Who's Writing the Prescriptions? Patients, Drug Companies, and Insurers Exert Increasing Influence on Physicians

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Cover Story -August 2000  

By Laurie Stoneham  

A 52-year-old man calls his internist and asks for "that Bob Dole stuff." A prescription for Viagra is mailed to the patient -- no questions asked, no exam required.

Hearing rave reviews from her sister about the pills that have chased away the blues and evened out those roller-coaster mood swings, a 44-year-old woman asks her obstetrician-gynecologist to write a prescription for Zoloft. The physician complies, without even attempting to diagnose depression.

These are actual examples of everyday patient-physician encounters that make the prescribing of medication a multibillion-dollar business and an expected practice that's part of the American health care culture.

These vignettes also demonstrate the constant pressures exerted by patients, managed care drug formularies, and the giant pharmaceutical industry that affect how and what a physician prescribes. Their influence is increasing, and writing a prescription is not always just about what's best for the patients.

Pushing the consumer  

Patients asking their physicians for prescription drugs by name is now commonplace. Joe Graedon, pharmacologist and author of the popular People's Pharmacy books and syndicated newspaper columns, a public radio program host, and Internet site operator, calls such requests the result of a "full-court press of promoting drugs through direct-to-consumer advertising" by drugmakers. Pharmaceutical companies will spend close to $2 billion this year courting patients to ask their doctors about the drugs they manufacture.

It's seductive marketing that has had an impact on the American psyche. Mr Graedon sees it as "a growing tendency to medicalize the human condition." He points out that the manufacturers of popular serotonin reuptake inhibitors (SSRIs) are eager to promote their products as treatments for everything from depression, anxiety, and obsessive-compulsive disorder to premenstrual syndrome, bulimia, and even shyness.

For many, Viagra was viewed originally as a treatment for older men suffering from impotence. Now, it is also being sold to younger men who may think their love lives aren't what they could or should be if they are not having super erections.

"Even the language of disease has changed," Mr Graedon points out. "We're no longer dealing with impotence, it's now 'erectile dysfunction,' and incontinence is couched as 'an overactive bladder.'"

The economic culture  

There's a lot of gold in them there pills. Billions. Last year, 2.8 billion prescriptions were written in this country, according to health care industry watchdog, IMS Health. The pharmaceutical consulting firm of Scott-Levin estimates that retail sales of prescription medications totaled $111.1 billion last year. Leading the pack was Premarin, a coagulated estrogen for postmenopausal women.

Phil Lee, MD, who has written several articles and books on prescribing practices and is the former assistant secretary for health with the US Department of Health and Human Services, says writing a prescription at the end of a patient visit is essentially a cultural phenomenon . "It validates the patient's complaint, legitimizes his illness, and makes him feel better to walk away with a prescription," said Dr Lee, senior scholar at the Institute for Health Policy Studies at the University of California, San Francisco, School of Medicine.

He recalls a French colleague who characterized American medicine as "the one ill, one pill, one bill system of health care."

Patient pressures  

David Butler, MD, a family practitioner in Austin, abhors direct-to-consumer advertising "because it colors the whole encounter. Patients are already set on their treatment, predisposed to a diagnosis." He says it's necessary to get the patient back on track. "I need them to talk to me to begin the cognitive process of evaluating their condition and arriving at a diagnosis and treatment plan. Otherwise, I could make an error."

The Austin Regional Clinic practitioner dissuades patients from asking for a particular medication. "I've had a lot of patients leave the practice because I didn't write a prescription for an antibiotic they thought they or their child needed. My patients now know that I just won't do it."

Surendra Varma, MD, a pediatrician with Texas Tech University Health Sciences Center in Lubbock, says while he doesn't mind patients asking questions about drugs they've seen advertised, he knows that ads don't tell the whole story and may even include misleading information. As a consequence, he has to take valuable time away from patient care to discuss the results of studies referred to in drug ads.

