Doctors are pressured into prescribing what's best for manufacturers and
wholesalers, not patients

DRUG GIANTS PULLING THE OLD SWITCHEROO

Presidential commissions rarely make as much news as presidential
positions, but a report issued last week by the Health Care Quality
Commission is, like a Clinton denial, more notable for what's missing.

Mark Green, public service advocate for the City of New York, is
particularly disturbed by one omission. "The commission," he told me,
"ignored the growing problem of drug switching, whereby drug companies buy
intermediaries which coerce HMOs to switch to their products. Basically,
the system we have now is that whoever pays the piper gets the
prescription."

Here's how the scheme works. The big drug companies have bought up the
three largest drug wholesalers, which create preferred drug lists
(formularies) for use by the insurers and HMOs. If doctors or pharmacists
don't choose the "preferred" drugs on the ratings list, the HMO might
refuse to reimburse the patient, and the doctor risks not getting paid.

Moreover, for his refusal to switch to the drugs on the list, the
prescriber risks being ejected from the HMO and losing a major source of
his income. On the other hand, doctors are often given a few dollars for
choosing the preferred drug.

In its 1993-94 guidelines, Prescription Card Services, the largest and most
influential drug rater in America, covering 50 million Americans, informed
doctors and pharmacists that Prozac "is no more effective than other
anti-depressants, and is much more expensive," But in its 1994-95
guidelines, PCS claimed that Prozac had fewer side effects than the cheaper
anti-depressants, which were "more toxic." Was PCS suffering from one of
those manic mood swings drugs like Prozac are supposed to alleviate? or did
the fact that Eli Lilly acquired PCS in 1994 have something to do with it?

After evidently ingesting some "non-preferred" FDA truth serum, a former
senior official at Lilly who was reluctant to let me use his name said:
"The whole point of buying PCS was to influence the formulary lists and
protect Prozac. You make sure your drugs are on the formularies and your
competitors drugs are not. If Lilly bought PCS, there was no way they were
going to let Zoloft get ahead of Prozac." Depressing news from the world of
anti-depressants.

After the PCS deal, Randy Tobias, chairman of Lilly, gleefully boasted that
"This purchase will help sell even more Prozac." It turns out that selling
Prozac can cheer you up more than taking it.

Another drug giant, Merck, was forced to pay a settlement of $1.0 million
to 17 states in 1995 for drug-switching practices involving its Medco
subsidiary. Medco pharmacists, who had given excessively favorable
treatment to Merck products, were thereafter required to reveal their Merck
connection to their customers.

These extraordinarily profitable exercises in biased self-evaluation have
an extraordinary human cost among ordinary people. This month, the Wall
Street Journal reports that "the FDA has been canvassing reports of serious
adverse reactions as the result of drug switches." Money magazine cites the
example of a 65-year-old Tennessee woman who had to have surgery when her
ulcer medication was switched after her physician had tried in vain to
convince her pharmaceutical benefit manager that the substitution was
risky. "They had to remove 35 percent of my stomach," she said. If only she
had known of the small profit a drug company had made from that third of
her stomach, I'm sure she'd feel better.

Even HMOs are livid at having to foot the bill for pricey yet substandard
drugs. Just think how bad you have to be when HMOs think your bad.

A survey of 151 pharmacists in New York state found that 74 percent believe
that "therapeutic substitutions diminish the quality of medical care."

This is not just a local issue for your family doctor. The federal
antitrust fervor that has been unleashed against the monopolies of the
robber barons in the past and the Bill Gates and Microsoft in the present
needs now to be directed at the pharmaceutical giants pushing their own
drugs with tactics the Medellin cartel would admire.