by Edison Wong, MD
With the recent proposal to repeal the so-called Massachusetts “gift ban” (more appropriately referred to as the “interaction ban”), I asked myself who stands to gain the most from such bans?
Is it the consumers or patients? Is it the physicians or their practices? Is it the federal or state governments? Nope. Sadly, it is the insurers who gain the most, at the expense of patients.
The argument for “interaction bans” is that generics will save money over name-brand medicines, which are being “unnecessarily” or “irrationally” prescribed. Aside from being unclear who is defining necessary or rational in this debate, what is forgotten is who wields the most influence over the decision to prescribe a medication. The public is convinced that it is the physician, and, actually, that would make sense. And more recently, savvy public relations campaigns and advocacy efforts have convinced legislators (and the public, so the advocates claim) that it is the Pharma rep that controls prescribing. In reality, it is the insurance companies.
Insurance company actuaries decide which drugs are on the formulary (what they will cover) and which one is a preferred name-brand medicine (cheaper co-pay), based on benefit-to-the-bottom-line calculations. (Ironically, some generics are not even on a formulary list and are NOT preferred over name brands.) Consequently, these decisions, which are based on the whim of the insurer, dictate whether a patient has access to a medicine, not their physician, and definitely not the Pharma rep.
Does an intelligent Congressman or Senator really believe that a patient will blindly order a name brand drug when generics are available? What would they do in that situation? Why would they think the general public will be so eager to accept blindly a costly name-brand medicine when money could be saved? Some of my patients have to decide to forgo either food or medications. I hope Congress members realize they lack proper info about the situation and correct their version of reality.
Any practicing physician can attest that it is extremely challenging to get a name-brand medicine for patients, even after generics have failed. First, the physician must justify their clinical decision to the insurer by documenting the diagnosis and every other course of therapy that has been tried. The paperwork, called a “prior authorization” (PA), requires hours of labor-intensive, uncompensated work.
If the PA is approved, which is not guaranteed, the patient must then fend off their friendly pharmacist’s attempts to convert them to the cheaper “almost the same” generic alternative. What is NOT mentioned is that the suggested alternative is a different molecular entity with different efficacy and different side-effects (therapeutic substitution), and more insidious, that the pharmacy stands to make more money on the alternative.
And only in my State, if all of these barriers are surmounted, are patients then denied the use of manufacturer discounts and rebates, which could offset skyrocketing insurance co-pays. Needless to say, the prescription calculus is far more complicated than portrayed.
Among all these competing forces, neither logic no evidence suggests that a patient walking into a physician’s office will end up with an unnecessary and expensive bottle of pills because of a Pharma rep. This hypothesis only holds true in the minds of idealistic social science researchers whose primary interest is proving their repeated claim that a pen with a name brand label will bias and overcome all other obstacles.
Sadly, the true issue at hand is that many physicians will not or cannot perform the extra work required to obtain a name-brand drug even when it is safer or will work better than a generic because of the extra time or staff involved with the myriad paperwork, a real cost-driver of health care.
So the next time you hear of the egregious cases of Big Pharma exerting their control by ‘wining and dining’ physicians, take a moment to consider who really stands to gain by the proposed solutions and whether patients have even been entered into the equation.
Edison Wong is a physiatrist practicing in Massachusetts.
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{ 13 comments }
The insurers are definitely in the driver’s seat in terms of access to medication. My wife’s Rheumatoid Arthritis medication changed shape, not chemical formula, not dosage, and not manufacturer. This resulted in two months of back and forth to get approval for drug coverage. In the mean time, we had to pay the costs out of pocket. All this was because the identification number for the drug had changed…
The conference committee members who will be determining the fate of the “gift ban” repeal have been announced. please contact any/all of the below. Let them know your opinion on this matter.
· Sen. Karen Spilka – Metro West
· Sen. Ben Downing – Western MA
· Sen. Bruce Tarr – North Shore
· Rep. Brian Dempsey – Haverhill – Supported repealing the ban
· Rep. Garrett Bradley – Plymouth – Supported repealing the ban
· Rep. Viriato Manuel deMacedo – Plymouth – Not present
Doctors are clearheaded enough to eat a meal and then still think through to the best medication choice.
Do politicians hold themselves to this same standard? Are politicians willing to give up their lobbyist-paid occasions?
These medications have passed FDA-scrutiny, a very high bar.
Lectures are sponsored by competitors within a given pharmaceutical class, so doctors are likely to hear many different perspectives.
Lectures won’t be the sole place that doctors get information, with sophisticated knowledge-database availabilities currently.
In fact the lectures barely even mention the product and are well-balanced, given by the “thought leaders” who don’t want to seem beholden to a pharmaceutical company.
