Tuesday, August 21, 2007

US States Using Pharmaceutical Company Funded Program to Influence Physicians' Prescribing

The Pioneer Press just reported on how Minnesota, and other US states, use a program funded by Eli Lilly & Co which is meant to reduce physicians' supposedly inappropriate use of anti-psychotic medications. Eli Lilly is also the manufacturer of one such medication, olanzapine (Zyprexa).

One of the nation's largest drug companies is helping Minnesota cut costs and reduce questionable prescriptions of psychiatric drugs to poor and disabled residents.

Officials with the Minnesota Department of Human Services defended the program, which is funded by Lilly but run by an independent contractor, Comprehensive NeuroScience. State officials believe CNS has saved money for Minnesota's fee-for-service health plans, but more important, it has corrected some questionable prescriptions of expensive and powerful psychiatric drugs.

'Cost is an issue, certainly, but what is most important is that we get the right health care for patients,' said Brian Osberg, assistant commissioner of the human services department.

Twenty states have contracts with CNS, which identifies doctors who are prescribing psychiatric drugs outside of recommended guidelines for safety and effectiveness. A common problem is patients taking two or three antipsychotic drugs at once, despite an increased risk of side effects and no evidence that patients benefit by taking multiple drugs.

The states then send warning letters to doctors, who can decide whether to alter their prescriptions.

The article noted that states that use the Lilly program seem to have adopted policies that tend to favor Lilly and its products. In particular, neither Minnesota nor the other states that use the Lilly program uses prior authorization schemes to control drug use.

Opponents believe states are paying Lilly back for this help by keeping its drugs off prior-authorization lists. Such lists prohibit doctors from prescribing drugs without first gaining permission from the state.

Lilly is the manufacturer of Zyprexa, a top-selling antipsychotic drug. Minnesota's fee-for-service health plans spent more than $28 million on Zyprexa in 2005, and $103 million on antipsychotics in general. That more than doubled the 2000 total of $43 million for the plans, which cover 200,000 poor and disabled Minnesotans.

While other states have used prior authorization to curb these soaring costs, Minnesota has not. In fact, none of the states with Lilly partnerships use prior authorization to manage antipsychotic drugs.

Wisconsin had a contract with Lilly until last year, when the state's Medicaid agency placed antipsychotic drugs, including Zyprexa, on the prior authorization list. State officials were informed shortly thereafter that Lilly was canceling the program.

A Lilly spokeswoman acknowledged that the company is trying to discourage states from using prior authorization.

Furthermore, another of Minnesota's policies seems to tilt toward Zyprexa.

In February, Minnesota encouraged patients to split cheaper double-strength pills instead of taking multiple smaller-dose pills, which can save money for the state at the expense of drugmakers.

The 'dose optimization' strategy was required for Abilify, Geodon and Seroquel - which are competing antipsychotic drugs - but not for Zyprexa.

'Pure coincidence that dose optimization and tablet splitting are utilized exclusively for Eli Lilly's competitors?' asked Ben Hansen, who has sued to expose Michigan's partnership with Lilly. 'I don't think so.'

Human services officials replied that there was no financial benefit to placing Zyprexa on the pill-splitting list.

The program has its local critics:

If the state 'asks Eli Lilly to help decide how to buy prescription drugs, or even General Motors to help decide how to buy a car, I guess I'm going to be concerned about that,' said Ronald Hadsall, assistant dean of the University of Minnesota College of Pharmacy. 'That just smacks of conflict to me.'

A state's program to make physician prescribing more appropriate already threatens physician autonomy, but could be justified if physicians' relevant current prescribing is clearly not in patients' best interests, and if the program would clearly suggest prescribing more in patients' interests. However, the threat to autonomy cannot be justified for the sake of a program supported by a single drug company which seems to tilt the playing field in that company's favor. The state's use of this program seems to be participation in a stealth marketing scheme, made worse by its association with the aura of government power

Hat tip to Kaiser Daily Health Policy Reports.

1 comment:

Ben Hansen said...

The Pioneer Press reported, "Human services officials replied that there was no financial benefit to placing Zyprexa on the pill-splitting list."

Minnesota officials ought to consult Kansas officials, Oregon officials, Massachusetts officials, and Stanford University too.

In a study published August 2002 in the American Journal of Managed Care, researchers at Stanford University concluded that pill-splitting of Zyprexa would reduce the cost by 31%.

The Kansas Drug Utilization Review Board reported in its May 2006 Newsletter that dose consolidation of Zyprexa would save Kansas over $500,000.

The University of Oregon College of Pharmacy reported in December 2006 that a pilot program implementing dose consolidation of Abilify, Risperdal and Zyprexa saved over $200,000 the first year.

The State of Massachusetts not only requires prior authorization of Zyprexa, but also recommended in the July 2007 MassHealth Drug List Update that "dose consolidation should be considered."

Are Minnesota officials simply clueless, or are they directly influenced by Eli Lilly? I suspect both.

Ben Hansen
Traverse City, Michigan