Healthy Skepticism Library item: 5807

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Publication type: news

Whitney J.
Pushing Pills: Mining Prescription Records for Fun and Profit
SFGate ( San Francisco Chronicle ) 2006 Aug 6
http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2006/08/06/CMGTSJU4NT1.DTL&type=politics

Full text:

PUSHING PILLS
Mining Prescription Records for Fun and Profit

California has become a battleground in a debate over how Big Pharma’s
access to prescription data affects patient care and the price of drugs

Jake Whitney

Sunday, August 6, 2006
Page CM-10

One afternoon in early 2002, Dr. Brad Drexler, an obstetrician in
Healdsburg, got a visit from a pharmaceutical sales representative. The drug
rep was from a company called Berlex, and the drug she was selling was
Yasmin, a birth control pill that had been on the market for about a year.

Unlike some physicians, Drexler enjoyed visiting with drug reps, and saw
them routinely; only in rare instances did he refuse to speak with them. The
visit with the Berlex rep that day was typically pleasant. The rep was so
friendly, in fact, that she thanked Drexler for all the prescriptions he had
been writing for Berlex’s pharmaceuticals.

Drexler found the statement odd. He wasn’t in the habit of divulging to
salespeople how often he prescribed their company’s drugs, so he wondered
just how the rep knew. Drexler called local pharmacies and asked the
pharmacists if they had any knowledge of drug reps gaining access to
prescription records. But they were as befuddled as he was.

Then one day, a rep with whom Drexler was particularly friendly spilled the
beans. He told Drexler that he and his fellow reps were provided with
detailed prescription information, which was stored in their laptops, on
every physician in their sales territory.

“It bothered me in two ways,” Drexler said. “One, that this practice was so
hidden that neither I nor any of the pharmacists I spoke with knew it
occurred. And two, because this potentially changed the equation between
doctor and drug rep.” He added, “I felt like I lost a lot of privacy that
day.”

The discovery prompted Drexler to take his concerns to the California
Medical Association, where he had been a member of its House of Delegates.
He introduced a resolution there calling for the CMA to oppose drug company
access to prescription records.

Today, three years after Drexler’s resolution, California has become a key
battleground in a growing debate over how drug companies’ access to
prescription data affects both patient care and the price of
pharmaceuticals. A pilot program, to be launched imminently with 100
doctors, may determine just how easy, or difficult, it will be in the future
for pharmaceutical companies to access this information.

Drug companies have been buying prescription records since the 1990s, yet
the practice is still not widely known. Even many doctors don’t know it
occurs.

According to a Kaiser Family Foundation survey taken in 2001, 34 percent of
doctors did not know that drug companies had access to their prescription
writing history. In 2004, a survey sponsored by the American Medical
Association found that number to have shrunk to about 25 percent. And, like
Drexler, the more doctors learn of the practice, the more they try to stop
it.

The imminent pilot program had its genesis in 2003, when, spurred by
physician complaints and encouragement from the CMA, Assemblywoman Wilma
Chan, D-Oakland, presented Assembly Bill 262 to the California Legislature.
AB 262 would have banned statewide the use of prescription data for
marketing purposes.

Despite strong support from the CMA, opposition to Chan’s bill was intense.
Between its introduction in February 2003 and its demise in August 2004, AB
262 was amended 13 times to mollify various interest groups. Concessions
were made allowing prescription data to be collected for research purposes
— the bill’s opponents’ chief argument as to the benefits of the practice
— but, according to Chan, lobbying from the pharmaceutical industry and
data mining companies, especially IMS Health, crushed it.

Data mining companies such as IMS Health play the role of middleman in
tracking prescription records. These firms buy records from pharmacy chains
and other sources before repackaging them and selling them to drug
companies. When pharmacy chains sell the records, however, they do not
include patient names and, in some cases, the doctors who wrote the
prescriptions. So drug companies turn to a surprising source to complete the
prescription profiles: the AMA.

The AMA leases its “physicians’ Masterfile” to data mining companies and,
through them, subleases it to pharmaceutical companies. This Masterfile
contains personal and professional information, including the Drug
Enforcement Agency number on all doctors practicing in the United States.
And since every prescription written in the United States must include the
prescribing physician’s DEA number, drug companies use these
physician-unique numbers on the Masterfile to match prescription records to
doctors.

