Lilly: Help Us Help You NOT Prescribe Our Drug?

In a story best described as mind-blowing, it turns out Lilly, manufacturer of olanzapine (Zyprexa) is running a program to help state mental health programs not spend money irresponsibly on mental health medications. Yes, you read correctly. Apparently they are concerned that the $1.3 billion they raked in from Medicaid Zyprexa prescriptions in 2005 was just too much money. Sound strange yet?

Quotes from the relevant New York Times article (by Stephanie Saul) will be dispersed throughout, such as this…

Many states, looking to rein in the cost of expensive antipsychotic drugs like Zyprexa, have turned to an unusual ally for help — the very company that sells the drug. At more than $300 for a monthly prescription, Zyprexa, which is used to treat schizophrenia and bipolar disorder, is the single biggest drug cost for state Medicaid budgets. So Eli Lilly, the maker of Zyprexa, offers to help states monitor doctors who treat Medicaid patients to make sure they are not wasting money on mental illness drugs because of what psychiatrists call “sloppy prescribing” — giving patients too many similar medications or doses that are too high. Twenty states use Lilly’s free service. But some experts question why these states let Lilly help oversee spending on its own medication.

“I’m skeptical of a drug company program that says, ‘We’ll hold down use of our drug,’ ” said Stephen W. Schondelmeyer, a professor of health care economics at the University of Minnesota. He described such programs as thinly disguised marketing. Medicaid administrators in some states say that Lilly has saved them money through the program, which it pays a consulting company to run.

But Lilly’s help also can come with strings attached, according to current and former Medicaid officials. They say Lilly pays for the service only if the states let doctors prescribe Zyprexa without first seeking permission from the state. Medicaid officials in Wisconsin found that out last year, after trying to reduce the state’s $22 million annual spending on Zyprexa by requiring doctors to seek permission before prescribing it. Lilly responded by ending the program. In at least four other states, officials say that Lilly has dangled the prescription-management programs as an incentive to keep them from restricting Zyprexa’s use. Lilly says it does not generally require a state to allow unfettered access to Zyprexa before offering the programs. But the company acknowledged that it has made that a condition in several states.

Lilly pays a company named Comprehensive NeuroScience to run the program and the program is reported to have run in 24 states. How are “bad prescriptions” managed? Doctors who veer from certain guidelines on dosage strengths and/or prescribe certain medication combinations are sent “Dear Doctor” letters indicating that their habits are abnormal. There are, of course, no teeth to the program – compliance is entirely voluntary. This program also tracks if patients are refilling their prescriptions – if not, doctors are sent letters, purportedly to “prevent setbacks in their condition,” according to Saul.

Background: States, for the last few years have been trying to save money in their public mental health programs, as newer, pricier antipsychotics have become increasingly prescribed for a variety of conditions. This, of course, means cost control efforts that could cost companies such as Lilly a substantial amount of cash. Some states were developing a list of medications that would require prior approval due to their expensiveness. Many mental health advocacy groups rallied against such moves. Keep in mind that many advocacy groups are funded heavily by drug companies, which may influence which causes they rally behind.

Zyprexa, due to its quite high cost, was on its way to making several of these state’s prior-authorization-only lists, and then their program to manage “bad prescriptions” rolls out…

Lilly’s pitch in 2005 was, “we’ll fund this program is you put our product on the preferred drug list,” said David Beshara, chief pharmacy officer for Tennessee Medicaid. Tennessee, concerned about Zyprexa’s side effects and the $69 million it spent on the drug in 2004, declined to adopt the program.

And a bit later in the piece

Some states, notably Michigan and Missouri, have publicized results showing that the Lilly program helped save money. And they generally praise the program. “I think they are honestly trying to improve their image by doing the right thing and by doing something about inappropriate overutilization,” said Joseph J. Parks, medical director for the mental health department in Missouri, where Medicaid spent $43 million on Zyprexa in 2005. Dr. Parks has served as a paid consultant to Comprehensive Neuroscience.

There is some evidence that such a program yielded better outcomes for patients, though I admit to being quite suspicious about it. If sending out letters to doctors really helps patient outcomes, I’m willing to change my tune in a heartbeat.

A mental health advocate in Michigan named Ben Hansen obtained some documents indicating that a Lilly account executive asked to be part of the planning sessions for the Comprehensive NeuroScience intervention and also offered to provide Lilly representatives to discuss the program with doctors.

Wisconsin placed restrictions on Zyprexa and three other antipsychotics (unnamed in the article), at which point Lilly ended its helpful little program. The state claims its spending on those drugs dropped by $4 million.

Now let me be absolutely clear. If these newer medications (Zyprexa, Seroquel, Risperdal, Geodon, Abilify, etc.) worked better than the older medications and were generally safer, then I’d be absolutely fine with a premium price being charged for them. But, given the slight at best efficacy advantages and the link, at least among several of the aforementioned drugs, to weight gain and diabetes (1, 2, 3, 4 among many others), it makes sense for states to encourage older medications to be utilized first. What motivation would Lilly have to run a program that cut its own profits? Am I entirely missing something here? Read the whole story over at the New York Times. Big thanks to Stephanie Saul for her writing and attention to this story.