Let the Pharmas Data Mine Prescription Records

Today’s Managing Health Care Costs Indicator is 3.99 billion

Vermont, New Hampshire and Maine have passed legislation prohibiting pharmaceutical companies from using data from aggregators that track physician prescribing practice for marketing purposes.  The Supreme Court heard arguments yesterday about whether these laws should be struck down as restrictions of free speech.

Physicians wrote 3.99 billion prescriptions in 2010 , a rich database that can be used to increase the value of the health care system, or to market increased use of high margin medications.

I don’t have a lot to say about the constitutional issues posed by this legislation, but I’ve been thinking about the practical implications.  When I was in full-time clinical practice, I was always surprised that the drug representatives who visited our practice knew which drugs I used and which I didn’t.  Frankly, I didn’t much like it.  However, I certainly learned that my prescription practices were being watched.

The pharmaceutical companies use this data to focus on which physicians are more likely to be persuaded to prescribe the drugs that they were targeting –which were often high-priced high-margin brand name medications.  The legislators in northern New England saw a powerful public policy reason to restrict use of this data. They saw physicians prescribing unnecessarily expensive medicines, impoverishing patients, raising the cost of health insurance, and increasing the cost of state Medicaid programs.  Further, they also explicitly allowed use of this data for purposes felt to be socially beneficial, such as research or quality reporting.

The pharmas, the data aggregators, and the American Medical Association have lined up in opposition to these state efforts to restrict data mining.  The AMA is concerned that physicians might be inappropriately profiled, and also incidentally  makes more money from licensing physician lists than it does from member dues each year. 

 

I hope that the Supreme Court does not uphold the states’ rights to restrict the use of this data . I think there is a good public policy reason to let the pharmas use this data – even while knowing that their intent is to increase profits, which will drive up the cost of health care.  

I fear that if the pharmas are not allowed to use this data in a way that  they find commercially viable, it’s highly likely this data will not end up being developed.  It’s fine in theory to restrict the use of this data to “socially valuable” purposes like research, physician quality profiles, and counter-detailing.   But there are large costs involved in sorting through this data, and lack of an “anchor customer” to underwrite the cost makes it more likely that this data will never see the light of day.

Transparency can help decrease variation, and can be used to develop profiles in which physicians are most cost-effective.  I imagine a future where patients will be able to have robust information about the practice patterns and quality of their physicians. Open databases are more likely to lead to accountability and systematic improvement than databases subject to large restrictions on their use.  I support the open availability of this data, even when it will be sometimes be used in ways that don’t make me happy.

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It's A Health Care Problem: Not A Debt Problem

Today’s Managing Health Care Costs Quote is

The federal government does not have a spending problem per se. 
What it has is a health-care problem

Click to Enlarge.  Link  

That’s from James Surowiecki in this week’s New Yorker. 

He’s pointing out, as many progressive bloggers and columnists  have recently noted, that the Ryan plan would lower overall federal spending by shifting costs of Medicare to the elderly and costs of Medicaid to states and to beneficiaries. 

The Affordable Care Act has laid out a series of cuts (or decreases of planned increases) which would help make Medicare more affordable, but would be painful for doctors, hospitals, pharmaceutical companies and medical device manufacturers.  It would cut as much as a trillion from health care spending over the decade. By contrast, the Ryan plan would increase the overall cost of health care while shifting the burden away from government.

A third approach would lower the deficit far more – and that’s offering a public option to compete with existing health plans. That’s because the government could negotiate lower prices and exert more cost-control pressure on health care providers.  This isn’t especially welcome among insurers or providers.  The CBO suggested this could save $15 billion a year by 2020. 

There is a historic “iron triangle” of cost, quality and access – you can’t change one without making a tradeoff in another. There are some places where it appears we can increase quality and decrease costs (more childhood immunizations and fewer hospital acquired infections and medical errors). Alas, the dollars in these areas are small.

Surowiecki suggests a new iron triangle: senior access to care, reduction of the debt, and no change in provider payment. He tells us we can only have two of these three simultaneously.

The Managing Health Care Costs Indicator will be back with the next post.

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Tamiflu: Less Effective and More Dangerous Than Initially Believed

Today’s Managing Health Care Cost Indicator is $10 billion

That’s how much the world spent on influenza preparedness in 2009; about $4 billion was spent in the US alone.  Two billion dollars were spent on purchase of Tamiflu (Olseltamavir).

However, there is increasing evidence that Tamiflu has more serious neuropsychiatric side effects than initially thought, and the evidence of its effectiveness appears to be overstated. There was a well-referenced review of this in the current issue of New York Review of Books. 

The initial approval of Tamiflu was based on a manufacturer-sponsored metaanalysis of ten studies, 

only two of which had been published in peer-reviewed journals.  Researchers associated with the Cochrane Collaboration initially published a positive review of the medicine, but have more recently been rebuffed in their efforts to obtain the primary data from those three studies.  The author of the metaanalysis has ‘lost’ the data, and  the pharmaceutical company which markets Tamiflu in the US has only been willing to share summary data. 

There are powerful reasons why initial small studies tend to overstate the effectiveness of a medication. That’s why we need more comparative effective research, which must be continued after a drug is approved for marketing. 

Keeping us safe from influenza, either avian or swine, is pretty important.  The FDA needs to do more to be sure that the drugs we spend billions on are both safe and effective. 

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