Pfizer Lobbyist: Kickbacks To Docs Are Bad
20 CommentsBy Ed Silverman // May 2nd, 2008 // 9:58 am
Especially if those kickbacks are paid by insurers that give docs incentives to switch to a generic from Lipitor. And that’s the hot issue this week in the Colorado legislature, where a bill would prevent insurers from enticing physicians with cash to prescribe fewer brand-name meds.
The bill is opposed by AARP, Kaiser Permanente and the Colorado Association of Health Plans, but backed by patient advocates and Pfizer, the Associated Press reports. Pfizer lobbyist Colin Kennedy, however, declined to comment on whether the bill would benefit Pfizer financially. Nothing like candor to help vet the issues.
In fact, Pfizer is scrambling to bolster its best-selling cholesterol pill and has made a point of contacting state medical associations about insurer incentives in hopes of fending off cheaper generics. But what about enticements given docs to prescribe brand-name meds?
Ask Lynn Parry, the immediate past president of the Colorado Medical Society. She notes drugmakers are still able to offer lunches or dinners to provide info about a disease for which they sell a drug. “It’s not a hard sell by any means and I think they work as hard as they can to not directly influence, but they’re a business,” she tells the AP. Hmm… How much of a difference is there between incentives?
This debate has been popping up around the US over the past year, ever since a Michigan health plan rolled out an incentive plan that was widely criticized and then cancelled, but not before prompting a few states to consider legislation to limit or end the practice. Watch a video here.
One Colorado physician says the bill is a good idea. “If you just let money drive this, some people are going to get hurt,” Earl Carsten, a family practitioner, tells The Denver Post. “It bothers me that yu’d even have to think about a law prohibiting that.”
Doc
“Its not a hard sell by any means…” - When will these folks wake up? The ’soft sell’ is much more insidious, pharma sales is strategically built so it does not seem like a sale. Why do you think so many MDs think they are not influenced? The subtle pyschological, qid pro quo, is the primary objective in rep/doctor relationships. Trust developed over time and providing small tokens is a very powerful influence, even more so, that pharma can say it isn’t, due to the small dollar value.
Dan
The managed care companies paying docs to switch to generics is thier response to branded pharma paying docs in one way or another to acquire thier loyalty.
AJP
All participants in the healthcare model should be “at risk”. Risk models are the ultimate level playing field.The patient is at risk for falling in the donut whole for over use of brand products , MD are at risk b/c it comes out of their overall PMPM compensation and and insurers are at risk for overall cost of products. Risk behooves all! Finally tell all what the cost of product really cost , without rebates and the like. Upfront in your face cost and let all player in the healthcare system determine what behooves them!!
Jack2
Directly paying the doc for switching a script (on a per script basis no less!) should be a big no-no. I totally agree with Pfizer.
Why does AARP care?
Justice in Michigan
It may surprise some that I agree with Pfizer too. Kick-back schemes are incentives to corruption. The Baycol story should be a case in point.
Once again I write as an owner of a small number of shares in the company that makes the most commonly used generic simvastatin.
I wonder how many other shareholders will join me?
rep
“The subtle pyschological, qid pro quo, is the primary objective in rep/doctor relationships. Trust developed over time and providing small tokens is a very powerful influence, even more so, that pharma can say it isn’t, due to the small dollar value.”
So a subtle psychological quid pro quo is ‘worse’ than a direct cash quid pro quo from insurers? My $8 a person lunch is going to outweigh a $25,000/ yr payout from a single insurer? Not likely, and that’s in part why we’re seeing such a big swing to generics the last few years.
I’m not opposed to generics. But clearly there are some situations where the branded does have a benefit.
The problem as I see it is that virtually none of this is known by the public. Direct payments to physicians? Nobody knows. Direct payments to your pharmacist to switch? Nobody knows.
Let’s get it all out in the open and let the chips fall where they may.
Atlex
Dan,
This law would essentially level the playing field. Pharma companies are not allowed to pay for scripts, so managed care plans should have the same restriction. Your comment about lunches isn’t analogous; plans can still buy office staff or the physician if they want to spend time providing information. This law would restrict direct quid pro quo.
Atlex
Jack2
As usually Atlex is dead on.
If insurers want to go in and buy docs lunch while educating docs on proper official treatment guidelines (which are normally so out of date they include few branded drugs), or lecture about the inappropriate use of polypharmacy (which drives up healthcare costs) - fine.
