IN THIS ISSUE of the Journal of Ambulatory Care Management, Health Care For All (HCA) discusses a comprehensive plan to control costs, building upon the recent healthcare coverage expansion in Massachusetts (Bertko, 2007). This plan addresses criticism that broad healthcare coverage cannot be achieved without curbing growth in healthcare costs.
The National Physicians Alliance (NPA), a multispecialty physician organization working to restore physicians' primary emphasis on the core values of our profession-service, integrity, and advocacy, commends HCA on this ambitious proposal. We look to work with the HCA and other organizations to achieve the goal of equitable, affordable, high-quality healthcare for all.
As one of the fastest growing expenditures in healthcare, prescription drugs represent an important focus area for cost containment (Zuckerman & McFeeters, 2006). In recent years, aggressive pharmaceutical marketing has contributed to inappropriate prescribing of expensive brand-name drugs (Wazana, 2000). The NPA supports efforts to limit commercial influences on physician prescribing and is actively advocating for one of the specific policy actions proposed by the HCA: a ban on the sale of provider prescribing data. Currently, data on prescriptions written by individual physicians is sold by pharmacies to "Health Information Organizations." Personal profiles on each physician are constructed by linking these pharmacy data with personal information sold by the American Medical Association (AMA). These profiles are then sold to pharmaceutical companies, which use the information to target specific providers with tailored marketing strategies designed to influence their prescribing behavior (Steinbrook, 2006). When informed of this practice, three quarters of physicians in the United States disapprove of the sale of their prescribing data to drug companies (Kaiser Family Foundation, 2002).
It is notable that no other national physician organizations have advocated for a ban of the practice. The AMA has instituted a little-advertised "opt out" policy, which is limited to 3 years at a time, and places the burden on individual physicians to periodically register and enroll to stop the sale of their data. Such an onerous system does not go far enough to prevent detailing of providers, as it only restricts sales representatives and their direct supervisors from accessing the purchased data but not other pharmaceutical industry personnel (Mussachio & Hunkler, 2006). The AMA made more than $44 million from database products-among them the sale of physicians' individual data. With such a strong, obvious conflict of interest, the AMA should not be the sole gatekeeper for the pharmaceutical industry's access to this data (AMA, 2006).
Certainly, there are ways by which tracking physicians' prescribing practices can be useful. For example, post-market research may be done to identify problems with a given product. Alerts may need to be sent to physicians if a problem is discovered with a pharmaceutical product. Quality improvement efforts may also rely upon these data. While the pharmaceutical industry claims it needs individual physician data for such surveillance, many of these tasks are currently carried out by the Food and Drug Administration. The NPA does not seek to ban any of these legitimate uses of prescribing data.
It is the sale of data for commercial uses that we oppose; this practice has detrimental impact on both the quality and cost of healthcare. Prescribing data has been called the "greatest tool in planning (an) approach to manipulating doctors." (Whitney, 2006, p. CM-10). Marketing of new products by pharmaceutical companies is often aggressive, and the information the industry provides is often biased and incomplete, emphasizing the benefits of a medication and minimizing its risks (Cardarelli et al., 2006; Lexchin, 1997; Ziegler et al., 1995). It has clearly been shown that physicians' prescribing patterns can be easily influenced (Coyle, 2002; Wazana, 2000). Drug company representatives, armed with prescribing data often without the knowledge of the targeted physician, are able to fine-tune their sales pitch and manipulate physician "incentives" in real time to achieve their market goals. As physicians respond to these sales pitches and incentives, their prescribing of drugs drives up healthcare expenditures when cheaper and sometimes safer and more effective alternatives exist. Moreover, there are numerous examples of the rapid adaptation and off-label use of medications or devices encouraged through this aggressive marketing jeopardizing patient safety, as recent news illustrate.
It is the goal of the NPA to successfully advocate for legislation at the state and national levels to ban the sale of prescribing data for commercial and marketing purposes. New Hampshire has already enacted such a law, and other states are considering similar action. Organizations such as the HCA and the NPA seek to build broad support for these safeguards, and we encourage healthcare providers and patients to join our effort. As this article went to press, a federal court overturned the New Hampshire law. However, the legal battle appears far from over as the state attorney general considers an appeal and other states are poised to act with similar legislation.
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