Healthy Skepticism Library item: 19535

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Publication type: news

Stolberg SG, Gerth J
High-Tech Stealth Being Used to Sway Doctor Prescriptions
The New York Times 2000 Nov 16
http://www.nytimes.com/2000/11/16/us/high-tech-stealth-being-used-to-sway-doctor-prescriptions.html

Full text:

As a busy internist, Dr. Bruce Moskowitz frequently prescribes cholesterol-lowering medicines and osteoporosis drugs for his elderly patients. Like most physicians, he is no stranger to pharmaceutical sales representatives, and he often chats with them about his preference in medication.

But the drug companies know more about Dr. Moskowitz than he realizes. Over the past decade, with the advent of sophisticated computer technology, pharmaceutical manufacturers have been quietly compiling resumes on the prescribing patterns of the nation’s health care professionals, many of whom have no idea that their decisions are open to commercial scrutiny.

These ‘‘prescriber profiles’‘ are the centerpiece of an increasingly vigorous — and apparently successful — effort by drug makers to sway doctors’ prescribing habits. To create them, pharmaceutical marketers are buying information from pharmacies, the federal government and the American Medical Association, which generates $20 million in annual income by selling biographies of every American doctor.

The profiles do not contain patient names. But they do offer drug companies a window into one half of the doctor-patient relationship. And they are raising important public policy questions, both about the privacy of doctors’ prescribing decisions, and how much commercial pressures influence them.
‘As an extension of the doctor-patient relationship, doctors are entitled to privacy,’‘ said Lawrence O. Gostin, an expert in health privacy at the Georgetown University Law Center.

In describing the profiles as ‘‘a fundamental violation’‘ of that privacy, Mr. Gostin said they also raise ‘‘an extremely important policy question, which is to what extent are health care prescribing practices influenced by commercial concerns?’‘

That question is now front and center in the political debate. With the price of prescription medication high on the national agenda, the impact of marketing on the cost of pharmaceuticals is at issue. But while the public discussion has focused largely on the recent trend toward advertising directly to patients, the industry still spends most of its money wooing doctors.

Of the $13.9 billion that the drug companies spent promoting their products last year, 87 percent, or about $12 billion, was aimed at doctors and the small group of nurse practitioners and physicians’ assistants who can prescribe some medications, about one million prescribers all told.

‘‘The pharmaceutical industry has the best market research system of any industry in the world,’‘ said Mickey C. Smith, a professor of pharmaceutical marketing at the University of Mississippi. ‘‘They know more about their business than people who sell coffee or toilet paper or laundry detergent because they truly have a very small group of decision makers, most of whom still are physicians.’‘

Pharmaceutical sales representatives have been a staple of American medicine for decades. Their courtship of doctors is intensive and expensive, and their largess runs the gamut, from trinkets like prescription pads and pens, to staff lunches at hospitals and medical offices and offers of free weekends at resorts.

Prescriber profiles play a significant role in the courtship; pharmaceutical marketers say they use the reports to help determine which doctors should be offered certain perks. And the perks themselves worry ethics officials at the American Medical Association, who are trying to discourage doctors from accepting them, even as the association’s business side sells information that facilitates the giving of gifts.

Dr. Moskowitz, of West Palm Beach, Fla., is one example. In late August, he received an invitation from two drug companies, the Bayer Corporation and SmithKline Beecham, asking him to a private dinner at the Morton’s of Chicago Steakhouse, an expensive chain restaurant not far from his West Palm Beach office, on the evening of Sept. 18.

The topic was high cholesterol, including an update on Baycol, a drug the two companies jointly market. For his feedback, Dr. Moskowitz would be designated a consultant and given a $250 honorarium, along with his choice entree. He declined.

‘‘Drug companies ask me, ‘How can we change your prescribing, what would it take, do you want to serve as a consultant?’‘ Dr. Moskowitz said. ‘‘The schemes get more and more desperate.’‘

Although most doctors do not believe that such entreaties affect their professional behavior, some studies suggest otherwise. Dr. Ashley Wazana, a psychiatry resident at McGill University in Montreal, recently analyzed 29 studies on the effects of gifts to doctors.

