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Tuesday, June 5th 2007

Do Docs Prescribe Too Much Procrit?

The same old question: how do drug companies influence physician prescribing habits? The New York Times looks at “payments” for anemia drugs.

Industry analysts estimate that…payments — to cancer doctors and the other big users of the drugs, kidney dialysis centers — total hundreds of millions of dollars a year and are an important source of profit for doctors and the centers. The payments have risen over the last several years, as the makers of the drugs, Amgen and Johnson & Johnson, compete for market share and try to expand the overall business.

Let’s be clear what we’re talking about here. The physician practices aren’t getting a big check with you know, the word “Commission” on the Re: line.

Federal laws bar drug companies from paying doctors to prescribe medicines that are given in pill form and purchased by patients from pharmacies. But companies can rebate part of the price that doctors pay for drugs, like the anemia medicines, which they dispense in their offices as part of treatment. The anemia drugs are injected or given intravenously in physicians’ offices or dialysis centers. Doctors receive the rebates after they buy the drugs from the companies. But they also receive reimbursement from Medicare or private insurers for the drugs, often at a markup over the doctors’ purchase price.

Medicare has changed its payment structure since 2003 to reduce the markup, but private insurers still often pay more. Combined with those insurance reimbursements, the rebates enable many doctors to profit substantially on the medicines they buy and then give to patients.

No matter how they’re earning profit off these deals, you imagine it provides a pressure to overuse the drug. But I think there is a functional difference in between getting discounts on the drugs and…getting paid to use them.

Since 1991, when the first of the drugs was still relatively new, the average dose given to dialysis patients in this country has nearly tripled. About 50 percent of dialysis patients now receive enough of the drugs to raise their red blood cell counts above the level considered risky by the F.D.A.

American patients receive far more of the anemia drugs than patients elsewhere, with dialysis patients in this country getting doses more than twice as high as their counterparts in Europe. Cancer care shows a similar pattern. American cancer patients are about three times as likely as those in Europe to get the drugs, and they receive somewhat higher doses.

The fact not addressed adequately by the NYT’s article is that for smaller practitioners Medicare’s reimbursement scheme for these drugs mean they lose money on them. Much like the complaints PCPs have about some vaccines – it simply is not profitable for some smaller hem/onc and nephrology practices to stock and dose these synthetic erythropoietins. Yet they have to for their patients.

It is for those practices that the rebates are defended.

The biggest problem in the abuse of these drugs may lie with the big boys:

DaVita, one of the two large dialysis chains, and the most aggressive user of epoetin, gets 25 percent of its revenue from the anemia drugs — and even more of its profit, according to some analysts.

Even a JAMA study found that the two big for profit dialysis chains were the major offenders in the potential abuse of EPO.

For-profit dialysis centers administer higher and more doses of the anemia medication Epogen to kidney disease patients than not-for-profit centers, according to a study published on Wednesday in the Journal of the American Medical Association, Reuters/Los Angeles Times reports. Amgen manufactures the treatment.

According to the study, not-for-profit dialysis centers reduced doses of Epogen administered to participants after they reached recommended hematocrit levels, but for-profit centers continued to increase doses (Reuters/Los Angeles Times, 4/18). In some cases, for-profit dialysis centers administered doses of Epogen three times higher than those administered by not-for-profit centers, the study found (Chase, Wall Street Journal, 4/18).

Doping? He Just Got Caught Up With A Physician Over Prescribing EPO

Whatever the financial incentives for overuse of EPO, it is the health concerns which have prompted these most recent turn of events. The concerns aren’t all new. But they do keep piling up.

A July 1st write up from Reuters says,

An updated analysis of data from studies of anemia drugs used with cancer treatments showed that they increase risk of death and blood clots, an industry newsletter reported Friday.

The findings showed that use of the drugs, which include Amgen Inc.’s Aranesp and Epogen as well as Johnson & Johnson’s Procrit, increased risk of death by 11 percent and risk of blood clot by 59 percent when compared with oncology patients who did not use the drugs, according to the Cancer Letter.

Yet, even before the most recent sullen meta-analysis of their use in Cancer Letters, other studies had prompted Medicare to consider limiting when it will reimburse physicians for the use of the drugs.

Amgen shares were battered again yesterday after Medicare proposed to sharply curtail reimbursement for the company’s biggest selling product, the anemia drug Aranesp.

The proposals, which would also apply to Johnson & Johnson’s anemia drug, Procrit, follow recent reports suggesting that the drugs, widely used to treat anemia in cancer patients, could actually be making the tumors worse or hastening deaths.

Citing such evidence, the federal Center for Medicare and Medicaid Services, proposed limiting the duration of treatment and requiring that anemia reach a certain severity before therapy can be started. The Medicare agency also proposed denying reimbursement for use of the drug for patients with certain types of cancer, including common ones like those of the breast, lung and colon.

I will say that I am thoroughly surprised that these anemia drugs are the biggest hunk of the Medicare drug reimbursement pie. Medicare spends more money on no other drugs.

Physicians need to be more transparent about their relationships with drug companies. It truly is a matter of public relations and the future of health care in this country. Revelations and mini-”scandals” like this (even involving only a small number of providers) only strengthen the opinion that physician reimbursement is expendable and fair game in the attempts to control the spiraling cost of health care in this country. It really isn’t the time to forfeit any good will.