Transcript No Slide Title

The Prescription Project:
Ending Conflicts of Interest;
Promoting
Evidence-Based Prescribing
Marcia Hams, Director of Prescription Policy Initiatives
The Prescription Project
National State Attorneys General Program
Columbia Law School, 5/10/07
The Prescription Project is a
collaboration of
Community Catalyst and
The Institute on Medicine as a
Profession
Funded by Pew Charitable Trusts
Community Catalyst
Community Catalyst is a national non-profit
advocacy organization established in 1997
to increase consumer participation in
shaping the U.S. health care system to
ensure quality, affordable health care for
all. It works in numerous states with state
and local organizations as well as other
national organizations.
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Institute on Medicine
as a Profession
The Institute on Medicine as a Profession seeks to
shape a world inside and outside of medicine that is
responsive to the ideals of professionalism. IMAP
supports research on the past, present, and future
roles of professionalism in guiding individual and
collective behavior. It aims to make professionalism
relevant to physicians, leaders of medical
organizations, policy analysts, public officials, and
consumers. IMAP’s programmatic agenda is carried
out through the Center on Medicine as a Profession
of Columbia University.
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www.prescriptionproject.org
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The Problem
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Out of control industry marketing
Industry influence in government
Quality of care compromised
Pharmaceutical costs out of control
Consumers can’t afford their drugs
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Rx Marketing to
Doctors
• Industry spends $12B/year on drug
marketing to MDs ($13,000/MD)
• 90,000 sales reps (1 for every 5 MDs)
• Gifts, lunches, trips, educational
grants, entertainment, free samples
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Impact of marketing
on prescribing
• Even small gifts create obligation and
influence prescribing decisions
• Free samples create loyalty to brand
• Newest, least tested, drugs promoted
and often prescribed
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Impact on costs
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Marketing is 30% of cost of drugs
Only 10-15% spent on R&D
Expensive me-too drugs over prescribed
Generics under prescribed; cost 30-80%
less than brand names
• 17% of cost increases due to switches to
more expensive drugs
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Prescription Project Goals
• Reduce conflicts of interest created
by the pharmaceutical industry’s
marketing practices in the medical
profession and among payers
• Increase reliance on evidence-based
prescribing among providers and
purchasers
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Prescription Project Strategy
Advance practical public and private policy
solutions to meet these goals among:
– academic medical centers
– medical professional societies
– public and private purchasers
– providers
– policy makers/regulators
– consumers and advocates
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Drivers of Prescription Reform
• Consumers want access & affordability
• Media and public opinion
• Public and private payers seek to
preserve programs and benefits
• States seek to sustain expansions of
coverage/benefits
• MDs and other providers who seek to
reestablish trust in medicine
• The Quality Movement
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Reducing Conflicts of Interest:
Self-Regulation
• Academic Medical Centers
• Professional Medical Societies
(which also publish Clinical Practice
Guidelines)
• Hospitals and group practices
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Journal of the American Medical Association
January 25, 2006
(2006; 295: 429-433)
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Recommendations to Academic Medical
Centers for Controlling Conflicts of
Interest
Activity
Regulation
Gifts, meals directly to
physician from industry
Eliminate
Provision of free samples,
other patient-use products
Vouchers, other indirect
distribution system
Speakers’ Bureaus and
Ghostwriting
Eliminate
Payment for physician and
trainee travel
Contributions to a conflictfree central facility
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Recommendations to Academic Medical
Centers for Controlling Conflicts of
Interest
Activity
Regulation
Direct support for CME
Consulting, speaking
honoraria, and research
contracts
Contributions to a conflictfree central facility
Transparency; Specify terms
of service and be available
for public inspection
Formulary and other
purchasing decisions
Decision-makers must be
conflict free
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Conflicts of Interest:
Public Policy Solutions
• Vermont statute (2002): Disclosure. Reports by
AG on amounts to MDs (by specialty, not name)
• Minnesota statute (1993): $50 limit for gifts but
many exemptions; disclosures published by
Board of Pharmacy
• Maine (2003): disclosure of expenses>$25
• West Virginia (2004): Broad disclosure but no
individual MD names
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Evidence-based prescribing
• Expand reliance on evidence-based
systematic reviews
• Expand use of generics
• Implement academic/counter detailing
• Prohibit sale of prescriber data for
industry marketing
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Promote evidence-based
reviews to shape prescribing:
public sector
• Expand use of Drug Effectiveness
Review Project to shape Preferred
Drug Lists; now in13 states
• Statutory requirements to use EBM
as basis for public purchasing
(WA ’05; proposed in VT and MA
‘07)
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Promote evidence-based
reviews to shape prescribing:
private sector
• Create standards for accountability
• Minnesota Coalition utilizing DERP
based CRBestBuyDrugs
• Health plan/insurer/employer interest
• Public/Private partnerships: Puget
Sound Health Alliance
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Academic/Counter Detailing
Public Programs & Payers
• Pennsylvania senior Rx PACE
program (rigorous evaluation
underway)
• West Virginia and Vermont
• New legislation proposed in Proposed
in VT, ME and MA. New Hampshire
interested.
