensibly clinical, often are
really designed to cut costs. Insurers or other groups may use these
communications to steer doctors toward cheaper drugs that may be inferior to
more-expensive competitors.

Tarra Ryker, a Lilly spokeswoman, says the Cymbalta contract isn’t meant to
stop communications that are “backed up by clinical data” and “presented in
a fair and balanced manner.”

The company also has contracts with the same language for the antipsychotics
Symbyax and Zyprexa. “There are a lot of things that are said to physicians
and prescribers that in a lot of cases cannot be backed up with scientific
evidence,” Ms. Ryker says.

One type of communication that might be disallowed under the contract would
be a description of side effects for Cymbalta that didn’t also describe its
benefits, she says. Another possibility: a side-by-side price comparison
between Cymbalta and a generic. A comprehensive list of prices for all
antidepressants, however, would be OK, Eli Lilly says.

Others in the insurance industry say the contractual restrictions don’t
compromise their communications with doctors. Mohit Ghose, a spokesman for
America’s Health Insurance Plans, an insurance-industry trade group based in
Washington, says, “The signing of contracts does not in any way interfere
with the ability of clinicians [at insurance companies] to discuss or
disseminate information on the appropriateness, efficacy and safety of any
given drug.”

Eli Lilly says more than 100 medical facilities belonging to the Minnesota
Multi-State Contracting Alliance for Pharmacy, a St. Paul-based group
purchasing organization including student health services, regional
psychiatric treatment facilities and hospitals in many states, are signed on
to agreements for Cymbalta this year. Representatives reached at several of
the member facilities said they weren’t aware of these restrictive terms in
their discount contracts. Lilly says it hasn’t revoked any discounts among
this group for noncompliance with those terms.

The power of the contractual restrictions depends, in large part, on how
much credence doctors give to the information they get from an insurer or
other medical facility. Larry Fields, president-elect of the American
Academy of Family Physicians, of Leawood, Kan., says while doctors generally
pay attention to such information, they rely primarily on doctors
associations and other sources that “don’t have a dog in the fight.”
Insurers, hospitals and other health facilities are “trying to save money,”
Dr. Fields says.

Still, some people in the industry see the contract terms as a troubling
lever for drug companies to use. Stephen W. Schondelmeyer, a
pharmaceutical-economics professor at the University of Minnesota,
Minneapolis, worries drug makers could invoke the clause if they suspect a
drop in sales is the result of medical questions raised by an insurer or
health facility. “I would never say that having a clause in a contract, even
if it’s not implemented, has no effect,” he says. “It has the potential to
be acted upon.”

Also restricted under the Cymbalta contract is “negative educational
counterdetailing.” Counterdetailing is the industry name for efforts, often
made by insurers, to counterbalance drug makers’ sales pitches (which are
often referred to as “detailing”). Counterdetailing efforts commonly push
patients toward generics or poke holes in drug makers’ claims about their
products.

People in the drug industry say counterdetailing often serves to steer
patients toward cheaper drugs. Counterdetailing “language is probably in
everyone’s contracts,” says Jack Cox, a spokesman for Pfizer Inc., New York.
He declines to comment on Eli Lilly’s or Pfizer’s practices specifically,
but adds that insurers and others who make drugs available to patients “will
come in with clinical data, but their goal is financial.”

Counterdetailing and the D.U.R.s restricted under the Lilly contract are
generally communications aimed at doctors and others who prescribe drugs —
not at patients.

The contract says that it isn’t meant to preclude an individual physician
“from making an independent prescribing decision based on such physician’s
medical judgment in the best interest of patient care.”


Write to Sarah Rubenstein at sarah.rubenstein@wsj.com

_______________________________________________

 

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Far too large a section of the treatment of disease is to-day controlled by the big manufacturing pharmacists, who have enslaved us in a plausible pseudo-science...
The blind faith which some men have in medicines illustrates too often the greatest of all human capacities - the capacity for self deception...
Some one will say, Is this all your science has to tell us? Is this the outcome of decades of good clinical work, of patient study of the disease, of anxious trial in such good faith of so many drugs? Give us back the childlike trust of the fathers in antimony and in the lancet rather than this cold nihilism. Not at all! Let us accept the truth, however unpleasant it may be, and with the death rate staring us in the face, let us not be deceived with vain fancies...
we need a stern, iconoclastic spirit which leads, not to nihilism, but to an active skepticism - not the passive skepticism, born of despair, but the active skepticism born of a knowledge that recognizes its limitations and knows full well that only in this attitude of mind can true progress be made.
- William Osler 1909