I don’t even care if they go in and give presentations about distributing scarce health-care recourses and to consider value for cost. A lot of times insurance companies get characterized as the bad guy, unfairly, because in their role of cost containment they run into opposition from individual patients, HCPs, and pharma companies.
But this an intrusion at the direct doc to individual patient level. Insurers should not be able to do it - not just because pharma companies can’t do it (although that’s true) - but because it’s not right.
M Helm, MD
The need for a law on this seems odd to me. In healthcare, the golden rule still applies - that is “he who has the gold makes the rules.”
If a health plan - self insured or indemnity - wishes to affect prescribing practices, this is easily done. All that is needed is a benefit design which recognizes the importance of directing “market share” for treatment choices, and the correct set of incentives/disincentives. Paying bonuses or kickback to prescribers in any form whether this is a direct payment based on market share or some sort of “risk pool” which providers can split seems completely unneeded. Is this a ‘red herring’ issue created by Pfizer to attract more attention, and confound the debate about the value of brands vs. generics (specifically Lipitor vs. generic statins)?
There are multiple tools that can be used to drive market share to one or another drug. One is prior authorization requirements for agents other than the selected “preferred” agents. The PA requirements don’t even have to be excessively burdensome. Another approach is for the plan to establish the a maximum amount for the pharmacy benefit for this class of drugs. The capped amount should be sufficient to fully cover the costs of, for example, simvastatin - the most potent statin availble generically. There are many more concepts and tools which are effective, and there are always bells and whistles which can tweak such a policy to maintain equity for patients with more severe disease.
I know exactly how effective these types of pharmacy policies can be. For example, how about a >500,000 member health plan with >95% share of simvastatin for more than two years. Vigilance for negative health impacts have revealed none, and the “avoided costs” of other branded medication was huge. Our poster on this was titled “Having your cake and eating it too.”
Regarding the level playing field comments, time and again, the relationship selling tactics and social obligations created by the actions of pharmaceutical sales people have been shown to be more powerful in influencing behavior than would be expected with a direct economic analysis. The efforts by PhRMA _do_ affect the individual physician-patient interaction. If that wasn’t true, and there was not a considerable return on that $8/per person lunch for an office of 75, or that $.10 pen, sales reps would not call on physician offices.
However, given who pays for a doctor’s service, PhRMA will always be at a disadvantage _IF and WHEN_ a payor decides they really do care about what treatments are used and what outcomes are acheived. When the payor is ready and willing to design benefit plans and incentives or barriers which move the patient and the prescriber in that direction, PhRMA may as well join the effort, or give up.
Since I live and breathe this every day, I’m also a little confused about why we need to spend federal or state tax revenues to create “counter-detailing” forces. If the benefit design is done thoughtfully, you can create a “path of least resistance” leading to the pattern of treatment (and outcomes) desired. Look at the Pitney-Bowes or the “Asheville Project” examples.
Of course if the design isn’t built on the best medical evidence, and built with socially conscious and altruistic guiding priniciples there is the potential for a disasterous result. I think this may be why insurers are so often (and sometimes deservedly) cast as the bad guy.
Paul
Accepting this practice would mean that we trust insurance companies to be acting in the best interest of patients.
Unfortunately, time and time again, we have seen that this is far from the case. In the opinion of some, including me, insurance companies and managed care organizations are worse than pharma companies.
So, are you still sure you want them to provide kickbacks?
HorusCat
M Helm,
You are right on in the simple ways in which payors can influence prescribing–and put the burden on the patient if he/she wishes to have a brand-name vs. generic. The problem is that payors use these schemes to discourage use of expensive meds for which there is no generic equivalent. I see this every day with MS patients who face an $800 co-pay every month.
Much of the “insidious” salescatship which I do is not against generics–it is to influence a physician to choose my branded med over other branded meds. I am lucky bec CNS conditions are less amenable to generic prescribing than say hypertension or dyslipidemia.
M Helm, MD
HCat,
I’ve been on all sides of this issue. I think the answers are not to be found in the tradtional approaches. Nor can all the players continue to play the same (type-cast)roles…
Self-insured and government sponsored plans need to be smarter (or hire smarter consultants) to focus on the desirable health outcomes, not just focus on the costs. Yes, in the past, “managed-care” often meant finding ways to manage to not pay for care. It offends me that the focus in managed care pharmacy these days is more about “specialty” (code for expensive) medications. I’ve found that if you manage the common/frequently used medications well (ie towards the ones with good outcomes and away from those with unknown/unproven benefits), there is a lot more money left for covering those kinds of expensive treatments (assuming that the expensive meds actually provide some value - see the story on Dr. Vagelos’ recent talk).