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Academic Detailing/MD
Education Private Payers
• Kaiser, Health Partners in-house
• Potential for employer interest
• Minnesota Coalition/payers using CRBest
BuyDrugs for MD education
• Proposed ME and MA bills allows for
private plans to subscribe to public
initiative
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Academic Detailing:
Evaluation and Best Practices
• Show Me the Evidence: Best
practices for using educational visits
to promote evidence-based
prescribing
A two-year evaluation program from
May 2004 to April 2006
By the Canadian Academic Detailing
Collaboration and Drug Policy Futures
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Programs Evaluated in the
U.S. and Canada
• Kaiser Permanente, Colorado; Brigham and
Women’s Hospital, Harvard Medical School;
Accessible Intelligent Medication Strategies,
West Virginia; Veterans Administration, Greater
Los Angeles
• B.C. Community Drug Utilization Program;
Alberta Drug Utilization Program; RxFiles
Academic Detailing Program, Saskatchewan;
Prescription Information Services of Manitoba;
Dalhousie Academic Detailing Service, Nova
Scotia
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Evaluation conclusions (1)
• Academic detailing is working
Effectively influences prescribing practices
Randomized controlled trials show
improvements in the performance of health
professionals receiving visits from academic
detailers
• Success is dependent on the credibility of
the program and the detailers
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Evaluation conclusions (2)
• Well-produced printed materials and handouts
are useful to physicians
• Costs to provide academic detailing services
vary widely and depend on a number of factors
• An evidence-based approach to medicine is
increasingly important to physicians
• Academic detailing programs should be more
thoroughly evaluated to strengthen programs
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Maine LD 839
• Will establish an academic detailing
program
• Targets prescribers and dispensers
participating in publicly funded health
programs
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Maine LD 839 cont.
• Requires investigation of partnership with
VT and NY; and a review of
Pennsylvania’s program
• Program design phase will include all
stakeholders, including the MaineCare
Advisory Committee and the MaineCare
Drug Utilization Review Committee
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Maine LD 839: Funding
• Pharmaceutical manufacturer
payments to the State
• Tobacco Manufacturers Act
• General Fund
• Savings the program itself generates
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Vermont S.115:
Comprehensive Rx Legislation
• Will establish a preferred drug list based
on Evidence Based Medicine and a prior
authorization system for state programs
• Bans the sale of prescriber information
unless the physician explicitly “opts-in”
• Requires PBM transparency and
establishes required practices
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Vermont S.115 cont.
• Establishes an annual $1,000
manufacturer fee for each pharmaceutical
company selling prescription drugs to state
programs
• Establishes a pharmacy discount plan for
certain seniors and individuals below a
specified income threshold
• Prohibits “unconscionable pricing”
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Vermont S.115 cont.
• Establishes an evidence-based
prescription drug education program for
state program health care professionals
There may be collaboration with other states
in establishing the program
Includes establishment of a pilot program to
provide generic drug samples
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Massachusetts
Cost/Quality bill: Rx sections
• Establishes Evidence Based Medicine as
basis for MassHealth Preferred Drug List
• Establishes joint purchasing consortium
for all state agencies that adopt this PDL
• Establishes academic detailing
• Prohibits sale of prescriber data for
pharmaceutical marketing
• Establishes clinical trials registry
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Academic Detailing Funding
• Start-up funding is difficult,
particularly for small Medicaid
programs, despite expected future
savings
• Medicaid state funds matched by
federal funds
• Potential for use of settlement funds
in pharmaceutical cases?
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Contact Us:
The Prescription Project
30 Winter St. 10th Floor
Boston, MA 02108
www.prescriptionproject.org
Main Office (Boston): 617-275-2853
New York Office: 212-305-4184
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