It is a competitive world and Massachusetts needs to keep attracting the best doctors. Many doctors don’t appreciate losing the collegial atmosphere of sponsored functions.
http://doctoringtheevidence.blogspot.com/2010/07/massachusetts-only-state-that-prohibits.html
You are letting your belief system get in the way of reality. Recent studies show over 50% of MDs do not prescribe appropriately given present knowledge. The physician (a retired surgeon no less) presenter who gave this lecture at a recent grand rounds then applied it to our IPA and found that over the over 50% mis-prescribing held for our hospital staff. The bottom line: Doctors do need input on proper prescribing. They should however be self governing by educating themselves from reliable sources or getting proper information from trusted sources at venues like grand rounds. Insurers and drug companies should not be part of the equation. Their agendas do not fit with our clinical work.
Excellent analysis. The operative assumption by the social(ist) engineers is that either some of us will be lulled into shilling for a drug manufacturer (which occasionally happens, unfortunately), or that the rest of us are weak-minded and easily manipulated. Unless the tokens offered are of sufficient value to qualify as evidence of kickbacks, it insults the entire medical profession. Given our busy schedules, I would argue that it actually does impede our ready access to new knowledge, and impairs the rights of merchants to get our attention.
Interesting points. However, the research indicates a few problems with laying the issue at the feet of “social(ist) engineers” (most of whom are likely not socialist, though that’s always a nice little firebomb to throw at your opponents, truth be damned).
First, all people, no matter how smart, are open to influences and nudges. There’s a reason that the pharma industry spends billions on marketing each year — and it’s not because they think they cannot influence physician behavior in their favor. The pharma reps will be happy to provide you with information that highlights how wonderful their drugs are; just don’t expect them to give you anything that might show that the competitor’s drug is better, even if it is. In fact, being busy means that you are more likely, not less, to accept the evidence you have at hand and not the evidence the rep didn’t bother to give you (since it didn’t support the use of her drugs); “busy schedules” means less time to conduct independent research, which is exactly what the pharma reps that you have time to see hope will be the case (the ones you don’t have time to see are the ones that might have that other info).
From NEJM:
Doctors and Drug Companies, by David Blumenthal, MD, MPP
Responses to Doctors and Drug Companies (letters from Laura Lambert, MD, and Elizabeth Jenny-Avital, MD; further response by Blumenthal)
And from the pharma rep side:
PLoS Medicine: Following the Script: How Drug Reps Make Friends and Influence Doctors, detailing the techniques pharma reps use to influence doctors (as part of those billions spent).
Money quote [emphasis mine, to highlight the point that their job is to make their drug look good enough for you to prescribe it over the competitor's -- in other words, it's not to provide you with complete information, it's to anchor you on their drug(s) as the default(s) so you don't try the alternate, whether or not the alternate is any better]
Well written! Thank you for posting this.
The concept that most physicians can be corrupted by a lunch/dinner interaction with drug reps and will prescribe to the detriment of the patient will not withstand scrutiny. On the other hand, there are many valuable components of the interation that eventually help the patients.
It isn’t just travel insurance that this is happening with. When I checked in online for a recent flight United gave me page after page of “options” (Premier boarding, extra leg room, better meal menus, etc.) on screens where the accept button was prominent (and sometimes marked “Continue”) but the opt-out button was very hard to find.
Your analysis of the Gift Ban is so wildly off the mark that one’s first response is to question whether you have confused this issue with another current controversy: there is simply nothing in this law that either encourages or discourages the prescribing of brand-name versus generic drugs. And even on that point your argument is entirely circular, begging the question as to why any clinician would assume that branded products are superior in the first place.
But your agenda becomes dismayingly clear a couple if paragraphs in: your real targets here are the “idealistic social science researchers” whose work has highlighted the harmful effects of unregulated interactions with industry sales representatives.
From that point, your argument descends into a transparent apology for the drug and medical device industries. Your assertion that “no evidence suggests that a patient walking into a physician’s office will end up with an unnecessary and expensive bottle of pills because of a Pharma rep” is simply false. It’s far from a matter of opinion: readers of this blog are strongly advised to review the landmark 2006 JAMA series “Health Industry Practices That Create Conflicts of Interest” (authored by, among others, former NEJM editor Jerome Kassirer), as well as the Institute of Medicine’s most recent analysis and recommendations on this issue. Are these the “idealistic social science researchers” you’re referring to?
Dr Recht, I know this post is long, but bear with me and read it as maybe you will see how your remarks can be taken. Are you working as an employeed physician? Maybe by an insurance company? Those of us who work in clinical work see exactly what Dr Wong is stating is very true and how ridiculous it sounds that a 2 cent or even a $500 gift is going to make a difference in prescribing habits.
