The following column appears today on THCB, in the op-ed pages of the Los Angeles Times and at ProPublica.
Your doctor hands you a prescription for a blood pressure drug. But is it the right one for you?
You’re searching for a new primary care physician or a specialist. Is there a way you can know whether the doctor is more partial to expensive, brand-name drugs than his peers?
Or say you’ve got to find a nursing home for a loved one. Wouldn’t you want to know if the staff doctor regularly prescribes drugs known to be risky for seniors or overuses psychiatric drugs to sedate residents?
For most of us, evaluating a doctor’s prescribing habits is just about impossible. Even doctors themselves have little way of knowing whether their drug choices fall in line with those of their peers.
Once they graduate from medical schools, physicians often have a tough time keeping up with the latest clinical trials and sorting through the hype on new drugs. Seldom are they monitored to see if they are prescribing appropriately — and there isn’t even universal agreement on what good prescribing is.
This dearth of knowledge and insight matters for both patients and doctors. Drugs are complicated. Most come with side effects and risk-benefit calculations. What may work for one person may be absolutely inappropriate, or even harmful, for someone else.
Antipsychotics, for example, are invaluable to treat severe psychiatric conditions. But they are too often used to sedate older patients suffering from dementia — despite a “black-box” warning accompanying the drugs that they increase the risk of death in such patients.
The American Geriatrics Society has labeled dozens of other drugs risky for elderly patients, too, because they increase the risk of dizziness, fainting and falling among other things. In most cases, safer alternatives exist. Yet the more dangerous drugs continue to be prescribed to millions of older patients.
And, as has been well-documented by the Los Angeles Times and others, powerful painkillers are often misused and overprescribed – with sometimes deadly consequences.
As reporters who have long investigated health care and exposed frightening variations in quality, we wondered why so much secrecy shrouds the prescribing habits of doctors.
The information certainly isn’t secret to drug companies. They spend millions of dollars buying prescription records from companies that purchase them from pharmacies. The drugmakers then use the data to target their pitches and measure success.
But when we tried to purchase the records from the companies that supply them to drug manufacturers, we were told we couldn’t have them — at any price.
We next turned to Medicare, a public program that provides drug coverage to 32 million seniors and the disabled and accounts for one out of every four prescriptions written annually.
We filed a Freedom of Information Act request for prescribing data. After months of negotiation with officials, we were given a list of the drugs prescribed by every health professional to enrollees in Medicare’s prescription drug program, known as Part D.
What we found was disturbing. Although we didn’t have access to patient names or medical records, it was clear that hundreds of physicians across the country were prescribing large numbers of dangerous, inappropriate or unnecessary drugs. And Medicare had done little, if anything, about it.
One Miami psychiatrist, for example, wrote 8,900 prescriptions in 2010 for powerful antipsychotics to patients older than 65, including many with dementia. The doctor said in an interview that he’d never been contacted by Medicare.
A rural Oklahoma doctor regularly prescribed the Alzheimer’s drug Namenda for patients under 65 who did not have the disease. He told us it was because the drug helped calm the symptoms of autism and other developmental disabilities, but there is scant scientific support for this practice.
Among the top prescribers of the most-abused painkillers, we found many who had been charged with crimes, convicted, disciplined by their state medical boards or terminated from state Medicaid programs for the poor. But nearly all remained eligible to prescribe to Medicare patients.
If you or a loved one were a patient of one of these doctors, wouldn’t you want to know this?
We have now taken the data and put it into an online database that allows anyone to look up a doctor’s prescribing patterns and see how they compare with those of other doctors.
This information is just a start. It can’t tell you if your doctor is doing something wrong, but it can give information that allows you to ask important questions.
For instance, why is your doctor choosing a drug that his peers seldom do? Does your doctor favor expensive brand-name drugs when cheaper generics are available? Has your doctor been paid to give promotional talks for drug makers?
And we’d like to see the day when all prescribing by all health professionals – not just in Medicare – is a matter of public record.
