SLA: When we formed the pharmacy project out of the Governor’s Office of Healthcare Reform, we looked at what we thought were good policies with regard to prescription drugs that ought to be implemented across all of our Commonwealth programs. One of the projects – the Independent Drug Information Service – is generically called academic detailing. Going back to 1995, we experimented with an academic detailing demonstration project by putting in the field half a dozen people to see how effective it might be. In 1996 we shut it down and we didn’t restart it again because we felt that the PACE program’s drug utilization review initiative, which has mandatory edits at the point of sale, accomplished more than counter-detailing without the added expense. For the PACE system to shut down the prescribing of a drug like Vioxx, for example, it doesn’t cost more than a few cents because we just change the protocols at the point of sale to reject the claim. But that doesn’t result in very much education. Nothing we can do through the prospective drug utilization review process can impart the kind of information that we can by actually visiting the doc and discussing it with them. In recent years we have taken another look at academic detailing because this administration wants to expand some of the things that we’ve done in PACE to all the other state pharmacy programs, in which case a concept like this becomes more cost-effective.

SLA: We have people out in the field who, not unlike detailers for the pharmaceutical manufacturers, are calling on physicians who have a high number of PACE enrollees and educating them with respect to prescribing in appropriately half a dozen different therapeutic classes, starting with Cox-2 inhibitors and proton pump inhibitors. Administration of the program falls under the Office of Health Care Reform, with PACE doing most of the day-to-day management of it. The clinical direction is coming out of Harvard Medical School in the person of Jerry Avorn, M.D., who is an international expert on such a program and has trained a team of people from Pennsylvania for three days at Harvard on academic detailing, the drug classes that were selected for attention and why they were selected, and the message that we wanted to get across to physicians. We have ten detailers with backgrounds largely in nursing and pharmacy – a couple of them have doctorates in pharmacology – who are going out and sitting one-on-one with the doctors. They ask for 15 minutes of a physician’s time to go in and educate the physician with regard to a particular category of drugs.

SLA: We’ve pulled out certain categories of drugs where we think there is the potential for overutilization or misutilization, where we believe that the physicians truly need to have medical evidence, in terms of when they should be prescribing these products and when they should not, given the diagnoses and medical history of the individual. Two classes – Cox-2 inhibitors and proton pump inhibitors – are the ones that we will address exclusively between now and the end of the calendar year. There’s been a lot of controversy surrounding the use of Cox-2 inhibitors and despite the fact that there’s only one left in the U.S. market, we still have concerns about the possible overuse and misuse of Celebrex. Proton pump inhibitors – I think it’s pretty widely known and accepted – are overused to a significant extent. Beginning in 2006, we’ll also be looking at pain medication, statins, antihypertensives and antiplatelets. This is not about not prescribing a particular drug because of cost. It’s really about what makes the most sense for the patient. The average person on PACE is a 78-year-old widow, and one of the first groups that went out started detailing doctors about underutilization of anti-osteoporosis medications.

SLA: It launched back in the spring, while the boots on the ground happened in September.

SLA: In 29 Pennsylvania counties, primarily in the southwest around Pittsburgh, southeast around Philadelphia, northeast in Allentown and Wilkes-Barre, and in Harrisburg. The areas were picked because they have the largest PACE enrollee concentration. We’re visiting physicians who have the highest percentage of PACE enrollment. In Philadelphia, for example, we have selected 300 docs who represent the highest volume PACE prescribers. This isn’t picking bad docs versus good docs – this isn’t profiling. We’re picking the highest volume prescribers because we think from the data we have that over-prescribing in all of these classes is just endemic. By early 2006 we want to fold in physicians in Medicaid and the State Employee Retiree Benefit Program.

SLA: We’re starting with 500.

SLA: I would say several thousand, once we fold in all the other state programs.

SLA: Probably say not until mid-2006. We want to see how it goes in these 29 counties for the first year and then determine whether or not we should go statewide with it.

SLA: Not the same kind. We use knowledge as the incentive. That’s why it’s called the Independent Drug Information Service. The way we’re promoting it is that it’s the Commonwealth – state government – that is providing the impetus and the underwriting for this initiative through the Harvard Medical School, which I think is a fairly prestigious name, and we are offering an educational benefit to physicians. I have not found from past or current experience that there is any lack of incentive here. What I find from physicians is, first and foremost, they’re elated that somebody representing the Commonwealth in an official capacity is coming to talk with them.

SLA: I can’t imagine that we would do more than two or three visits a year. But if a physician practice wanted us to come back for some reason, I can’t imagine we wouldn’t do that. With respect to all of the drug classes, there will be a four- to five-page leave-behind that will condense what is available in the class, what its appropriate use is, and recommendations for following nationally endorsed and accepted protocols on treating illnesses within each of the respective classes.

SLA: This type of program is used in other countries around the world. West Virginia started a similar program for state-employed retirees within the past year. There’s not another state that has taken the concept and expanded it so comprehensively. What wegleaned from the experience of the program’s applications in other countries is that it’s been very effective. But health care systems of other countries are a lot different from what we have here in the United States.