Industry pressures  

Visits from pharmaceutical representatives "detailing" the benefits of their drugs are part of practicing medicine in this country. It happens regularly, and perks are offered and received as part of the interactions. In exchange for the "face time" with their customers, salespeople shower physicians with everything from free samples to meals, tickets to sporting events, educational seminars, and expensive gifts.

Several physicians noted that they give some of the thousands of dollars of free samples they receive to uninsured patients.

Still, physicians are under a lot of pressure to prescribe the newer drugs, according to Gregg Lucksinger, MD, a family physician in Austin. Pharmaceutical representatives "are leaving free samples of new drugs all the time so it's sometimes easy to forget that older, less expensive, but very efficacious, drugs are available. I think we have to continue to remember to use the older drugs, too."

Dr Butler relies on drug representatives to give him valuable information about the products they represent. "I have a couple of dozen pharmacy reps whom I genuinely like and trust and, quite frankly, whom I'm loyal to," he said.

He recalls one of the representatives of a recently launched sleep aid admitting that the drug wasn't that much more effective than an over-the-counter medication. "Now, I trust that guy and others, particularly those who've been doing it for a long time, to give me accurate information."

As a dermatologist who specializes in treating skin cancer, Aaron Joseph, MD, doesn't write a lot of prescriptions anymore in his Pasadena practice. Still he talks with pharmaceutical reps fairly regularly and believes that for the most part they offer reliable information. "The reps who have been in the business for 10 or 20 years are reputable on the whole and don't BS you. They give you information in a simple, straightforward way."

The time spent at dinners and sporting events, Dr Butler thinks, is particularly valuable because that's where relationship and trust are built. "You have to get beyond the salesmanship."

But pharmaceutical reps shouldn't be the sole source of information, Dr Varma believes. "We as responsible physicians should weigh all of the information and do independent research of the literature and use the Internet to learn what we can about these medicines," he said.

San Antonio family physician Abe Rodriguez, MD, agrees. Along with the information received from drug reps, he thinks it's essential for physicians to read journals and attend medical meetings to learn the latest and most accurate, unbiased information.

Physicians receiving honoraria or travel reimbursements from a pharmaceutical manufacturer in exchange for discussing the company's products with other physicians is not uncommon. However, some doctors frown on the practice. Dr Varma thinks it's unethical. "We should not be bought by the pharmaceutical industry," he declared.

For Dr Lucksinger, however, having a specialist come for an in-office lunch to discuss various kinds of therapies is very helpful. "I can learn more in that hour than I would talking for a week with a sales rep."

Full disclosure of a speaker's relationship with drug companies is something Texas Tech and other medical schools instituted years ago. If a speaker is chosen by and supported by the pharmaceutical company, it is noted that the presentation is being underwritten by a grant. "We call these guys 'hired guns,' and we know it's biased information," said Donald Wesson, MD, chair of internal medicine at Texas Tech Health Sciences Center in Lubbock.

Dr Wesson explains the preferred sponsorship arrangement as one in which the company provides an unrestricted grant to reimburse the travel expenses of speakers the university selects. In this case, the company's support is acknowledged and it is clearly stated that the speaker has no relationship with the sponsoring organization.

Managed care pressures  

Having spent a number of years practicing in the Navy, Dr Butler cut his teeth on drug formularies and saving money by prescribing lower-priced drugs. Still, he asserts that "having to work with formularies is No. 1 on my list of headaches -- and that includes everything in my life, including two preteen children."

He is not alone. According to the most recent biennial survey of physicians by the Texas Medical Association, 58% of the reporting physicians say they have seen specific cases in their practices where managed care policies adversely impacted the quality of patient care. Of that 58%, 75% cited restricted formularies as a cause of poor quality care. In a significant change from the last survey in 1998, restricted drug formularies have replaced denial of a referral to a specialist as the most frequent cause of poor care.

Dr Butler says he tries to prescribe the least expensive option 90% of the time. Then, when he wants something that's not within the managed care plan's formulary, "my staff has this huge hassle with phone calls and additional paperwork to do a little tap dance with some HMO to prescribe the drug I think my patient needs. The sheer chaos of it is what's so frustrating."

