May 11, 2009

No Bias Anywhere Here: The Future Of Bias

If Carrie at the end of Carrie and the melting Nazi guy at the end of Raiders had a kid, and then set him on fire, that's what I look like right now.

A study on "prior authorization."

Some drugs are covered by insurance, some are not; insurance companies have medication formularies.  e.g. Zoloft may be covered, Lexapro might not be.  If a doctor wants to use Lexapro, he has to fill out a prior authorization form detailing his reasons for choosing the non-formulary drug.  The request can be allowed or denied.  The point of it is simply to-- nudge-- the doctor towards the formulary drug.

BACKGROUND: Prior authorization is a popular, but understudied, strategy for reducing medication costs. We evaluated the impact of a controversial prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes...CONCLUSIONS: Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users.

What do the authors want to be true?


First, let me explain why the conclusions of this study, (prior authorization leads to a  "substantial public health benefit and cost savings" (as the editor summarized in his editorial entitled, "The Change We Need In Healthcare"   (yeah, that's what he called it; soon we'll see "Dopamine Blockers in Schizophrenia: Mission Accomplished"))) are completely misleading.

Despite what you and logic might think, insurance companies and Medicaid do not pick their formulary based on what is most efficacious, or even what is cheapest.  They put things on based on the deal they strike with the drug companies.  By "deal" I mean "payoff." By "payoff,"  I mean "kickback,"  in a mechanism so needlessly complicated it can only be on purpose.  Many "non-preferred agents" are cheaper/better/safer than the "preferred agent."

If we move to a single payer model (BTW: will never happen, ever, I'll explain why) that payer may be able to negotiate lower prices overall, but it will be because of the "deals" and not because of judicious evaluation of safety or efficacy.  If the FDA can't competently evaluate safety and efficacy, do you think Medicare can, and still account for the third variable of cost?  And what would we need doctors for?

And think about the way the clincial decision is made.  These deals occur outside and before the doctor-patient interaction.  The doctor has no choice but to use the products available to him.  He has the option of going off-formulary, but it is so difficult that it is impractical.  In other words, Pharma and the insurance company have colluded to control the market.  You didn't like it when Microsoft did it.  Isn't this the definition of racketeering?


What do the authors want to be true?

disclosure prior auth.JPG

I know what a "Department of Ambulatory Care and Prevention" is.  But do you know what a "Harvard Pilgrim Health Care" is?

Oh, they're the same thing.


Imagine if Harvard's department of surgery was sponsored by Intuitive Surgical; or their psychiatry department was sponsored by Pfizer.  Imagine those pairs then went on to make policy decisions, like teaching residents that the DaVinci system is first choice for surgeries; or teaching med students that Zoloft is first line for depression. Those would seem like conflict of interests that would never happen in today's anti-bias climate.  But there you go.

You might not think this is as bad as Pfizer running the Harvard Psychiatry, but it's actually much worse, because there are competing alternatives to Pfizer but there are no alternatives to insurance-- especially if we get a single payer.

I'd like to point out that Harvard has banned drug pens from the school because that influences prescribing.

What are the chances that an academic at Harvard on the brink of becoming Associate Professor is ever going to "discover" that preferred drug lists aren't a good idea? 

If you want to see what the next ten years in medicine look like, stop looking at Astra Zeneca.    The next unholy alliance is between academic medicine and insurers/providers.  The placebo controlled trials on the treatment of bipolar will no longer be controlled by Abott (Depakote off patent 2008), but by United Healthcare.

Academics won't be scrambling to get Pharma grants; they'll be looking for Aetna grants.  And ten years from now, when we finally wake up, we'll be asking how we let insurance companies and government ever get so close to medical education, how we let them "corrupt" our residents.

While we were distracted by Carlat for repenting his Big Pharma ways, no one noticed the answer:

beth israel.JPG
The answer is: some spots opened up, and they were available.