Published in January in The Journal of the American Medical Association, Dr. Wazana’s analysis found an association between meetings with pharmaceutical representatives and ‘‘awareness, preference and rapid prescribing of new drugs and decreased prescribing of generics.’‘

His conclusion? ‘‘We are influenceable,’‘ Dr. Wazana said.

In an effort to save money, and also to avoid this influence, some clinics and hospitals have imposed a ban on free drug samples and visits from sales representatives and discourage doctors from taking consulting fees like the one offered by Bayer and SmithKline Beecham.

Among them is the Everett Clinic in Washington State, a group practice of 180 doctors that cares for 250,000 patients. Its officials say that drug costs have declined since the ban.

‘‘Pharmaceutical marketing would often lead to physicians prescribing more costly medicines than are necessary,’‘ the clinic’s medical director, Dr. Al Fisk, said.

But Dr. Bert Spilker, a senior vice president with the Pharmaceutical Research and Manufacturers of America, an industry trade group, said marketing ‘‘serves an essential function in the health care delivery system’‘ by helping to educate doctors, so they can prescribe drugs more appropriately.

Drug companies, however, are often reluctant to disclose details about their marketing efforts, particularly the use of prescriber profiles.

‘‘If we talk about what we do and how we do it,’‘ said Jan Weiner, a spokeswoman for Merck & Company, ‘‘then our competitors will know a whole lot more than they know now.’‘

The A.M.A. Master List

Singling out doctors is not new, but detailed prescriber profiles have been available only since the early 1990’s, when most pharmacies adopted computer systems to process insurance claims, said Pat Glorioso, a marketing executive at I.M.S. Health, a leading pharmaceutical market research concern and one of two companies that specialize in collecting records of pharmacy sales.

Through the profiles, a drug company can identify the highest and lowest prescribers of a particular medicine in a single ZIP code, county, state or the entire country. They can learn, for example, which antidepressants a particular psychiatrist favors.

‘‘It’s very flexible in the way we can slice and dice the information,’‘ Ms. Glorioso said. ‘‘As technology has improved, we have just ridden that wave.’‘

When pharmacies sell records of prescription drug sales, they do not show names of patients or, in some cases, their doctors. But those records are typically coded with identification numbers issued by the Drug Enforcement Administration to doctors for the purpose of tracking controlled substances. The government sells a list of the numbers, with the corresponding names attached, for fees that can run up to $10,200 a month, depending on how widely the list will be distributed.

The American Medical Association, meanwhile, sells the rights to what it calls its ‘‘physicians’ master file’‘ to dozens of pharmaceutical companies, as well as I.M.S. Health and other market research concerns. Though only about 40 percent of American doctors are dues-paying members of the medical association, the database has detailed personal and professional information, including the D.E.A. number, on all doctors practicing in the United States.

Pharmaceutical marketers consider the master file the gold standard for reference information about doctors. Combined with the records of pharmacy sales, the file helps create portraits of individual doctors, their specialties and interests. As the nation’s largest doctors’ group, the medical association has maintained the master file for nearly 100 years, and has licensed it for more than 50. It is so complete, A.M.A. officials say, that even the dead are included.

‘‘We’re trying to provide a reliable database, which is accurate, so that it can be used appropriately to focus efforts on ways that are beneficial to the patient,’‘ said Dr. Thomas R. Reardon, the association’s past president, who was designated by the group to address these questions.

There are some restrictions, Dr. Reardon said: the roster cannot be sold to tobacco companies and it cannot be used to deceive doctors or the public. While they say sale of the master file brings about $20 million in annual income to the association, officials would not say what they charge individual companies.

Much of the information in the association’s database is available from sources scattered around the country. But one major element is not: the medical education number, which the A.M.A. assigns to new medical students in order to track them throughout their careers. Most doctors do not even know they have one.