It’s not only patients who benefit when medicine is more transparent. Doctors too can gain by comparing themselves to their peers and to those they admire. Clinics can see how their staffs stack up. And researchers can track patterns and examine why doctors prescribe the way they do.
One doctor told us that after studying our online database, he cornered his colleagues and peppered them with questions about their prescribing. Most, he said, were surprised when he told them their drug tallies.
Many aspects of doctors’ practices remain private. The number of tests they order and procedures they perform. The number of times they make mistakes. These data could help inform the public, too.
In the meantime, arming yourself with prescribing information allows you to be more active in your health care or that of an aging or disabled loved one.
Charles Ornstein and Tracy Weber are senior reporters at ProPublica, where this piece was originally co-published with the Los Angeles Times.
Categories: Uncategorized
Well, it is very important to keep a check on the Medicines, which the Doctor Prescribes. If you will be completely unaware of those, you will be more prone to be fooled. Even if you are just suffering from a Fever, you need to take care of the Medicines, which your Doctor Prescribes.
Take Care, and Stay Healthy!
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The easy answer is that you can’t know but I guess if you are faced with a condition you should bridge the knowledge gap as much as possible.
http://www.docboard.org/ok/ok.htm
Anyone who argues that the medical establishment is in the pocket of the drug companies has their head buried in the sand. And the drug companies have blood on their hands….
“We have now taken the data and put it into an online database that allows anyone to look up a doctor’s prescribing patterns and see how they compare with those of other doctors.”
From the description of the patients I doubt any would be interested in looking this up – especially the drug addicts. HIPPA may prevent their relatives from taking any action.
What do people expect for a 10-15 minute office visit except for the quick chemical cure.
The perfect drug could be taken once a day, have no side effects, be cheap, and 100% effective for the condition it was prescribed. The perfect drug does not, and likely will never, exist. All drugs come with side effects. Many of these are known at time of FDA approval, and many are not until after widespread usage by the general public.
There are many medications inappropriately prescribed yes. However, our society in general, and patients in particular, demand a “pill for every ill.” This of course does not mean we need to comply with a request, or demand, if we do not feel it is in the patient’s best interest.
However, let me provide an example of Oxycodone or Oxycontin, since these synthetic narcotics are often over-prescribed. Lets say John Doe, who is 18 y/o, and has a sporting accident where he fractures his leg. His orthopedist may operate and then prescribe one of these drugs for pain control. However, after one to two weeks, he is dismissed by the orthopedic surgeon who then refuses to prescribe the medication anymore. The patient is referred back to his family doctor. John Doe may still be in pain and may still need a narcotic from time to time. However, the line between this need for pain control and abuse is fine and at times hazy. If the family doctor feels that line has been crossed he may refer John Doe to a Pain Management doctor, who is besieged with legitimate pain patients and addicts. The PM doctor’s task is daunting at best, to sort out who is in pain and who is now an addict.
I tell this story because it is real, common, and understandable. It does not mean that any of three doctors treating John Doe have prescribed a drug for misguided or nefarious reasons.
To say that “Among the top prescribers of the most-abused painkillers, we found many who had been charged with crimes, convicted, disciplined by their state medical boards or terminated from state Medicaid programs for the poor. But nearly all remained eligible to prescribe to Medicare patients”, ignores the many doctors who do prescribe these medications for legitimate reasons.
Florida now does have an on-line database of drug abusers which providers can access. Recently the privacy of the database was breached with HIPAA violations.
Generic drugs are not always safer for a patient. Generics come in A,B and C categories depending upon the % of bioavailability compared to the brand name. Talk about secrecy; good luck finding out which one your pharmacy has prescribed to you. And the manufacturer may change from time to time without the patient ever being informed.
In 2014, the drug promotional money given to doctors will be public information. So if a drug rep brings my office staff lunch, ( a practice which my group no longer allows), my name will be posted as accepting $10 worth of salad and or sandwiches by XYZ Pharmaceuticals on-line. Where is the information which shows how much Big Pharma lobbyists gave to congressmen to influence their votes in a favorable fashion? No where.