I might disagree with you on the idea that CNS conditions are less ammenable to treatment with older, generic medications. Many examples abound… But, I don’t want to lose the point of the thread here.
If the employers and people who ultimately have to deal with the consequences of short-sighted financial cost-focused “management” work toward actually improving health outcomes, this will lead to different-looking benefit plans. These plans can move everyone toward a goal of better health/more productivity/more efficient use of resources. At the same time this can also result in significant overall cost savings and efficiency.
However, the idea that an insurance company or other intermediary should adopt the tactics (current or historic - honorable or discredited) of a “competing” interest is NOT the answer to more efficient use of limited resources. It would result in yet more money (which could be directed to patient care) wasted on gimmickery. Why does Pfizer think there is a need to spend a large amount of their money (lost profits for their shareholders) in lobbying efforts for a law to prevent a stupid use of already scarce healthcare resources when there are simpler, more effective means to change prescriber behavior?
Doc
Rep,
Yes the one dollar ‘token’ gift has more impact, because it is done millions of times vs a few big kickbacks, which are rapidly diminishing due to Govt action. Your logic is exactly like the doctors, “I’m not getting anything of real value, therefore I am not influenced”. If you are or have been a rep, you know how much influence can be built in that rep/MD relationship over time and how it indeed does create an under the radar qiud pro quo.
HorusCat
Doc,
I don’t see anything wrong with building a relationship with doctors. That’s the whole point of sales. Why is pharmaceuticals any different than anything else? Food, cars, OTC stuff, vitamins…
Everyone is starting from the premise that somehow marketing pharmaceuticals is unethical. I disagree. We live in a regulated free-market, capitalist society. Sales and marketing within legal guidelines is part of that.
Former pharma Marketing Exec
I like what Dr. Helm has to say on this matter and agree on many of the points raised. It does look more and more like a red herring.
HC - no one is saying that marketing pharmaceuticals is unethical. We are suggesting that pharmaceuticals should be managed less like consumer goods. I’ve said this time and time again, patients do not have a choice, they do not pick their disease nor do they pick their treatments. They are beholden to treatment decisions being made by their health care team. We owe it to them as well as ourselves to ensure that we are not interfering with the patients right to access fully informed consent and be involved in the decision making process.
Surely you see as we all do, that it happens at times that patients may not be fully informed about treatment alternatives and that this can be linked to physician prejudices and biases that have been influenced over time by the relationship with a particular pharmaceutical company.
Dr. Helm said it right, “he who has the most gold makes the rules”. When one company can capture so much market share based on highly over priced drugs marketed in a strategic segment, they can effectively shut out other competition and over influence the “rules of that disease segment”. That is very dangerous for the patient and for the physicians. I am suggesting that this is entirely the crux of the matter here.
Do I think more power should reside with insurers? No, I do not think they have shown that they can effectively put the patient first before the issue of cost. It is a squeeze play, on the one hand we have profits before patients, on the other hand we have cost reduction first, treatment options second. No matter how innovative we are with treatment approaches, we need to figure out how to make sure it reaches the patients in a timely and cost effective manner that doesn’t override the “un-biased” (hopefully) decision making of the physician.
When you stand back and look at all the pieces of this puzzle, it is amazing that patients finally do access treatment.
Much work is needed.
HorusCat
Surely you see as we all do, that it happens at times that patients may not be fully informed about treatment alternatives and that this can be linked to physician prejudices and biases that have been influenced over time by the relationship with a particular pharmaceutical company.
Justice,
I would argue that patients aren’t informed of all their treatment alternatives because the doctor only spends 4 minutes in the room with them. I have seen myself when I go to my PC–I’m in the room 15 minutes, doc comes in and checks me out, and he’s gone. And I know the guy-he and my parents are friends (so 45 sec of my 4 minutes is spent talking about my mother). Same is true in specialists’ offices–neuros spend 30 minutes with a new patient–and most of that is diagnosing. Then they write a scrip for the drug they always use for that condition, talk about the three most common side effects, and move on to the next patient. They just aren’t reimbursed for spending time with a patient discussing alternatives.
