Wednesday, October 22, 2008

Pharma & Pharmacy: CVS and Merck Team Up to Sell Drugs!

Let me start off this post by stating though I may be critical of certain practices of certain drug companies, I am by no means anti-pharma. Though the pharmaceutical industry is one of the most profitable industries, they bring valuable products and research to the public and the issues surrounding big pharma are far more grey then black and white in my opinion.

That said, I was somewhat shocked when I received a letter from CVS/Caremark about one of my patients. The patient was identified by name, date of birth and medication. The letter stated that this patient was identified by "through CVS Caremarks prescription claims data as having one or more prescriptions filled for metformin or a thaizolidinedione as their only treatment for diabetes." Actos and Avandia are the two thaizolidinedione availabe in the US, and metformin is the most commonly prescribed diabetes pill.

I have received similar notifications before, but usually because patients had only filled one or two prescriptions in a 12 month period for a medication (like the ones above) that they are supposed to be taking every day, thus alerting me to the possibility that my patient may not be taking their medications.

However, this letter was different, because I knew this patient was very compliant with all of his pills. This letter went on to say that I should consider prescribing Januvia for my patients (like the one listed) whose diabetes may not be under control. The bulk of the letter discussed information about Januvia. In very small print at the bottom of the page, it said "funding for this communication was provided by Merck & Co." You don't have to by a doctor or health care industry insider to figure out which company make Januvia.

I have no problems with Januvia. I actually will add this medications to my patients who are on metformin and/or a thaizolidinedione, who are not at a goal hemoglobin A1c of less than 7%. However, it is disturbing that the pharmacy is pushing a drug on behalf of a drug company. CVS/Caremark fills or manages more than 1 billion prescriptions annually through its approximately 6,300 CVS/pharmacy stores across the country. Ironically, the Wall Street Journal just reported that Merck just cut 7200 jobs. Perhaps they feel they can fire their reps, and let CVS and their employees sell their products. This is a bad mix, because both companies profit from prescriptions filled.

It is now well known that the drug companies collect prescribing data on physicians, but they only know what drugs physicians are prescribing and not who they are prescribing them for. Pharmacies obviously know what the doctor prescribes and which patients get it, but it is a privacy violation to share this with the drug companies. By funding promotional material through the pharmacies, the drug companies can target physicians at a patient specific level, bypassing patient confidentiality issues.

Though today it was only a letter promoting a drug attached to a patient who might potentially need it, what's next? Will I be receiving promotional calls from my local CVS pharmacy which seems like a professional to professional communication, but is really a disguised sales pitch? Will the retail pharmacist get a pop-up message when a patient is refilling a certain medication to ask their doctor to prescribe another? We are a free market society, and drug companies have a right to market their products, but the letter I received today is just plain wrong. It might even be illegal.


pharmalot said...

Hi Matt,

So you're saying you've never received such a letter before? And any idea whether your patient would have had coverage for Januvia at a comparable rate to whatever you had prescribed? Would it be fair to say the Merck pill is generally more expensive?


Anonymous said...

Ed, for reference according to Lexi-Comp one month of Januvia costs $190.00 and one month of a standard dose of Metformin, generic is about $12.00.

Dr. Matthew Mintz said...

I have gotten letters from insurance companies or their pharmacy benefit manager (i.e. Merck Medco) with patient specific data regarding refills of prescriptions. These are the insurance company's way of telling me my patient is not taking their medication regularly or taking to much (i.e. narcotics, sleeping pills, duplicate prescriptions). This information is sometimes helpful.
I have gotten mailings from CVS with generic advertising of their services, but not marketing a specific drug. I have gotten TONS of mailings from various drug companies promoting their products (on average 3 a day). However, I have never gotten patient specific data from a pharmacy (CVS) that was funded by a drug company that promoted a specific drug.
Januvia is much more expensive than metformin, but to me this is not really the main issue. Januvia is by enlarge a second tier co-pay, meaning that for my patients (who all have insurance) the cost is about $20. A mentioned in the orginal post, I think Januvia is an appropriate drug for some diabetic patients (most who can not be controlled on metformin alone). My concern is with the drug company getting to the doctor with patient specific data through the pharmacy, bypassing patient confidentiality. If I get a advertisement from the drug company, I can look at it or ignore it. However, when I receive information about my patient from another health care vendor, I am morally (and I think legally) obligated to look at this. There is good data to suggest that drug company advertising is effective. Is it more effective if it is patient specific? I would think so.

Mr. MedSaver said...

The fact that a pharmacy chain (CVS) and a PBM (Caremark) have merged has you confused. But make no mistake about it . . . it was the "Caremark" part of CVS/Caremark--not the CVS part--that sent you this letter.

This is just another example of the types of tactics PBMs will employ to create revenue. Ever wonder why certain drugs in the same class will have lower copays than others? All ARBs, for example, cost about the same. However, Diovan might have a $30 copay, while Benicar will have a $50 copay on a certain insurance plan. Of course, you you probably have drug reps assault you at your office every day telling you that their drugs are on certain tiers of different insurance plans.

The reason for this lies in the fact that manufacturers will pay PBMs a rebate--that is often not passed on to the health insurance company--for such preferential treatment.

My guess is that Caremark is getting a high kickback from Merck whenever they process a Januvia prescription. Therefore, it's in Caremark's best interest to push this drug as much as possible. Of course, if the patient or the health insurance has to pay more for this, Caremark really doesn't care.

Anonymous said...

"Will I be receiving promotional calls from my local CVS pharmacy which seems like a professional to professional communication, but is really a disguised sales pitch?"

That will never, ever happen.


And don't be confused by the CVS-Caremark merger. You didn't receive this letter from the pharmacy, you received it from the PBM part of the company. And I'm surprised that they sent you a letter about a brand-name drug. Pharmacies make money on generic drugs, and PBMs save money when generic drugs are dispensed.

In this case, Januvia is far less expensive than either of the TZDs, which is probably why they prefer it.

Mr. MedSaver said...


PBMs don't save money when generic drugs are dispensed because PBMs don't pay for the drugs to begin with. PBMs are nothing more than a "middle man" or "pass through." PBMs pay the pharmacy for a prescription, and then turn around and bill the health insurance plan (usually at a higher rate). PBMs have zero incentive to lower pharmacy costs-unless it makes them more money by increasing their spread, etc. Check out my blog for a more in-depth explanation:

Dr. Matthew Mintz said...

RJS and Mr. Medsaver,
Thanks for your posts. Yes, I understand that the letter was from the PBM, but this was a little too hard to explain in an already long post. That said, it is the same company. If pharma is partnering with the PBM, what's to stop them from partnering with the local drug store? Though I agree this is less likely to happen, "never" is a pretty strong word.
This is a very worrisome trend. I am not anti-Pharma, and I think they have a right to advertise their medications. However, I have a right to ignore these ads if I choose. By sending patient specific data through a pharmacy or PBM, I am now obligated to look at this information. In addition, since this is an advertisement disguised as clinical information, this is a very deceptive practice.

Anonymous said...

A friend of mine received a similar letter regarding Fosamax, paid for by Merck and generated from Walmart pharmacy records. These are considered marketing communications and are exempt from HIPAA.