People, who are patients, are not machines. We can’t insert a widget into them and expect it to work perfectly and predictably. They may take the medicine incorrectly with a bad result which may also result in what you call a “physician mistake.”
I am retiring from medicine next year in part because I am tired of faceless on and off-line regulators looking at me under a microscope. I am tired of getting letters from insurance companies asking me why Mr. Jones isn’t on a statin for example, when he is intolerant of them and that is documented in his chart. I am tired of a PBM changing my patients blood pressure medicine every 3-4 months just because they got a better deal on a different ace-inhibitor or beta blocker.
Some of the authors’ criticisms are well-founded, but others oversimplify the complicated business of drug prescribing and patients’ idiosyncrasies. More non-physicians looking over my shoulder, breathing down my neck, and second-guessing my years of practice experience, will only serve to cause less good people to enter medicine and make those of us in retire early. And with ACA on the horizon and more patients and less doctors, that is a prescription for disaster.
I think the premise of Ornstein and Weber is absurd (e.g. that doctors get some sort of secret black cloak over their practice that nobody else benefits from).
While we’re in the interest of full disclosure, why cant I find teh following things on ProPublica’s website?
1. Ornstein and Weber’s salaries
2. The salaries of the board of directors
3. A DETAILED BUDGET of operations
4. A DETAILED breakdown of funding sources
I’d really like this information and it is hard for ProPublica to proclaim itself an “independent” media outlet when they are completely non-transparent.
Actually, I would imagine a doctor in rural Oklahoma would see a fair number of elderly and disabled patients and want to help them with thearpies that are under consideration. An Internet connection is all he/she would need.
The overuse of meds in modern western bio-medicine will surely be recorded in medical history as a great tragedy of excess due to scientific hubris and greed. I call it “a true miracle industry gone completely sour”.
We must start with revising medical education away from deifying pharmacologic interventions for everything. There is “no cure for the human condition”
We must sentence culpable Big PhRMA CEO’s to serve jail sentences if they are found to be intentionally harming customers/patients. Fines and bad publicity are just not working.
A hopeful observation from my practice is that even blue-collar workers are asking me how they can reduce or eliminate excessive meds through behavioral changes – especially nutritional interventions.
The American Pharmacy of the future may very well turn out to be a fresh locally grown fruit and vegetable stand known as “The Farmacy”?
We’ll see how long that our pathalogical addiction to pharmaceuticals (many unsafe) lasts?
Dr. Rick Lippin
Southampton,Pa
I believe that information is provided by the pharmacies and the flow could be stopped.
Hi Al: I am in complete agreement that we should know the results of both successful and unsuccessful trials, as well as both studies that were and were not submitted for FDA review.
As for your latter point, unfortunately, I think it is moot. Drug companies know exactly who their top subscribers are and who they gave gifts to. The generous companies and expectant gift receivers are quite voluble with one another, I can assure you.
(inserting necessary plug for alltrials.net here.)
“data from drug company trials posted on the web before approval where not only patients and their doctors, but credible scientists who don’t work with the FDA, can comment on them. ”
Vik, my understanding is that pharmaceutical companies provide the studies they wish to the FDA and it is those studies that are reviewed before FDA approval. I would prefer that the pharmaceutical companies be forced to label a study before it is begun as to one that will be sent to the FDA for approval and not permit that study to simply be dumped and unknown. Only those studies should be the primary basis of any approval.
I would also like the pharmaceutical companies denied access to the records that state how much an individually named physician uses their product. That way if they give a gift to incentivize use of a product they would have no way to know if that gift succeeded in incentivizing the physician.
that list re Beers criteria is indeed interesting. I’m not surprised to see so much glyburide prescribed; a little surprised to see so much amitryiptyline. What exactly surprised you?
In general I find older people taking a lot of anticholinergics and a lot of NSAIDs, and I do a lot of discontinuing of both. Doesn’t help that both types of drugs are easily available over-the-counter though.
