I’m in the process of reading Deadly Medicines and Organized Crime: How Big Pharma Has Corrupted Healthcare, by the Danish trials expert, physician, and epidemiologist, Peter C. Gøtzsche. I hope soon to have a book report for this blog. In the meantime I am going to comment on a New York Times article that Dr. Gøtzsche cites and that I apparently missed first time around back in 2006:http://www.nytimes.com/2006/01/28/national/28insulin.html?pagewanted=all&_r=0
Brief background: In early days pharmaceutical firms got insulin from pig and beef pancreas from slaughterhouses; that led to some problems with allergies. The next big advance was the ability to synthetically manufacture human insulin, which ended those problems. However, not content to stop there, various folks kept tinkering with insulin and came up with supposedly new and improved bioengineered forms, which are questionably better than plain human insulin, but of course are much more expensive. Gardiner Harris and Robert Pear summarized for the Times how Eli Lilly had at first cornered most of the U.S. insulin market, but that recently the Danish-based firm Novo Nordisk was trying hard to capture a good chunk of the market for its own products. In 2006 an investigation was going on to see if Novo Nordisk had crossed any legal lines in pushing their products.
The revelations Harris and Pear recounted (based on internal company documents they obtained) included how Novo Nordisk reps had paid “anchors” in doctors’ offices, usually nurses or medical assistants, to be on the lookout for patients taking insulin who could be switched to the Novo product, paying them on the basis of how many prescription switches they achieved—while all the while claiming that these folks were simply being paid to “educate” patients about diabetes. Novo also contracted with the Rite Aid pharmacy chain to give them special discounts on their drugs in exchange for help switching patients in their database to Novo insulin, and were found to have paid at least one Rite-Aid pharmacist what seems to be a kickback for patients who were switched.
What I most want to focus on here are two documents unearthed in the Times article. The first was a memo that Vikki Tolbert, a Novo district manager, sent to her staff of sales reps in March 2004:
“Our goal is 50 or more scripts [switched] per week for each territory….If you are not achieving this goal, ask yourself if those doctors that you have such great relationships with are being fair to you. Hold them accountable for all the time, samples, lunches, dinners, programs and past preceptorships that you have provided or paid for and get the business!! You can do it!!”
This memo is great because it’s a laundry list of all the forms of bribes that reps pay to docs, and that when either the reps or the docs are challenged about them, insist that all these things are not bribes at all, but rather education, or else have some other fully legitimate purpose, and the last thing on the reps’ minds is that the docs are in any way beholden to them as a result of taking these things. Here is as blatant a statement as I have ever seen that yes, it’s a bribe, pure and simple; if the docs take the money, they owe the rep the business in return.
So now we turn to Rite Aid. The corporation sent a letter to its pharmacists in February 2005, saying, “Each Novo Nordisk product we dispense brings us 20 to 40 percent better profit margin,” adding that these sales add millions of dollars to the corporation’s “bottom line.”
So what did Rite Aid have to say when told that one of its pharmacists was being paid by Novo to switch patients to their drugs? Well, of course they were shocked and had no idea that such a thing was going on.
Now, let’s back up a step. Last I heard, Rite Aid was a pharmacy chain, not a medical practice. I agree that pharmacists know a lot about drugs and it would be nice if physicians listened more to the advice that pharmacists could give them—as long as that advice was genuinely the pharmacists’ and not bought and paid for by the drug company. But bottom line is that doctors are supposed to prescribe drugs and the pharmacy is supposed to fill then script with the right drug, and help educate the patient about how to take it. If the doc has made a major error, such as prescribing Drug B to a patient already on Drug A where there’s a dangerous interaction between A and B, the pharmacist should call the physician immediately and warn of the problem—but that’s a far cry from switching equivalent drugs because Rite Aid makes a handsome bundle.
So the corporation is here sending a memo to pharmacists which is highly improper because it suggests a line of action that is quite contrary to the role of the pharmacy—but the company is simultaneously covering its own rear, so that if any pharmacist actually decides to cash in on this deal, and ask for an extra bonus from Novo for doing the switching, then the company can say it was all the fault of that one renegade pharmacist and had nothing at all to do with company policy.Dr. Gøtzsche, in his intemperately titled book, more or less concludes that Big Pharma and everyone who’s in bed with them will say various things about their activities—and we cannot believe a single word of it because they routinely lie through their teeth. Maybe that’s a bit far even for a pharmascold like me to go—more on that when I get to the book review post—but from this particular set of examples, you can see where he’d get such an idea.