This number, which enables computers to sort through the huge A.M.A. master file, is ‘‘the core element in the database of tracking physicians,’‘ said Douglas McKendry, a sales executive at the Acxiom Corporation, a pharmaceutical marketing company that recently formed a partnership with the medical association to manage the database.

‘‘The A.M.A. data helps identify the individual physicians that are being targeted,’‘ Mr. McKendry said.

Doctors who do not want their names sent to marketers can ask the association to remove them from the file, Dr. Reardon said. But in interviews, several prominent doctors said they were unaware that their biographies were being sold.

Among them is Dr. Christine K. Cassel, a former president of the American College of Physicians and chairman of the department of geriatrics at Mount Sinai School of Medicine in Manhattan. In Dr. Cassel’s view, information about doctors’ prescribing habits may appropriately be used by their health plans to improve quality of care. She called the commercial use of the data outrageous, saying, ‘‘This is not about quality. It’s about sales.’‘

Dinner and a Motive

Pharmaceutical marketing is big business not only for drug companies, but also for companies firms like I.M.S. Health and Acxiom, which cater to them.

Overall spending on pharmaceutical promotion increased more than 10 percent last year, to $13.9 billion from $12.4 billion in 1998. Experts estimate that the companies collectively spend $8,000 to $13,000 a year per physician. In recent years, as demands on doctors’ time have grown more intense, pharmaceutical marketers say they have been forced to become more creative.

‘‘You have to have a hook,’‘ said Cathleen Croke, vice president of marketing for Access Worldwide Communications Inc., which specializes in drug marketing. ‘‘If you offer them $250, that might get them. Or they are attracted to the prestige of being a consultant, that a company is asking for their opinion.’‘

The offer of dinner and a $250 consulting fee was sufficient to draw about a dozen South Florida physicians to Morton’s in West Palm Beach on Sept. 18. They gathered there, on a muggy Monday night, in a back room called the boardroom, where a slide show and a moderator from Boron, LePore & Associates Inc., the market research firm hosting the event, awaited their arrival.

Dr. Moskowitz, who has been in practice in West Palm Beach since 1978 and heads a group of 12 doctors, says he routinely receives — and rejects — such invitations.

The Morton’s dinner was not open to the public; had Dr. Moskowitz accepted, he would have been required to sign a confidentiality agreement. Instead, he told the companies he intended to take a reporter for The New York Times.

But when Dr. Moskowitz and the reporter showed up at Morton’s, the Boron LePore moderator, Alexander Credle, told them to leave.

‘‘This is a clinical experience meeting, a therapeutic discussion,’‘ Mr. Credle said. ‘‘There is an expected degree of confidentiality.’‘

Dr. Moskowitz asked Mr. Credle why he was invited; Mr. Credle had no answer. But in an interview a few weeks after the dinner, John Czekanski, a senior vice president at Boron LePore, said the invitations were ‘‘based on databases targeting physicians’‘ who prescribe cholesterol-lowering drugs or who might.

Boron LePore calls these dinner sessions ‘‘peer-to-peer meetings,’‘ and in 1997, it acted as host at 10,400 of them. Typically, they feature presentations from medical experts, on the theory that doctors are receptive to the views of their peers. With new drugs coming onto the market all the time, physicians are hungry for information about them. Pharmaceutical companies say it is that desire for education, rather than a free meal or modest honorarium, that draws many doctors to the meetings.

But the dinners are creating unease among officials of the American Medical Association’s Council on Ethical and Judicial Affairs, which in 1990 published guidelines that limit what gifts doctors may accept. The guidelines, which have also been adopted by the Pharmaceutical Research and Manufacturers’ Association, the drug industry trade group, prohibit token consulting arrangements, but permit ‘‘modest meals’‘ that serve ‘‘a genuine educational function.’‘

Compliance is voluntary, and Dr. Herbert Rakatansky, who is chairman of the A.M.A.‘s ethics council, says doctors routinely ignore the rules. That is in part because they are murky, as the dinner at Morton’s reveals.

