We should all pay attention to our nomenclature. It’s not about “conflict of interest” — it’s about (as Secretary Sebelius correctly says) “interest.” And having an “interest” is not necessarily a bad thing — as long as you’re transparent about it.
When it comes to “transparency,” we need to weigh “interest versus benefit.” Case in point: so-called “academic detailing” (AD).
According to the Big Daddy of AD, Jerry Avorn (Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology), “Academic detailing is when healthcare professionals (usually pharmacists) meet with healthcare professionals to provide them with information and educational tools on various treatment options and optimal care, to improve provider knowledge of medical treatment effectiveness, encouraging alignment of practices with established evidence.”
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(For the sake of transparency, it’s important to note that Dr. Avorn has his own for-profit academic detailing business that has a contract with the state of Pennsylvania.)
Left unsaid, but clearly implicit, is that such detailing is required to offset the devilish doings of the pharmaceutical industry. That’s why the more common appellation for academic detailing is counter detailing.
Why should anyone care? Well — not to put too fine a point on it — it’s now the law of the land. (That is to say that significant government funding has been provided to develop and roll-out academic detailing programs.)
As of October 2010, the Agency for Healthcare Research and Quality (AHRQ) has awarded five grants for a program on academic detailing and the “communication of CER results to physicians.” This program to disseminate comparative effectiveness research (CER) findings is supported by $29.5 million from the American Recovery and Reinvestment Act (a.k.a., “the stimulus package”).
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Where is the money going? Good question.
One contract, for $11.7 million, went to Total Therapeutic Management (TTM) and is specifically intended for physician outreach and education. TTM is a company that focuses on chart abstraction, data mining, and physician and patient education for a predominantly commercial client base — health plans, pharmacy benefit managers, employers, and pharmaceutical companies.
The goal of this contract is to integrate AHRQ’s comparative effectiveness research, products, and tools into clinical practice through 9,000 on-site, face-to-face visits with clinicians, nurses, health plan formularies, benefit managers, and other healthcare professionals.
Other recipient organizations under the overall program:
• $18 million to Ogilvy Public Relations Worldwide, Healthcare Division to create a publicity center and another contract for $8.6 to create regional dissemination centers.
• A $4 million “continuing education award” to Prime Education (an educational design and accreditation company focused on continuing medical education programs).
• $2.4 million to IMPAQ International (a social science research and consulting firm that specializes in impact evaluations for a client base of predominantly U.S. government agencies) to evaluate the impact of the other four contracts.
But there are some problems. Only a few small studies demonstrate that academic detailing reduces overall healthcare costs (direct and/or indirect) — and most only demonstrate reduced prescription drug expenditures.
To that point, reducing the amount of money spent on drugs without improving the quality of care significantly limits the impact of detailing programs on overall healthcare costs. In fact, it just reinforces the concept of “fail first” — a strategy that’s good for payers (including our nation’s biggest payer, Uncle Sam) — but bad for patient outcomes.
A study fielded by the National Consumers League demonstrated that switching a patient to a generic medicine doesn’t always result in positive outcomes:
• 15% of general Rx users saying that they or a family member experienced therapeutic substitution.
• Nearly half of Rx users (47%) were dissatisfied (or their family was) with how the process occurred and report that this substitution did not result in lower pocket costs.
• More than a third (40%) said that the new medication was not as effective as the original one, and nearly a third (30%) experienced more side-effects following the substitution.
• Large majorities of Rx users think that the potential side effects of the new medication, the patient’s medical history, how well the drug works and the prescribing physician’s opinion are factors that are absolutely essential when decisions are made about therapeutic substitution.
The repercussions of choosing short-term savings over long-term results, of cost-based choices over patient-centric care, of “fail first” policies over the right treatment for the right patient at the right time are pernicious to both the public purse and the public health. Skimping on a more expensive medicine today but paying for an avoidable hospital stay later is a fool’s errand.