What I see happening is that physicians prescribe what they learned to use in residency. Out in practice, that’s great for the rep whose drug he learned to use; other reps have to persuade him that it is worth the time and effort to learn to use a different drug. This is more true for CNS drugs than anti-hypertensives, I would say, but still–a doc learns how to dose one ARB and deal with it’s side effects…he’s going to use the same one over and over. Formulary issues are huge–if a doc has a critical mass of patients in one plan and that plan restricts a drug, the doc won’t use that drug very frequently in ANY of his patients, because he doesn’t have time to figure out which plan they have. Then it is a rep’s job to convince him that the benefits of the drug outweigh the pain-in-the-ass factor of the insurance process.
The issue that seems to arouse the most ire is the generic vs branded one, and I think that is more complicated than a rep selling the doc on the branded drug. I have many docs who have had negative experiences with generics in the CNS arena–and patients have had negative experience, too. And some docs just bristle at being told my a high-school graduate how they can treat their patients.
The other hot button seems to be that people think doctors are only prescribing drugs because reps are pushing them to, especially for mental illness. I think this is due much more to the current material reductionist view of the brain and consciousness than drug reps. Docs are taught that emotions, thoughts, behaviors, beliefs are nothing more than chemical and electrical signalling–in that context, using other chemicals to change the signalling process makes perfect sense.
Doc
HCat,
You get to choose your own car, food, OTC meds etc. Your MD chooses you Rx products. Remember the majority of Rx products are consumed by the elderly, who often are not in a position to argue with their doctor what product is best for them. Also the Federal Govt (you and me) pays for about 40% of all pharma Rx products. I have stated here before, profit is good - as long as it is obtained ethically and legally. I think if you look at pharma over the last number of years, there is no shortage of very questionable marketing and sales practices. There are certainly companies that are ethical, but many are over the line. The basic industry issue for sales will continue to be: Essentially sales forces of non-medical people that are rated and incentivized to sell their product to make more money and win incentive trips. This combination is ok, if you think that pharma companies are balanced in what they teach these non-medical reps and what they expect from them. Do you want your signifcant other, child, parent getting treatment for a life threating disease from a MD that has been ’sold’ by a rep who three months earlier was selling cell phone service? I would prefer not to have that situation, you may choose differently.
HorusCat
Doc,
Again, I’ll say that doctors are prescribers out of habit–starting with what they learned in residency. Most physicians are not “early adopters,” so when a new product comes out, they don’t jump on it right away. Only after time do they decide it is worth the effort to try a new product–because they perceive benefits that their go-to med doesn’t have. Most of these new meds are in the same class as the ones the doc already uses–especially in primary care. Rarely does a new class of med come into the primary care arena–memantine might be one example (and that had been on the market in Europe for 20 years before it came here; Chanitx is another example). Any rep can tell you with a new med that the vast majority of their doctors are slow to adopt its use. One exception I can think of is Viagra, and well, let’s just say male physicians were very gung-ho about that drug.
So, in the primary care setting, which is the only place you will find a rep such as you describe, the meds are primarily competitors within well-characterized classes of drugs: anti-hypertensives, anti-diabetics, anti-dyslipidemics, cholinesterase inhibitors, anti-infectives, anti-depressants, analgesics like pregabalin and the NSAIDs. Not exactly life-threatening medicine.
In the specialty arena, I can tell you there ain’t any 23 year-old former cell phone sales reps. And the training is grueling and on-going. In fact, the specialty reps in my company are currently undergoing a re-testing phase that requires detailed knowledge of disease states and clinicals; and several reps that I know of personally have been terminated in this process.
And again, I will point out that a doctor is not reimbursed for spending the time with a patient and caregiver to go through all the options and non-Rx treatments. That, more than a drug rep’s influence, is responsible for the mish-mash of drugs the elderly are on. And family members who just want behavioral problems to “go away” or nurses in LTC who just want patients quiet and out of their hair.
