Surveillance of physicians' prescribing patterns and the accumulation and sale of these data for pharmaceutical marketing are currently the subjects of legislation in several states and action by state and national medical associations. Contrary to common perception, the growth of the health care information organization industry has not been limited to the past decade but has been building slowly over the past 50 years, beginning in the 1940s when growth in the prescription drug market fueled industry interest in understanding and influencing prescribing patterns. The development of this surveillance system was not simply imposed on the medical profession by the pharmaceutical industry but was developed through the interactions of pharmaceutical salesmen, pharmaceutical marketers, academic researchers, individual physicians, and physician organizations. Examination of the role of physicians and physician organizations in the development of prescriber profiling is directly relevant to the contemporary policy debate surrounding this issue.
In recent years, many physicians have become alarmed by the ease and clarity with which the pharmaceutical industry is able to study their prescribing habits (2–4). With a few keystrokes on a handheld personal digital assistant, a sales representative can cross-reference real-time data sets to analyze week-by-week changes in prescribing for a particular drug; compare the data against those of her local and national colleagues; analyze use by diagnosis, specialty, and types of medical practice; and then use those data to fine-tune a sales pitch or allocate marketing resources. Prompted by a growing sense of outrage among physicians, several state legislators, state medical associations, and the American Medical Association (AMA) have put forward a series of proposals to limit the distribution and use of prescriber data (5). In May 2006, the AMA initiated an opt-out program—the Prescribing Data Restriction Program (PDRP)—through which physicians can deny pharmaceutical representatives access to their individual prescribing data (6). The following month, New Hampshire became the first state to prohibit the sale of prescriber information for use in pharmaceutical sales and marketing. A joint suit by health care information organizations (HIOs) to have the law overturned is currently being heard by a federal court (7).
Contrary to common perception, the business of selling prescriber data—the bread and butter of the HIO industry—did not emerge suddenly over the past decade. Private companies that monitor physicians' prescribing practices were founded in the aftermath of World War II, as the growth of the prescription drug market led to increased marketing interest in understanding and influencing prescribing patterns (8). This surveillance has not simply been imposed on the medical profession from the outside. As the PDRP opt-out program suggests, the AMA has played an active but carefully limited role in marketing physician-specific data. This article will provide a brief sketch of how pharmaceutical marketers and other groups gained access to data on physician's prescribing patterns and the role that physicians and physician organizations have played in generating and distributing prescriber information.
Focusing on the Prescription
The system of federal laws mandating prescriptions for the sale of pharmaceutical products was not fully established until 1954, and pharmaceutical salesmen in the first half of the 20th century expended more effort persuading pharmacies to stock their medications than they did persuading physicians to prescribe them (9). In the late 1940s, as a robust pipeline of novel pharmaceutical agents led to an increasing market for brand-name, prescription-only pharmaceuticals, the act of prescribing became a subject of increasing importance for the industry to understand (10). By focusing the key site of consumer decision making to a well-bounded set of professionals, pharmaceutical consumption through prescription enabled the development of more efficient marketing strategies. A single advertisement placed in 4 popular magazines in 1958 would cost more than $80 000 ($500 000 in 2007 dollars) and would reach only a fraction of the consumer market, while the same advertisement placed in the 4 leading medical journals would cost less than $3000 (roughly $20 000 in 2007 dollars) and would reach every physician in the United States (11). In addition to medical journals, physicians could be directly accessed through a growing legion of sales representatives. As the drug firms' most direct form of contact with the physician, sales representatives began to serve not merely as mouthpieces for their firms but as sense-organs as well..Conclusions
If it withstands the current appeal by the HIO industry, the recent action of the New Hampshire legislature will mark the end of one of the most comprehensive market research experiments in U.S. business history. As a well-bounded population of proxy consumers with total representation via the AMA Physician Masterfile, the medical profession has become one of the most easily defined and efficiently studied sectors of consumers in the U.S. economy. While the New Hampshire law would disrupt this complete market surveillance, the AMA's PDRP will continue to allow the sale of prescriber data for marketing purposes. It is possible that prescription data sets would no longer be useful to pharmaceutical sales representatives if a substantial proportion of physicians were to choose to opt out. According to the AMA, however, only 7000 of roughly 650 000 actively prescribing physicians have enrolled in the PDRP to date; only 25% of surveyed physicians are even aware that the program exists (American Medical Association. Personal communication).
In the past year, some physician groups have questioned the ethics of prescriber data collection as an invasion of the physician's privacy. However, these arguments seem tenuous. Physician–patient confidentiality has historically been invoked to protect the privacy of the patient, not the physician, and HIO companies were already maintaining strict anonymity of patient information in all of their data products long before the Health Information Portability and Accountability Act. Unlike the patient, the physician is expected to act as a public figure, whose prescriptions and chart notes are legal documents and whose actions are generally being made more transparent, not less so, by the work of the American health polity, as evidenced by the growing practice of outcomes reporting (28). It is perhaps more fitting to question the ethics of prescribers who participate in market research panels and translate their physician–patient relationships into a market research instrument for an industry with an interest in manipulating prescribing practices.
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