Wednesday, June 26, 2013

Bribery Still Works: The Case of Bystolic

A lot of catching up to do with recent news that happened while I was off on vacation; but for now, here's the latest from our friends at ProPublica, home of the important Dollars for Docs campaign:

Charles Ornstein, Tracy Weber, and Jennifer LaFleur told NPR:
--about the findings of a comparison between Medicare prescribing data and drug company payments to physicians. They focused especially on Bystolic (nebivolol), a beta-blocker anti-hypertensive manufactured by Forest Labs.

There are two schools of thought in the comments quoted in the report. One is that Bystolic is indeed a unique drug, that justifies its higher-cost as a brand-name drug despite so many tried and true beta blockers being available as generics. Supposedly its side effects are less, especially interference with breathing, for example.

The other is that there is simply no scientific evidence that nevibolol is anything other than a classic "me too" drug, and that so far as we know there is no reason to prescribe it given its higher price.

Guess which point of view is expressed by docs paid as speakers for Forest Labs. Guess which point of view is expressed by national experts in cardiology that have no such conflicts of interest.

What is especially instructive from the interviews is how the old, old, tired rationalizations still have staying power: "I have never felt that there were any expectations or pressure on the part of the company that I would prescribe it more or at all," ... said [Dr. Gary Reznik, Los Angeles cardiologist and top US prescriber of Bystolic, who was paid $3750 by Forest to give talks in 2012].

Here's a special gem:
"Another top prescriber, internist Mark Barats, of West Hollywood, Calif., said he uses smaller doses of Bystolic to achieve the same effects as higher doses of generic medications. 'It has much less side effects, particularly much less side effects on the respiratory system,' he said.
"'I've never seen anything that contradicts what Forest said about Bystolic,' said Barats, who was paid $3,750 to speak for Forest in 2012."

OK, let's see if I get this. It is not the job of Forest Labs to prove a scientific basis for their claims about Bystolic. Rather, if somebody thinks those claims are wrong, it is up to those other dudes to do a study and contradict Forest. Until that time, we should all believe 100 percent whatever the Forest reps tell us. A whole new approach to evidence-based medicine...

Anecdotes aside, what about the policy implications? ProPublica quotes several drug companies as explicitly denying that prescribing levels have anything to do with which docs are offered positions on their speakers' bureaus. As is standard, they insist that they use only the physician's expertise and credentials in making such decisions.

So ProPublica found that among those paid to give company talks are 17 of the top 20 Medicare prescribers for Bystolic; 9 of the top 10 prescribers of Novartis's Alzheimer drug Exelon; and 7 of the 10 top prescribers for GlaxoSmithKline's asthma drug Advair Diskus.

Could it be that we are seeing a pattern here?

As I have said before:
--the available evidence from the inside has shown that drug companies hire rotten speakers who prescibe a lot of their drug, and fire excellent speakers who don't prescribe a lot of their drug. As I have also said before:
--it seems that the drug companies would be quite happy to have their paid speakers give talks for rooms of cardboard cut-out people if it came to that, because the real issue was bribing the speakers to continue to be high prescribers, and not to "influence" anyone else. But of course you can never say that out loud, so the industry charade demands that you stoke the doc's ego and tell them how influential they are in the community and that's the only reason you are hiring them, cross your heart and hope to die.

Memo to 3 out of 20 top Bystolic prescribers, 1 out of 10 top Exelon prescribers, and 3 out of 10 top Advair prescribers: you all need a new agent. How come you're not getting your cut?

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