Also, I also do a lot of reducing drug doses…for example,last year after careful consideration & conversation w a family we decided to try an anti-psychotic in an elderly parkinson’s patient who had become quite paranoid. The involved neurologist first suggested an antipsychotic which is definitely NOT first choice in Parkinson’s, and then went on to propose a dose which is 4 times higher than what I start people on. This doctor laughed at my proposed “tiny dose,” but that’s what we started with. The patient got better, the family is thrilled, and they now have refused to consider a trial off the drug, to my mild dismay…but at least this patient is on a small dose rather than a big dose.
It is hard to get prescribers to change what they do, so I’ve concluded that we’re more likely to see progress when we provide families and patients with the education and information. Your project’s data is a good tool and I’m looking forward to seeing how the public makes use of this info.
This is one of those pieces of “investigative” journalism that is so seductive. No thinking person can oppose more transparency in medical care, right? So, this must be a great idea. And, of course, we should single out physicians, because it’s all their fault (physicians…read carefully, I’m with you on this one). Maybe. Maybe not.
People have been talking about — and failing at — health care transparency ever since I got into the industry. Indeed, my first public policy mentor, former Maryland Attorney General and gubernatorial candidate Steve Sachs, in 1986 became first state AG to force the feds to let him publish fees charged to Medicare by physicians in his state so that people there could learn about variation in medical care charges. Nice that the folks at ProPublica have now caught up with Steve.
Any robust conversation about the role played by pharmaceuticals in the health care system must start with acknowledging that, like virtually all medical care services, there are plusses and minuses. The medication revolution has been expensive and not without unresolved problems, but it has also helped to dramatically reduce hospital length of stay (a far more expensive and dangerous service), allowed the modern plague of HIV to be transformed into a treatable chronic disease, and, through biologics such as Epo, not only greatly improved quality of life for many people, but won bike races.
If we are going to reform the pharmaceutical marketplace — oh, heck, let’s go do that right now because all our other “market” reforms have worked so bloody well — let’s start at the root…drug development. Instead of just seeing what docs prescribe, I’d like to see data from drug company trials posted on the web before approval where not only patients and their doctors, but credible scientists who don’t work with the FDA, can comment on them. Right next to that, let’s also see all the “donations” drug companies make to physician and hospital trade groups.
The Prescriber Checkup is an obtuse game of gotcha in which the presumption is that you can judge quality from an administrative database. Not on this planet. Not unless you do things such as, along with showing a physician’s prescribing patterns, you show his or her community’s demographics. Does the prescribing pattern look like it belongs or not? You must also take into account legitimate off-label prescribing, which can result not only from published studies indexed in standard compendia, but also from a physician’s empirical observations. Isn’t that, after all, part of the art of medicine that we hear so much about?
Finally, there is this: it is a database of Medicare recipients. A 2012 American Hospital Association report, citing CDC data, notes that 80% of seniors have at least one chronic condition. Further, 66% had two or more, and the longer people live, the accrual continues. So, telling me Medicare patients use lots of drugs and maybe even some that are prescribed off-label in hopes of relieving troubling symptoms that are otherwise refractory, is not exactly earth shattering news. If a doc is truly facilitating polypharmacy or over medicating with narcotics, by all means, yank their license and send them to jail. But, there are quantum leaps to be made between criminality, malfeasance, negligence, laziness, and just plain dumbness.
If you really want to know prescribing data, use the states as your lever. Every pharmacy must be licensed. Make it a requirement of licensure in the state that every pharmacy must dump its data, shorn of all patient identifiers, into a database managed by the state board of pharmacy, which is answerable to the legislature, governor, and attorney general. Let drug companies, docs, and consumer advocates hash out who gets access to what and how. You still won’t get at quality of care issues (except in very egregious cases) because you cannot connect the drug data points to a patient, which requires care audits.
I looked up both my current physician and my last one. Ho hum. And, that’s really what this story is: when you finish parsing all the breathless sensationalism, you realize that it’s all seduction and no sex.
Thanks for the great comments so far. We have a lot of additional information on our site (http://projects.propublica.org/checkup/) to provide context and answer FAQs (http://www.propublica.org/article/prescriber-checkup-faq).
