Healthy Skepticism Library item: 2184

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

Gold R.
States Battling High Drug Costs Appeal to Doctors to Help Fight
The Wall Street Journal 2001 Aug 22

Full text:

Jorge Acosta, a medical internist, is reviewing a “report card” of his prescription-writing habits with Ileana Soto, a pharmacist dispatched by the state of Florida to help rein in the state’s Medicaid drug costs.

The report card shows that, in the past several months, he prescribed a greater percentage of generic drugs compared with other physicians in the state. But his record on asthma medications isn’t as good: Just 10% of his prescriptions were on a list of preferred, lower-cost brands, compared with 40% for his peers. “Oh, so I have to improve?” he asks Ms. Soto.

Score this visit as a win for Ms. Soto, who is helping Florida fight back against a powerful marketing tactic used by big pharmaceutical companies. Known as detailing, it involves sending an army of sales representatives to doctors’ offices, where they leave pamphlets promoting their products in waiting rooms, and deliver free drug samples and other freebies ranging from pens to sports tickets.

Alarmed by 15% to 20% increases in pharmaceutical costs paid by Medicaid and other state health-care programs, Florida and five other states are deploying their own troops to urge doctors to write fewer prescriptions and to switch to cheaper drugs, such as generics, when medically feasible.

The states’ campaign, called counter-detailing, has chalked up some encouraging, albeit modest, early results. In October, Ms. Soto visited 88 doctors that, according to Medicaid-claims data, tended to prescribe costlier, brand-name anti-inflammatory drugs such as Vioxx, made by Merck & Co., and Celebrex, made by Pharmacia Inc. and Pfizer Inc. During her visits, Ms. Soto explains to doctors that generics like ibuprofen or naproxen can be just as effective — and less expensive for the state: under $20 a prescription, compared with $77 for Vioxx and $87 for Celebrex. (The drug companies say their products are better at preventing bleeding ulcers and other gastrointestinal side effects associated with the generics.)

Three months later, the doctors were writing fewer prescriptions for Vioxx and Celebrex, a change that is expected to save Florida Medicaid $196,000 annually. Ms. Soto has since moved on to other classes of drugs, with similar results, and Florida now is assembling a team of 10 counter-detailers. Alabama, Arkansas, Maine, Michigan and Oregon also have programs; Washington and Mississippi plan to start counter-detailing soon.

Despite such promising developments, counter-detailing is, for now, a soft sell. The states rely mainly on education to encourage doctors to change. If they don’t, says Arkansas Medicaid Director Ray Hanley, the states could take more draconian steps, such as canceling Medicaid contracts or limiting reimbursements. “Right now, we are trying to lead with the carrot instead of the stick,” he says.

In May, Arkansas sent letters to doctors who, according to claims data, habitually prescribe name-brand drugs when generics are available. One physician was told that for the fiscal year ended last June, he had prescribed branded drugs costing $22,899 that would have cost $6,256 if he had opted for generics. Arkansas is following up the letters with visits by state-contracted pharmacists.

The pharmaceutical industry doesn’t object to counter-detailing “as long as the states don’t compel the doctors to prescribe certain medicines,” says Jeff Trewhitt, spokesman for the Pharmaceutical Research and Manufacturers of America, a Washington, D.C., trade group. “They have the same First Amendment right to educate physicians that we have.”

Whatever the outcome, doctors’ offices are growing crowded with conflicting marketing messages. When Ms. Soto shows up, frequently a drug-company detailer also is waiting to make a pitch. “Everybody is trying to talk to the doctor,” says David Schulke, executive vice president of the Washington-based American Health Quality Association, which represents medical peer-review groups. “The prescriber holds the keys to the vault.”

The states face a formidable foe in drug makers. Companies spent $4.8 billion on detailing in the U.S. last year, up 11% from the year earlier, according to IMS Health, a Westport, Conn., drug-market- research firm. Detailers made 61.4 million visits to doctors last year, and the industry spent an additional $2.5 billion on direct-to-consumer advertising, such as television and magazine ads.

In contrast, Florida’s counter-detailers made 740 visits to doctors from October through June. Pennsylvania abandoned a counter-detailing effort in its drug-subsidy program for the elderly after several months in 1993. “It worked, but it was very labor intensive, cost a lot of money and it didn’t really have any staying power,” says program director Tom Snedden.

But since then, a cottage industry of claims-data-management firms has emerged to serve insurers, employers, states and others seeking to control health-care costs. Florida is paying its contractor, ACS State Health Care LLC of Atlanta, a subsidiary of Affiliated Computer Services Inc. of Dallas, $11.7 million a year for a range of services, including scanning millions of prescription records to zero in on doctors who rely heavily on the latest blockbuster drugs.

Meanwhile, drug costs have ballooned to become the fastest-growing line item in most state health-care budgets. One of every five dollars spent on pharmaceutical drugs is paid for by a state program.

Ms. Soto, who became Florida’s first counter-detailer after growing frustrated when doctors ignored her suggestions when she worked as a pharmacist, says doctors are often more willing to talk to pharmacists than drug-company sales representatives about the effectiveness and side effects of drugs. A market-research firm found that counter-detailers get an average of 13 minutes to make their case to doctors, while drug-company representatives get between 90 seconds and five minutes.

The report cards comparing physicians’ prescription habits to their peers have been a particularly effective ice-breaker. “You can’t just say ‘save money.’ You have to have something that won’t make them grumble about interference with their practice,” says William Golden, professor of medicine at the University of Arkansas, who helped design that state’s counter-detailing campaign.

The report card is Ms. Soto’s main weapon against drug companies’ marketing blitzes, which are in full view when she stops by Dr. Acosta’s office on a recent morning. Waiting-room tables are overflowing with pamphlets touting brand-name drugs, left behind by detailers. “I am trying to do what’s best, but it’s not easy,” Dr. Acosta says after escorting Ms. Soto to his office, which has a clock promoting Viagra, Pfizer’s impotence treatment.

His patients often demand the latest blockbuster drugs after seeing TV commercials. “The advertising is working,” he says. “They know what is new.” If he declines to prescribe the requested drug, he fears his reputation will suffer in the Cuban-American community he serves.

Ms. Soto listens sympathetically. “It’s not like we’re checking up on you. We’re just giving you information,” she says, pulling out his report card. After taking in the mixed results, Dr. Acosta says, “I am willing to change … I am a guy who tries to play within the rules.”

She tells him Medicaid isn’t telling him what to do. “Of course,” she adds, “we’d prefer you go with generics.”