SLA: We’re looking at about $80,000 a month to run this benefit. That isn’t a lot when you have an entity that’s spending $3 billion a year on prescription drugs – that’s the amount that the Commonwealth either directly spends or reimburses through all of its programs that offer prescription benefits, including the state Medicaid program, the PACE program and the state employee retiree program.

SLA: I’d have to say tens of millions, but I couldn’t quantify it any better than that because it’s hard to ascribe causality. Just because our detailer visits a doc and their Cox-2 prescribing in PACE drops by 50 percent doesn’t necessarily mean that it was directly as a result of our visit. It’s a high probability, but not directly. The harder part comes when you try to estimate the savings by saying, "Okay this person lived another 15 years, was on this medication for all of that time, and the price during that time has gone up by this amount."

SLA: No. This has nothing whatsoever to do with that. These folks are not going in and talking about any specific brand. They’re going in and educating the doctor as to the class of drugs and the kinds of things that you need to be looking at before you ever get to the issue of a prescribed product.

SLA: Not directly. We’re not interested in promoting any brand over another. What we’re suggesting to physicians is that some brands within a class may be more appropriate than others, given their side effect profiles. It doesn’t have anything to do with who is the manufacturer or what the brand is.

SLA: My personal opinion is no. In fact, I’m seeing a contraction of detailing by the industry – I think that’s pretty well documented. I don’t think an expansion or contraction of detailing by the pharmaceutical industry will have anything to do with what we’re doing. On the scale of things we’re just a blip. We live in a country that represents a $240 billion-a-year retail drug expenditure. As big as Pennsylvania is, we’re only a $10 billion market. I can’t see any company stepping up their detailing force in Pennsylvania just to counteract this program.

SLA: We think it’s primarily the former. One-on-one with docs is the most effective way, particularly when you’re in their office setting. As far as counteracting what the pharmaceutical manufacturers are doing, that’s not necessarily the purpose of this initiative, but it certainly does work that way, to some extent. I used to call this counter-detailing until Jerry Avorn at Harvard came up with what I’ll call the euphemism "academic detailing." Unfortunately, a side effect of what we’re doing is to offset what the drug manufacturers are trying to do in marketing their product.

SLA: The anecdotal evidence we had in the mid 1990s was that physicians embraced it because they appreciated the opportunity to speak with an official representing the Commonwealth and get information that was not market-biased. In the present program, one detailer in Pittsburgh reported that she has had very positive experiences with the physicians she’s visited.

SLA: We’ve tried lots of things over the last 20 years, starting with physician profiling and writing letters to physicians who we thought were out of track with their peers. Our evaluation of that was that it just took us nowhere. We tried a retrospective drug utilization review (DUR) in the late ‘80s where we sent letters to physicians immediately after the drug was dispensed if we had a concern, and there was never any evidence to show that that worked very effectively. That’s what led us to the online, real-time point-of-sale drug utilization review in ’92, which time and again has shown it is very effective, particularly from an administrative cost standpoint. But it doesn’t do a good job in educating the physician about why we took the step that we did and trying to convince the physician that it’s better to prescribe in a different manner, and having that transfer to other patients in the practice. So, we’ve tried lots of things. I don’t know that there is anything out there that we haven’t tried. Prospective DUR, which has now been around 13 years, has stood the test of time as being quite effective and we’re just now trying to complement it by wrapping it around an educational component that can benefit not just PACE but all state pharmacy programs.

SLA: At least for the time being, we’re going to look generally at whether or not there is a change in the prescribing pattern of the physicians we visit a month or two after the visit. Whether or not we can attribute causality to that is another question – only a rigorous, independent evaluation would address that. We’re not planning at this point to do any formal, independent evaluation. That may come later, but the cost associated with that could be pretty significant. We’ll be able to get a good sense internally as to how well the program is working.

SLA: No, not at this point. We don’t want physicians to get the sense that the state is preparing a report card on their prescribing and that there may be some adverse reaction coming down the road. I would like to dispel any notion that that’s the purpose of this initiative. It’s not. It’s purely education.

SLA: Absolutely. They will be called and asked if one of our folks can come in and meet with them for 15 minutes. If they say no, they say no. It doesn’t mean we won’t try again. This is really a service on our part. Physicians shouldn’t feel like the state is looking to bring some sort of licensure action because they don’t open their door, or because we don’t get the results we think we should see. It has nothing to do with that at all. It’s simply about trying to help physicians better understand what might be the best clinical practice based upon the evidence that we have today. In the PACE program, we believe in the concept of open access and an open formulary. Where we limit access is based solely on clinical considerations, not with costs. We’ve felt, for the better part of 20 years, that if you can get good, clinically justified prescribing – eliminate or significantly reduce over-prescribing and mis-prescribing – you don’t have to have closed formularies. The evidence of overuse of prescription medications among Americans, particularly older Americans, has been profoundly demonstrated to be a major problem. We feel that, if you can squeeze that out, open access shouldn’t be an issue.