My point is that you make it sound like reps are omnipotent, with some sort of voodoo control over docs. That simply isn’t true. A rep may influence a doc to choose a particular brand of a class of meds, but rarely even has the opportunity to sell a new class of med. And most docs are not early-adopters (trust me, we see the numbers on that kind of thing). A rep may influence a doc to choose meds instead of non-Rx alternatives, but again, there a multitude of factors in that decision: an elder with Alzheimer’s sundowning and hallucinating and being abusive will respond to a dose of risperidone or quetiapine OR massage, soothing talk and other non-Rx therapies. Which is easier and cheaper? Is it only the rep pushing the anti-psychotic who is in control, or is it a system that reimburses for a nurse to give a misbehaving patient a pill, but not time-intensive alternatives?
It is just FAR more complicated than you paint it to be. Yes, doctors are influenced by the relationship they have with reps. But there are so many other factors in the prescribing decision that I believe are just as, if not more, influential. Believe me, I wish it were as easy as you make it out to be, because I have a med that requires a lot of nuance and trial and error–a kind of commitment to get to know it that most docs aren’t willing to make. But I have great relationships with them!!
FNP
Jumping in, since so much seems redundant. Hcat - if you are not a practitioner or physician then you are not speaking of what you know, other than the short visit with your doc. I give RX based on legitimate studies (not funded by pharma, however that is harder and harder to find)efficacy of medication, and I take into acct what the pt pays out of pocket. I always wait for 2 or 3 years to prescribe hot new meds on the market to see how many people actually die from the drug, I would rather wait than to kill off my patients.
I spend 1/2 hr with almost all my pts. I treat them as I would my own folks. I am on call 24/7/365. I make house calls. I spend the time. I write detailed detailed notes. I study every day. Sorry abt the I I I but most of my peers are just like me. We balk at pharma. No one provides monetary kickbacks to me or others and I don’t know of any docs that get $ from pharma (except the specialists who write the articles or give the speeches). The only folks who provide kickbacks are like MD Helm mentioned, the insurance companies and its a bit hard to dodge them. They remove the doc or practitioner from their list if too many referrals are made, or drugs used that are not on their formulary or too many labs and imaging done (ie the pencil pushers make the medical decisions who may be 2000 miles away). My bottom line is my pts. Their bottom line is the board of directors and the shareholders. And I have an independent practice as an FNP so the buck stops here.
As far as neuro meds, they are very very tricky. You cannot prescribe a generic in some cases just to save money, because the bioavailabilty is affected by the manufacturing process and the delivery process and the fillers. Actually in all meds, but switch one in a CNS patient and you may have trouble instantly.
Now for pharma: they push the drugs. They push hard. They bring big articles and statistics and everyone knows that any statistic can be skewed by anyone smart enough to do it. And the pharms (PFIZER in particular) provide money to the FDA to do research. Now that is unethical, esp when the FDA is supposed to be the watchdog of pharma!! So Pfizer whining about the kickbacks, thats called spin.
That being said, most of the drug reps I have ever come across have been nothing but courteous and I welcome their insight because most of them really want to understand the disease process. I am not against pharma. I dislike those who are paid handsomely to shave pennies off a medication so that the big shareholders (by the way if you have a mutual fund, you likely benefit from any one of the big pharmas)make another million. I am quite sure that the reps are better paid than me. They have company cars, the most awesome computers I have seen, and the best clothes on the face of the earth. If they would dress down a bit, be less offensively - rich - esp in my rural area, that would be better. Jeans, bring em on. If pharma would stop advertising on TV, if they would REALLY care abt patient care and the moral dilemmas, they wouldn’t charge pts going thru chemotherapy $4000/month or more, or 5 dollars a pill or more for CNS patients, or change formulations (the mechanics of putting the chemical content together) without regard or notice to docs, pharmacies or patients, then big pharma would gain some ground. At this point they are the least respected by the health care industry because of the $$$$$$$$$$ paid to the CEO’s, and same goes for insurance companies that won’t pay for cancer treatment for a child but gives the CEO a $4 billion in stock options.
The biggest ethical issue I see with pharma right now is the advertising. Five commercials in a row have to do with pharmaceuticals. Whats that cost? Who do you think that influences? The patient who wants that drug and they want it now.
ok off the platform now,
Family Nurse Practitioner
HorusCat
FNP,
I’d like one of those most up-to-date computers. I have an IBM Thinkpad. They don’t even make them anymore. I use my son’s laptop all the time–for $600 it wasn’t a bad deal, and it is much faster than mine! Lol. Company car is a good deal, although we do pay taxes on it and a surcharge every month to the company. And I probably wouldn’t pick a minivan, although I have to say it comes in handy with the kids.