The FDA has approved that the molecular structure of a generic drug can be 20% different than the Brand Name and I have personally seen patients who have been switched by their pharmacist to a generic then had a reaction. For the patient on some drugs such as anti-depressants this can be a dangerous outcome if not monitored closely. Yet the pharmacists are doing this without any call back to the physician and a high school graduate from the insurance company is telling the physician what they can and cannot prescribe according the insurance kickback from the pharmeceutical companies.
(As you know formularies are not based on evidence-based health outcomes.)
Those making the decisions for the physicians, the congress should have to live by the same rules, what is good for the goose, is good for the gander and that congress should ban all gift giving to memebers of House and Senate even by their constituants, if they believe that a pen will cause a doctor who paid a huge price to become a doctor to prescribe a certain way just because he recieved a pen then one could say that it would make good sense that a mug sitting on a Senator’s desk with a business name on it just may make them vote in a way not to harm said business just because the got the little gift???
By the way in Britain just heard that the argument for not giving physicians and patients decision making authority is that doing this is just like giving the “waiter in a cafe’ the right to create the menu”. So much for the medical education, right? Anyone can do it with a little research, right?
By your remarks, are you saying that the doctors are so presuadable that if they get a sticky note or dinner with educational information they can be influenced to prescribe a certain medication?? Are you really saying this? Most doctors I know, even if they got trips to Europe every year it still would not influence them to prescribe a certain way as they feel a responsibility to the oath they made and to the patients they serve.
American physicians are being sold a bill of goods and their rights are being trampled on and they cannot come to agreement long enough to have a voice. Your blog shows just how disconnected the profession is.
Dear Jo:
I read your post from beginning to end. Yes, I work full-time as a community psychiatrist in the Boston area (and have for more than 15 years). I don’t like dealing with insurance companies any more than you do — but that is not the issue here. The issue is this: gifts have consequences. Specifically, gifts to physicians cause changes in prescribing behavior. One can shout and scream and stomp one’s feet about it, and express all kinds of indignation about it, but that doesn’t make it any less of a fact.
I haven’t seen quite as much nonsense talked about a law in a while. “Interaction ban”? Puh-leeze. Nothing in the law prevents you from interacting with pharmaceutical reps. You interact with people who don’t buy you lunch, or bring you pens, or give you any other form of gifts, all the time. You even learn from them, on occasion; which of us has not buttonholed a colleague in the hallway or lunchroom (while each eating our own lunch, which we paid for ourselves), and asked a question about a tough case, or a confusing issue? I do it weekly at least, and probably so do you. Why does a drug rep have to buy you lunch to make you listen to their marketing?
The “idealistic social scientists” have less of an axe to grind than you do, I suspect. Furthermore, you conflate two issues-the ban on gifts and the generic prescribing law. There is good evidence for both laws. For the gift ban, you cite the evidence presented by social science in the same breath as you dismiss it, without any good evidence to contradict it; why is that? Regarding generics, I know as well as you do that in most situations, one PPI (medication for acid reflux, for the non-physicians in the audience) is the same as any other; one H2 blocker (different class of meds for the same problem) is the same as any other, most NSAIDS (ibuprofen-like drugs) work about the same barring differences in kinetics, and there hasn’t been any good evidence that any of the phenytoin (seizure medication) formulations work better than any others as long as levels are monitored. The list of acceptable substitutions goes on and on. There is *no good reason* to use brand name drugs in most instances. In rare cases there may be, and if you care for one of the rare cases, you should have to justify your use-extraordinary claims demand extraordinary evidence.
I find your essay arrogant and confused in its reasoning. Arrogant because you are clearly unhappy that anyone could think you would be swayed by gifts and smooth talk, when the evidence says that you are only human, and all humans are swayed by gifts and smooth talk. You seem to think that physicians are somehow immune to the blandishments which work on lesser mortals. Well, I’ve been to medical school, suffered through the torturous apprenticeship which is residency (in emergency medicine), and practiced emergency medicine for 16 years, and as yet I have not found myself a higher, or more enlightened person because of it; nor have I noted that my colleagues are in much better case, much as I respect them (and you, as one who has done the same). We are men and women just like our patients; education and training has not gifted us with better personalities, merely better knowledge.
Moreover, you confuse the issue of gifts with the issue of generic substitution, which is unhelpful at best, and deceptive at worst. If brand names are better, then I expect you (or any other defender of the practice) to cite evidence suitable for publication in its defense. The plural of anecdote is anecdotes, not data; no matter how many patients you’ve personally seen with the problem, it has not, when studied, risen to the level of evidence. Perhaps you are subtly sabotaging your patients expectations? After all, the one constant in your prescribing outcomes is you.
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