One study of schizophrenia drugs used in Georgia’s Medicaid program showed that, while step therapy saved the state close to $20 a month on drugs for every patient, the savings were more than offset by increased costs in other services. Indeed, the program saw a monthly increase of nearly $32 per patient in outpatient care.
As Harvard University health economist (and Obama healthcare advisor) David Cutler has noted, “Virtually every study of medical innovation suggests that changes in the nature of medical care over time are clearly worth the cost.” Access to care must be matched with quality of care.
There is little information on why so few AD programs attempt to measure overall healthcare cost reductions. This is likely due to the fact that measuring changes in prescription drug costs is a more manageable analysis than determining changes in overall healthcare spending. It also (in the “calling a spade a spade” department) fits into the general cognitive mapping of those who believe that pharmaceutical costs are the main driver of health care costs. (F.Y.I.: On-patent drug costs represent less than a dime on the American healthcare dollar.)
If the goal is better outcomes and lower costs — the problem isn’t the cost of pharmaceuticals. It’s the costs of non-compliance.
The New England Healthcare Institute estimates that $290 billion in healthcare expenditures could be avoided if medication adherence were improved.
A new study in Health Affairs demonstrates that people with four common chronic illnesses saved themselves — and the healthcare system — significant dollars by taking being medication adherent.
The CVS Caremark-funded report is based on an analysis of 135,000 patients with congestive heart failure, diabetes, hypertension and high cholesterol. The study found that people who took their meds made fewer visits to the emergency room and spent fewer days in the hospital. Specifically:
• Patients with congestive heart failure who took all their prescribed drugs saved $7,832 per year compared with those who didn’t.
• Patients with diabetes saved $3,756 by taking all of their meds.
• Patients with high blood pressure saved $3,908 when they filled all their prescriptions.
• Patients with high cholesterol saved $1,258 when they got the full benefit of pharmaceuticals.
The study concludes:
“Our findings indicate that programs to improve medication adherence are worth consideration by insurers, government payers, and patients, as long as intervention costs do not exceed the estimated health care cost savings.”
And according to a report from the Center for Technology and Aging (CTA), “Medication non-adherence is responsible for up to 33 percent to 69 percent of medication-related hospital admissions and 23 percent of all nursing home admissions,”
Adding new meaning to the words “penny wise, pound foolish.”
The CTA recommends a robust program of medical optimization (“med-ops”) via information technology as an important element to improving medication-related errors and improving medication adherence among older adults.
The report says “widespread use” of technology aimed at this population could save thousands of lives and billions of dollars.
“More widespread use of technologies that reduce the cost and burden of medication-related illness among older adults is urgently needed,” said David Lindeman, the center’s director.
AHRQ funding for such programs: zero.
The worst part about rushing headlong into academic detailing is that is no clear articulation or transparency regarding the specific rules and regulations that will govern the behavior and activities of AHRQ-funded detailers.
Some of those unanswered (and, alas, unasked) questions:
Q: What safeguards are in place to certify that physicians are being presented information that is unbiased? Previous government detailing efforts have often focused on demonstrating their own value by highlighting the cost effectiveness of initiatives through savings generated from the increased utilization of generics and other low cost therapies.
Asked another way — how can an “academic detailing” program funded by our nation’s largest payer be considered neutral? Just like detailing programs run by pharmaceutical companies, there is an inherent “interest.” And that’s okay — as long as that “interest” is transparent. But “academic” it ain’t.
Q: What information is worthy of being detailed by these programs? Who decides and on what basis?
Q: What can they say or not say? Who decides? Will they have to play by the same rules as pharmaceutical representatives? And, importantly, what is the oversight mechanism? If academic detailers stray into off-label conversations, to whom does DDMAC send a letter? Whom does the Department of Justice investigate? Who pays the fine?
All this to say that, if academic detailing is the answer — what’s the question?
Peter J. Pitts is President of the Center for Medicine in the Public Interest and a former FDA Associate Commissioner