Leslie, to your point, we also created a chart on the most used Beers drugs in seniors in the Part D program. It surprised me. Does it surprise you? http://projects.propublica.org/checkup/riskydrugs
Also, be sure to check out the list of the top prescribers of Oxycontin in Part D in 2010. Many have been charged, disciplined, kicked out of Medicaid, etc.: http://projects.propublica.org/checkup/oxycontin
Would welcome additional thoughts.
Great post and terrific project! thanks for digging up this information and making it available for all to see.
In case anyone is interested in the American Geriatrics Society list of potentially inappropriate medications for older adults, it’s easily available to the public here:
http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf
They also provide a handy tip sheet on how to talk to doctors if one finds one of these medications has been prescribed:
http://www.healthinaging.org/files/documents/Medications/Beers_Criteria_Public_QandA_Feb_2012.pdf
I’ve found that concerned families really appreciate being able to access the Beer’s criteria, so would love for more people to know it’s available.
btw, I cannot review my own prescribing…I spent half of 2010 at the VA, and another several months on maternity leave…so no data avail for me.
“Seldom are they monitored to see if they are prescribing appropriately”
Physicians are monitored more than you might recognize. Patients, attorneys, health care organizations, second opinions, government agencies, pharmacists, hospital pharmacists, all sorts of committees, just to mention a few. But, the important thing that you mention is so. It is difficult to measure quality.
I actually enjoyed looking myself up on this and seeing what I prescribed. I do agree that transparency is a good thing, although I agree that context is missing, to some extent. There are many cases in which docs use meds in which there is “scant evidence” in that they work in specialties that have smaller sample sizes (the example of Namenda in autism is a good example) or where a medication is inexpensive and safe (such as Metformin for metabolic syndrome or even obesity).
Still, I am all for transparency, and do think we shouldn’t be prescribing in a way that we can’t justify if our numbers are made public.
It would be interesting to see how these numbers would change if medications were not advertised on TV, as patients coming in and, for example, requesting treatment for their “low T” is clearly a driver of prescriptions to some extent.
Agree on the need for transparency across all of these processes: Prescribing, marketing, detailing, filling, dispensing.
While we’re at it, let’s subject testing, medical decision-making, and communication skills to the same level of transparency.
You can bet, though, that invoking privacy rules (HIPAA, anyone?) status-quo-oriented parties of interest will fight transparency every step of the way.
“What I do in the exam room is between me and my patient.”
Edward Snowden notwithstanding, we KNOW all of this data could be easily available and tracked.
Congratulations on first rate investigative reporting- really excellent work laying bare a public health catastrophe.
Startling additional fact- our societal pill popping now results in more deaths from overdoses of prescription drugs than deaths from street drugs.
There are many culprits- the incompetent and/or unscrupulous doctors who overprescribe, the drug companies that oversell, the loose pharmacy distribution system which overdelivers, and the patients who pressure dangerous prescriptions or accept them passively.
There are obvious solutions. Expose the offending doctors to shame, discipline, and where appropriate criminal charges. End the freedom of drug companies to misleadingly push their products- only the US allows such unrestricted and irresponsible advertising to consumers . Monitor excessive pharmacy dispensing in real time- if Visa can proactively block fraudulent financial transactions, why can’t we develop a system to prevent questionable drug dispersal. And teach consumers to be informed and wary of pill solutions to every problem- starting a new med should be as big a decision and require as much study and care as buying a new house.
We have fought a forty year war on illicit drugs that we can’t possibly win. But we have not yet begun to fight the much needed war on the misuse of prescription drugs that we couldn’t possibly lose.
your heart is in the right place but
it would be nice if you provided context – even a single word or an adjective – when you slam a “hick doctor” (code keywords rural + oklahoma) as a mindless dupe of big pharma – maybe a line like “a treatment that some observers think could hold promise” … or clinical trials are still ongoing
or a qualifier of some kind – any qualifier ??????????????
http://icahn.mssm.edu/research/centers/seaver-autism-center/research/current-studies
Thanks for republishing this. Eager for everyone’s thoughts.