How important are the profiles to drug reps? “An enormous help,” said
Kathleen Slattery-Moschkau, whose 2005 film “Side Effects” is loosely based
on her 10 years peddling pills for pharmaceutical giants Johnson & Johnson
and Bristol-Myers Squibb. “They allow reps to enter doctors’ offices armed
and dangerous.”

Slattery-Moschkau said that when she was a rep she was given reports on
every doctor within her sales territory by drug class, as well as “numerous
other reports, such as the ‘Heavy Hitter List,’” which would include the top
physicians her company was trying to “convert.”

She said the profiles helped her decide which doctors “were worthy of
spending my monthly budgets on for lunches, dinners, days at the spa, etc.”
Overall, she said, the reports “were a great tool for determining which
marketing tactics worked best.”

Jamie Reidy, a former Pfizer rep who chronicled his days selling Viagra in
his 2005 memoir “Hard Sell,” put it bluntly: “Prescription data was our
greatest tool in planning our approach to manipulating doctors.” But the
pharmaceutical industry maintains that prescription profiles are collected
primarily for research and for other reasons beneficial to patients.

The Pharmaceutical Research and Manufacturers Association, in an e-mailed
statement prepared by Senior Vice President Ken Johnson, said that banning
the practice (West Virginia, Arizona, Hawaii and New Hampshire are also
considering or have considered legislation to ban or restrict it) “could
chill important research that protects and improves public health.”

The statement added that the data “can be analyzed by researchers to
identify poor prescribing habits,” and then cited a study by the Centers for
Disease Control and Prevention that used the data to examine antibiotic use
to help prevent antibiotic resistance and “reduce unnecessary prescribing.”
The statement concluded that, “Analyzing prescribing data is another way to
make sure patients all over the country receive the best possible care.”

The AMA shares this position. Its policy is that the data is collected for
research, for locating doctors to participate in clinical trials, to assist
in distributing drug samples and in case of a drug recall.

Robert Musacchio, the AMA’s vice president of publishing and business
services, said that as a general rule his organization has no problem with
the data being used for marketing purposes, as long as it is not used to
“overtly influence the physician/patient relationship.”

But critics point to insider revelations like those of Reidy and
Slattery-Moschkau as proof that drug companies use the data precisely in
this way: to influence doctors’ prescription writing. Drexler said it was
just this potentiality that engendered his 2003 resolution. He said his
concerns were that visits by drug reps, “could be used to inappropriately
reward doctors who were prescribing the company’s products.”

And that with prescription data in their hands, “the potential existed for
reps to influence doctors.” When asked whether Drexler’s fears were merited,
Reidy said yes, that reps “totally reward doctors,” but not so it’s obvious.
He illustrated: “Say Dr. X is prescribing a lot of Zithromax (a Pfizer
antibiotic) when he used to prescribe Amoxicillin for similar conditions. If
the rep rewards him by giving him gift certificates to Morton’s Steakhouse
and saying things like, ‘Thanks for all the business,’ then suddenly Dr. X
may feel sleazy and stop writing for Zithromax. On the other hand, he may
realize what’s going on and start asking the rep for gift certificates to
Peter Luger Steakhouse.”

Physicians’ staffs are also targets, Reidy said, especially nurses. He said
that in his case he would take nurses out to happy hour where he would thank
them for their help in encouraging Dr. X to prescribe Zithromax. Reidy said
this would make the nurses feel as if they were a part of his “team,” and
they’d “know that if the doctor keeps writing Zithromax they’ll be having
regular happy hours.”

Dr. Sharon Levine, an executive director with Kaiser Permanente, the
nation’s largest HMO, said that it is because of tactics like these that
Kaiser’s doctors are prohibited from accepting personal gifts from reps
(they are allowed to accept gifts that could benefit their practice — i.e.
they can accept a pen, but not a gift certificate to Morton’s), and have
never made their prescription records available to drug companies.

Studies support these concerns. A 2000 study published in the European
Journal of Clinical Pharmacology, for example, found that increased
interaction with drug reps led physicians to prescribe against their
patients’ best interests. A 2003 study in the American Journal of Bioethics
found that when a person accepts a gift, no matter how small, “the
obligation to directly reciprocate, whether or not the recipient is
conscious of it, tends to influence behavior.”

