Healthy Skepticism Library item: 16684

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Russell J
Lilly pays CVS Caremark to try to get doctors to prescribe Cymbalta
IndyStar.com 2009 Oct 18
http://www.indystar.com/article/20091018/BUSINESS03/910180396/1003/BUSINESS/Lilly+pays+CVS+Caremark+to+try+to+get+doctor

Full text:

Dr. Daniel Carlat, a Massachusetts psychiatrist, was puzzled as he read through the letter that had arrived in an official-looking envelope marked: “Confidential — May Include Protected Health Information.”

Often, such letters warn that a particular patient had failed to refill a drug or was receiving too many prescriptions of an addictive medication.

But curiously, this notice from CVS Caremark, a pharmacy benefits manager, was touting a specific drug, the antidepressant Cymbalta, made by Eli Lilly and Co. The drug was approved last year as a treatment for fibromyalgia, a chronic condition marked by pain, headaches and tingling.

“We are committed to providing health care professionals with information about drug therapy,” the letter said. “As part of this commitment, we are providing you with this issue of RxViewpoints, which focuses on the management of fibromyalgia with Cymbalta.”

The letter included “key points” about Cymbalta’s effectiveness in clinical trials, along with recommended dosages, possible side effects and risks. Then, in smaller type, in three places throughout the seven-page letter, came the disclaimer: “Funding for this communication was provided by Eli Lilly and Company.”

Carlat, a psychiatry professor at Tufts Medical School in Boston, said he found the letter deceptive — another way for Lilly to promote its drugs even after it has paid more than $1 billion in settlements for the inappropriate marketing of other drugs and has pledged to be more transparent in its marketing practices.

“This was designed to look like an important letter for a treatment for my patients, not what it really was — a paid promotion by a drug maker,” said Carlat, a well-known critic of drug marketing.

He dashed off a posting on his blog, scolding Lilly for “paying CVS Caremark to perpetrate this deception.” And he called CVS Caremark, one of the nation’s largest purchasers and providers of prescription drugs, a “pharmacy whore” for taking Lilly’s money.

Critics: Practice is misleading

Carlat was hardly the first doctor to feel tricked. Across the country, physicians are raising their voices about such mailings by CVS Caremark that appear to look like important patient information but turn out to be promotions for Lilly, Merck, AstraZeneca, Bayer and other pharmaceutical companies.

Several consumer groups, medical ethicists and privacy advocates also are raising concerns, saying the practice is misleading and not in the interest of good medicine. Consumers Union, a nonprofit group that publishes Consumer Reports, says it increases the chances that doctors will prescribe drugs that are inappropriate or cost more than alternatives that work just as well.

“This kind of drug marketing should simply be forbidden,” said Steven Findlay, senior health policy analyst at Consumers Union. “It does not fully inform doctors about drug treatment choices.”

“The idea that it’s even permissible is atrocious,” said Eleanor Kinney, co-director of the Center for Law and Health at Indiana University School of Law-Indianapolis.

For Lilly, the issue raises sensitive questions at a time when the company is holding itself up as an industry leader in ethics and transparency.

Lilly touts openness

In a speech last fall to the Economic Club of Indiana, John Lechleiter, the company’s chairman and chief executive, declared that Lilly was taking major steps to become more open to the public. Lilly, he said, was the first pharmaceutical company to disclose payments to physicians for research and education, with a database on its Web site, updated quarterly. Lilly also became the first in the industry to voluntarily make public its clinical trials data, he said.

“Lilly is striving to be a leader in improving transparency across our industry,” Lechleiter told the audience.

Yet some observers say the Cymbalta mailing raises new doubts about its transparent dealings. It also serves as a reminder that some of Lilly’s marketing practices in recent years have gotten the company in trouble.

In January, Lilly pleaded guilty to one misdemeanor for promoting the powerful antipsychotic drug Zyprexa for treatment of dementia, although the drug is not approved for such uses. The company agreed to pay $1.4 billion to settle a five-year investigation by federal prosecutors, the largest settlement on record for any federal whistle-blower lawsuit.

In another run-in four years ago, Lilly agreed to pay a $36 million fine to the government for falsely claiming to doctors that its bone-strengthening drug Evista also treats breast cancer, two years before it actually got approval to market the drug for that condition.

Each time, Lilly executives were forced to apologize and say the company would do better.

The partnership between CVS Caremark and drug makers has been going on for several years, some observers say. Melody Petersen, a former New York Times reporter who wrote a book exposing industry marketing practices called “Our Daily Meds,” said drug companies are only too happy to pay pharmacies to send promotional materials to doctors for new treatment options.

“The pharmacy knows what patients have been diagnosed with, fibromyalgia (in this case), and they know the doctor who wrote the prescription. They’re now selling that information. Most patients have no idea this is going on,” she said in an e-mail.