Whether the dinner was intended to educate doctors, or was part of a marketing campaign, or both, is not clear. In the $7.2 billion market for the cholesterol-lowering drugs known as statins, Baycol ranks last in sales, with just $106 million in sales last year. Bayer and SmithKline Beecham recently introduced a new dosage for the drug, and the companies said they used the Morton’s meeting to share new clinical data with doctors.

‘‘As far as we’re concerned, it’s educational,’‘ said Carmel Logan, a spokeswoman for SmithKline Beecham. But Tig Conger, the vice president of marketing for cardiovascular products at Bayer, said the company intended to teach a select group of doctors about Baycol, then use their feedback to hone its marketing message. And Allison Wey, a spokeswoman for Boron LePore, said the dinner was ‘‘part education and part marketing.’‘

Raising Ethics Question

While Dr. Rakatansky, of the A.M.A., could not comment specifically on the Baycol meeting, he had harsh words for these dinners in general.

‘‘We think 99 percent of those are shams,’‘ he said. ‘‘They are marketing devices and not true requests for information.’‘

As to whether the dinner fit the ‘‘modest meal’‘ criteria, that, too, is unclear, because the guidelines offer no specifics. At Morton’s in West Palm Beach, the entrees range from $19.95 for chicken to $32.95 for filet mignon — a la carte. The sales manager, Lauren Carteris, said the restaurant frequently was the site of pharmaceutical meetings for Boron LePore.

‘‘Doctors,’‘ Ms. Carteris said, ‘‘will only go to an expensive restaurant.’‘

To heighten doctors’ awareness about the ethics of accepting gifts, the medical association is beginning an educational campaign. In addition, The Journal of the American Medical Association devoted the bulk of its Nov. 1 issue to conflict of interest in medicine, including an essay entitled ‘‘Financial Indigestion’‘ that questioned the effects of pharmaceutical company gifts on doctors’ professional behavior.

But some prominent doctors say the medical association needs to address its own role, as a seller of information that helps drug marketers select which doctors to target.

‘‘It potentiates this gift giving, and implicitly endorses it,’‘ said Dr. David Blumenthal, a professor of health policy at Harvard Medical School who has used the A.M.A.‘s data for his academic research.

The sale of the master file to drug companies, Dr. Blumenthal said, ‘‘hands the weapon to the drug company that the A.M.A. is saying is an illicit weapon.’‘

Dr. Reardon, the past president of the medical association, dismisses such a connection. Doctors are responsible for their own decisions about whether to accept gifts, he said, adding, ‘‘I don’t think the database has anything to do with ethical behavior of physicians.’‘

Dr. Reardon noted that drug marketers could obtain information about doctors from other sources, including the federal government. But Mr. Gostin, the privacy expert at Georgetown, who is also the health law and ethics editor of The Journal of the American Medical Association, said that did not justify the association’s action.

‘‘We live in a society where, if you comb long enough and hard enough with sophisticated enough search tools, you can find just about everything,’‘ Mr. Gostin said. ‘‘That doesn’t mean it’s all right for people to assemble it, make it easy and sell it.’‘

As for Dr. Moskowitz, he is still receiving invitations from drug companies, despite his longstanding habit of spurning them. One arrived on Oct. 18, from Aventis Pharmaceuticals and Procter & Gamble Pharmaceuticals, who jointly market Actonel, an osteoporosis drug.

Attendance at the meeting, scheduled for Saturday , will be limited to 12 doctors, the invitation said. Breakfast and lunch will be served; in between, there will be a clinical discussion of osteoporosis, with 30 minutes reserved for doctors’ feedback. The honorarium is $1,000.

Medicine Merchants

Earlier articles in this series examined the financing of a blockbuster drug, how lower-cost generic drugs can be kept from the market, the availability and costs of drugs in the Third World, and alliances between drug companies and patient groups. Further articles will examine other issues related to the business of pharmaceuticals.

Articles in this series will remain available at The New York Times on the Web:

www.nytimes.com/drugs