And then there’s the cost. Drug companies lay out hefty sums for the
profiles. IMS Health, just one of a handful of data mining companies,
generated $1.7 billion in revenues last year, $847 million from its “Sales
Force Effectiveness Offerings.” Critics say pharmaceutical companies should
be spending that money seeking new medications. (The major pharmaceutical
companies generally spend more than twice as much on marketing as they do on
research and development. In 2005, for example, Pfizer spent $17 billion
globally on “selling, information and administration” and $7.4 billion on
research and development.)

Levine said that the high cost of the profiles manifests itself on drug
prices in two ways. Not only is the high cost reflected directly in higher
drug prices, but the data is used to persuade doctors to prescribe
expensive, brand-name drugs — often when much cheaper generics would do —
which jacks up co-pays and insurance premiums. Physician privacy is another
concern. Dr. Zoe Berna, a family practitioner in Vacaville, is against drug
companies gaining access to her records because she thinks she should be
free to write prescriptions without salespeople looking over her shoulder.
“I definitely feel (drug company access to prescription records) is an
invasion of my privacy,” she said. Berna added that she would support an
outright ban of the release of the data.

In California, at least, that possibility may have died along with AB 262.

But, according to Dr. Jack Lewin, the CMA’s chief executive officer, though
Chan’s bill failed to become law, it initiated almost two years of
negotiations among the AMA, IMS Health and the CMA, at the end of which a
happy compromise was reached.

Lewin went as far as to assert that the results of the compromise would
benefit physicians more so than Chan’s bill would have. “We could have
gotten (AB 262) passed in any event, except we think we have the better
option now,” Lewin said in an e-mail.

“The better option” is a new program, unique to the state, built around
three main facets.

The primary feature is an “opt out” mechanism that will allow doctors to
choose whether or not drug companies may access their physician-specific
data.

Second, for those physicians who do not use the “opt out” mechanism, IMS
will be required to send them the same data package containing their
personal prescription profile it sends to drug companies. In addition, IMS
will provide reports comparing the “opting in” physician’s prescription
patterns with those of area doctors who share the same specialty.

Third, physicians who “opt in” will be e-mailed, on a quarterly basis, an
unbiased educational newsletter about the latest medications and
developments in their field.

Lewin said that a pilot of the new program is imminent. The statewide
rollout is scheduled for January 2007.

The AMA launched its own “opt out” program on July 1. According to
Musacchio, the AMA’s Physician Data Restriction Program (PDRP) allows
physicians to request their individual prescribing data be hidden from
pharmaceutical sales representatives — similar to the California program,
but minus the requirements of IMS Health. (In both programs drug companies
would continue to have access to aggregated prescription data, including the
data of the physicians who have “opted out.”)

A spokesperson for IMS Health said in an e-mail that the company supports
the AMA’s PDRP program, and that the California compromise “will give
physicians better insights into their own practices and those of their
peers, helping to drive improvements in patient care.”

Critics, however, assert that both programs suffer from an inherent flaw:
with so many doctors still oblivious to the practice in the first place, the
reliance on an “opt out” mechanism is ludicrous — you can’t “opt out” of
something you don’t know exists.

One of the harshest critics, especially of the AMA’s program, is New
Hampshire state Rep. Cindy Rosenwald, D-Nashua, who in May pushed a bill
through the New Hampshire legislature that would ban statewide the release
of prescription data for all commercial purposes. Gov. John Lynch signed the
bill June 30, making it the first such legislation in the nation.

Rosenwald said the PDRP program doesn’t go nearly as far, and suggested it
was simply an effort by the AMA to prevent more bills like hers, and more
compromises such as California’s. Pointing out that the AMA generates
millions of dollars per year with the lease of its Masterfile (the AMA would
not comment on how much it made), Rosenwald said, “The AMA has absolutely no
incentive to stop the practice.”

(Mussachio said that the AMA recognizes that there has been inappropriate
use of the data, but there was no need for an outright ban because the PDRP
program gives physicians a choice. He added that a lot of younger physicians
like being presented with the data because it helps them measure their
“performance.”)

So what did Drexler think of these “opt out” programs, particularly the
California compromise he may have helped engender after an innocent
encounter with a birth control rep more than three years ago?

“I still believe drug company access to physician data should be banned,” he
said, adding that it may be time to “rethink (his) attitude” toward drug
reps. He concluded, “but the compromise is a good thing, because it’s the
best we could get.”

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New York freelancer Jake Whitney’s work has appeared in New York magazine,
the Long Island Press and Guernicamag.com.