Who is really prescribing that drug?
By Mike Wokasch

There was a time in the not-too-distant past when physicians were dependent on product and related medical information provided by pharmaceutical companies. Pharmaceutical companies had a prescription drug information monopoly. They controlled what product information to disclose and how to present the information to the market — almost exclusively to physicians.

Sure, medical journals were also an important source of drug information, but they published mostly the successful clinical trial results authored by clinicians on behalf of the sponsoring pharmaceutical company. And just think back to the days when even academic clinicians had to submit a request to the medical library for a literature search to get an article abstract, not even the full article. Information technology and the Internet facilitated easy, rapid access to product and medical information to virtually anybody willing to go online, including patients. This access to information provided a comprehensive data source — at least of publicly available data — for better and more comprehensive product reviews, including comparative analytics.


Which of the following has the biggest impact on which drugs physicians prescribe?
  • 1. Peer recommendations
  • 2. Treatment guidelines
  • 3. Hospital and pharmacy benefit manager formularies
  • 4. Insurance company and government reimbursement policies
  • 5. Patient demand instigated by advertising
Drug company control of product information made it easy to market and sell to individual physicians. This information exclusivity also established physicians as the only healthcare professional who could determine which products and brands were best for patients. Again, this changed with ready access to drug product and medical information. It made third-party evaluations and second-guessing of physician product choices easier, routine and institutionalized.

Physicians now face a labyrinth of influences on their prescribing practices. Beyond the obvious pharmaceutical company advertising and promotion, drug treatment choices — are driven by an amalgamation of managed market-imposed prescribing recommendations and constraints. Peer recommendations, treatment guidelines, hospital and pharmacy benefit manager formularies, insurance company and government reimbursement policies, as well as patient demands for specific products instigated by direct-to-consumer advertising, all impact which prescription drugs patients now end up taking.

Some influences are more direct than others. Recommendations, guidelines and policies are only as good as their enforcement. Today however, physicians cannot plead ignorance to institutional preferences. E-prescribing highlights product preferences at the time of prescribing, while electronic health records track and monitor prescribing behavior to support formulary compliance.

While the physicians may write the prescription, their choice of prescription drug treatment for a particular patient is now more determined, if not constrained, by this array of behavior-modifying influences and interventions. Based on the limited, credible comparative efficacy data for prescription drugs, these influences and constraints may be acceptable for “the masses” but what happens to the patient who responds differently than “the masses?”

Mike Wokasch, a pharmacist by training, is a 30-year pharmaceutical industry veteran, having held a number of positions of increasing responsibility at several large pharmaceutical companies including Merck, Abbott, Chiron, Bayer and Covance. Wokasch was also an executive at several technology-based companies including Promega, PanVera and Aurora Biosciences. He is the author of the book, "Pharmaplasia," which explores the changes needed in the pharmaceutical industry as it adapts to healthcare reform.