Formularies and other managed care rigmarole don't affect Dr Lucksinger. "I do what I think I need to do for my patients. And if a health plan becomes too difficult administratively, I'll drop it." Dr Lucksinger thinks more physicians need to adopt a similar attitude and practice.

Dr Rodriguez says he tries to rely on evidence-based medicine regarding the efficacy and economy of a medication, but he also is concerned about the patient's perception. "A patient has to feel confident in the drug I prescribe. If I change to a less expensive medication, for example, I have to spend time to explain that it offers the same benefits. And, generally speaking, prescribing generic drugs requires additional time to explain to the patient that the drugs are equally as good as brand name drugs."

Teaching prescribing  

Dr Wesson thinks the medical profession in general and Texas Tech in particular have not been aggressive enough in teaching young physicians about how to interact with the pharmaceutical industry. Just this past year, Texas Tech began including specific didactic instruction on how to interact with pharmaceutical representatives, how to process the information received from them, and how to determine when such relationships may be inappropriate to the point that they could compromise patient care. It is one of the few medical schools in the country to have such instruction, Dr Wesson says

"Our message is straightforward," he emphasized. "We tell our students and staff to always be suspicious because the information received from [drug] detail reps is biased. The person's goal is not to educate and not to put the patient's welfare first; it's to sell a product. The product may be a good one and one that should be used, but the motivation is expressly a commercial one," he said.

"I don't want to paint drug companies as evildoers," he added. "They are very helpful in providing academic support at a number of levels. These companies make a very positive contribution to the health care industry. But they are dedicated first and foremost to making money."

Medical students begin learning about generic drug therapy as part of the first- and second-year core curriculum, according to Dr Wesson. Brand names begin to be discussed in the third year, and prescribing practices are refined during residency.

In terms of prescribing patterns, Dr Wesson says the physicians at Texas Tech are taught to first evaluate the drug's efficacy for the diagnosed condition. If there is a choice of medications, the next consideration is side effects. Finally, if side effects are equal, price should become the final deciding factor. Academic health centers have to be supremely sensitive to cost along with providing the highest quality patient care.

Improving the practice  

The business of prescribing medication for patient care is extremely complex. The relationship between the pharmaceutical industry and the health care industry is increasingly intricate -- some would say even unhealthy, bordering on incestuous -- as pharmaceutical companies fund continuing medical education, underwrite educational grants, and pay for clinical trials of drugs.

And there are no easy answers. As biomedical and pharmacological technologies advance to offer newer, better prescription therapies, physicians will have to be able to objectively understand, decipher, and use increasing amounts of data.

Dr Lee believes a real-time information system available on a handheld computer that physicians could access when writing a prescription is the solution for avoiding or ameliorating the pressures exerted by patients, pharmaceutical representatives, and managed care organizations.

He envisions such a system helping physicians prescribe medications that offer patients the greatest therapeutic benefit. At the same time, the information would provide important patient protections by alerting physicians about potentially dangerous interactions both with other prescription medicines and with herbal remedies patients may be taking.

Mr Graedon sees the pharmacy of the future filled with computers for patients to use and robotics being employed to count pills and dispense medications. "Pharmacists will be elevated to serve as information specialists for both physicians and patients, answering questions on everything from drug interactions to side-effect profiles," he said.

"I think we're moving to a system wherein the patient and physician will have greater control over making decisions and managing costs," offered Jerry Patterson, executive director of the Texas Association of Health Plans. "For example, there may be something along the line of a defined amount of pharmacy benefits, and the patient and physician determine how those dollars are spent within those limits."

Meanwhile, how much control over writing prescriptions do physicians really have? It's impossible to answer that question definitively. What is clear, though, is that physicians are receiving, as well as dispensing, a lot of advice in the process.

Laurie Stoneham is an Austin freelance writer.  

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August 2000 Texas Medicine Contents
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