From the pages of the Tulsa World …
Commonsense cut to health care
By PETER PITTS
As Congress looks to slash federal spending, it ought to closely examine two health care initiatives run by alphabet-soup government bodies - one from the Agency for Health care Research and Quality (AHRQ), the other from the Patient-Centered Outcomes Research Institute (PCORI).
Over the past several years, these agencies' so-called "academic detailing" programs have spent tens of millions of dollars convincing doctors to change the way they write prescriptions. Unfortunately, these programs neglect patient health in favor of cost savings that in the long run may not amount to much of anything.
Who is the target?
"Detailing" is the practice of visiting health-care professionals to share information on the drugs they prescribe. The government's "academic detailing" is not done by actual academics, however. Rather, the agencies give an assortment of doctors, nurses, and pharmacists a set of government talking points and send them to meet with physicians and health-care professionals. Physicians are enticed into participating with the promise of continuing medical education credits, which they need to maintain their licenses and would normally pursue at their own expense.
The sessions often address drugs for diseases like diabetes, hypertension, dementia, and osteoporosis. The AHRQ now plans to expand its sessions to include guidelines on services such as mammograms and prostate screening. Each session concludes with specific recommendations regarding the doctor's prescribing habits.
Academic detailing might sound like a basic refresher course. But the government's contractors aren't reaching out to all doctors, or even focusing on those who need to improve patient care. Rather, they're targeting doctors who prescribe drugs often - even if those drugs work well, improve health, and save money over time by making hospitalization less likely.
The Department of Health and Human Services says the AHRQ program aims to promote "the cost-effective use of drugs," as opposed to practices that maximize health.
In addition, the detailers' recommendations are derived from research by PCORI and yet another government entity, the Preventive Services Task Force. This research is problematic for two reasons.
Dealing with humans
First, these studies are typically based on large-scale data sets rather than patient-by-patient analysis. The human body is complicated, and drugs that work for many patients may not work for all patients. Doctors often confront complex trade-offs - between effectiveness, interactions with other drugs, side effects, and price - that vary from patient to patient. And yet the government is advising physicians based on studies that ignore individual differences.
Second, just because this research bears the stamp of the federal government does not mean the findings are gospel and should be pushed on all doctors. Experts often disagree on important medical topics. For example, the Preventive Services Task Force recently recommended eliminating routine mammograms for women under 50. The American Cancer Society, on the other hand, continues to encourage mammograms starting at age 40.
In theory, it's possible that the detailers are presenting the research in a nuanced way - making clear that there is still a large role for physician discretion. But it's hard to know, thanks to a total lack of transparency.
As two former American Medical Association presidents noted in a recent letter, the AHRQ has failed to establish basic standards for disclosing how government money is being spent. The American people have no way of knowing how detailers are compensated, or even necessarily what they're supposed to achieve. The head of Total Therapeutic Management, a private firm contracted to conduct detailing for the AHRQ, says he measures success only by the remarkably unscientific standard of whether physicians say the sessions have been helpful.
Physicians rule
Moreover, the agency refuses to divulge which doctors are receiving visits from detailers and what they're being told - hiding behind privacy regulations designed to protect patients, despite no patients being present during these sessions.
Government detailing is also unhindered by the standard restrictions that apply when pharmaceutical representatives visit doctors - even though the government is also trying to influence doctors' prescribing habits for financial gain. For example, pharmaceutical representatives can't encourage "off-label" drug uses, and their promotional materials must be vetted by the FDA; neither of these rules applies to government detailing. And of course, pharmaceutical reps can't pay doctors to listen with continuing medical education credits.
It's time to end academic detailing. Physicians should prescribe the medicines they judge most effective, not the ones the government thinks will save money.