Some doctors say they are particularly upset when the mailings recommend a certain drug to treat specific patients, using private data collected in the course of managing benefits.

Dr. Matthew Mintz, an internist in Washington, D.C., got a letter last fall from CVS Caremark, telling him he should consider prescribing the diabetes drug Januvia, made by Merck, for one of his patients taking a different medicine. The mailing was sponsored by Merck.

“It’s just plain wrong,” Mintz said. “It’s an ad disguised as a professional-to-professional communication, using my patients’ private data.”

Dr. Howard Brody, a director for the Institute for the Medical Humanities at the University of Texas in Galveston, said he received mailings frequently while in private practice in Michigan, as recently as three years ago, and grew disgusted with them.

“It is designed to look like the informational mailings you often get from pharmacy management firms that tell you things about your prescribing patterns as a physician, or about problems with a certain group or class of drugs, so in that sense, it is designed to be deceptive,” he wrote in an e-mail.

Selling Cymbalta

The letter from Lilly was the latest step the company has taken to market Cymbalta, an antidepressant it launched in 2004. The drug is approved to treat an assortment of ailments, from depression to pain management. Last year, the Food and Drug Administration gave Lilly permission to market the drug for fibromyalgia, a condition that affects about 5 million people, mostly women.

Lilly hasn’t been shy about promoting the drug, both to doctors and consumers. Last year, the company spent $156.7 million on direct-to-consumer advertising for Cymbalta, promoting its use for depression and pain, according to Nielsen Monitor-Plus. That made Cymbalta No. 3 in the nation in ad spending, behind insomnia drugs Lunesta, made by Sepracor, and Ambien CR, made by Sanofi-Aventis.

The promotions have helped catapult Cymbalta to second place in sales among all Lilly drugs, ringing up sales of $2.7 billion last year, up 28 percent.

Last month, the company followed up with CVS Caremark’s letter to doctors.

Lilly defended the mailing, saying it was clearly marked as a paid communication in three places, including the bottom of the first page. Lilly also pointed out that the letter included risks and safety information about the drug — along with a black box pointing out that antidepressants such as Cymbalta increase the risk of suicidal thinking and behavior in children and young adults.

Angela Sekston, a Lilly spokeswoman, said many doctors value such mailings and denied that Lilly was trying to deceive them. She said the company has used such mailings to warn doctors about safety issues that it has uncovered, including a Caremark mailing in 2003 alerting doctors about a possible link between Zyprexa and diabetes.

Re-evaluating the practice

“Lilly’s intent is to share medically accurate and relevant information with health-care professionals,” she said. “To imply otherwise is just plain wrong.”

But after The Indianapolis Star raised the issue, Sekston said Lilly had no immediate plans to send any more such letters to doctors through CVS Caremark and was re-evaluating the entire practice.

“If it is not determined to be a useful vehicle to share appropriate medical information, we will not sponsor future issues,” she said.

Sekston added that if Lilly chooses to fund another promotional mailing to doctors through CVS Caremark, the company will consider possible changes, such as the letter’s formatting, the mailing envelope and the size of type pointing out that Lilly paid for the letter.

CVS Caremark said the letters are appropriate to help educate doctors about treatment options and could lower a patient’s bill.

“The letter does note that Cymbalta is on CVS Caremark’s preferred drug lists, which could lead to a lower insurance co-payment for patients,” said spokeswoman Christine Cramer.

Neither Lilly nor CVS Caremark would disclose how much Lilly paid for the mailings. Lilly said CVS approached it with the concept and asked whether Lilly would be interested in funding the mailings. Both sides said the letter was written by CVS Caremark employees.

CVS Caremark said the funding fee was proprietary information. “Funding for these mailings may be provided by pharmaceutical companies based on the fair market value of the services we provide,” Cramer said.

But the cost could be several dollars per letter, if past practice is any guide, at least as outlined in internal correspondence. In 2002, a company called AdvancePCS (later bought by CVS) began touting another Lilly product, the schizophrenia drug Zyprexa, in mailings to physicians across the country.

According to e-mails of negotiations later made public in court, AdvancePCS offered to send 120,000 letters a year to doctors and said it would charge Lilly $5 a letter.

In the documents, AdvancePCS said that the direct-mail campaign was “designed to influence key prescribers” as part of a “tactical plan for Zyprexa,” Bloomberg News later reported.

Lilly has declined to say whether it accepted that proposal and paid $5 a letter.

Some doctors say they are sick of the letters and wish the practice would end. Dr. Margaret Polaneczky, a New York obstetrician, got a letter from CVS Caremark promoting Bayer’s Yaz birth control pills for her patients.

“This sort of marketing by a drugstore chain for a big pharmaceutical company, under the guise of physician education, took me quite by surprise,” she wrote on her blog.

“C’mon, why don’t we all just stop playing around,” she continued. “Enough with the smoke and mirrors.”