Google, Nielsen, Health Care Limits, and Primary Care

Yesterday’s New York Times reported on a partnership between Google and the Nielsen company. The article made me worry even more than usual about the harried life of our primary care physicians.

With Google’s data mining capacities and Nielsen’s detailed tracking of television viewing, advertisers will soon have vastly more precise information about which viewers see which advertisements. Not too far down the road we can anticipate marketing targeted to individuals in accord with their television viewing and Internet use patterns. Direct to consumer drug advertising is already effective in driving demand for branded products and will become more so.

Think of what this means for the primary care physician (PCP). More and more patients will come to appointments with specific drug requests. When advertising has alerted the patient to a uniquely effective treatment, health is advanced and free speech serves its purpose.

But what about costlier, branded, me-too medications? For patients who will be paying for the medication themselves the PCP can be an adviser – “it’s your money, but I don’t think it is worth it for you.” For patients with tiered drug insurance the PCP can similarly advise as to whether the higher copay purchases comparable benefit.

Patients, however, will increasingly ask their PCPs to appeal on their behalf. Appeals are time consuming. When the appeal is clearly justified physicians grit their teeth and do what is necessary. But when it is for an advertising-driven me-too product physicians have to choose between spending uncompensated time trying to convince the patient that the drug is not called for or spending uncompensated time on an appeal they do not believe in.

Our health system has largely stopped putting primary care physicians at direct financial risk for the cost of the medications they prescribe, but PCPs are often subject to other forms of pressure about their prescribing practices. Placing PCPs between the Scylla of evidence based prescribing and the Charybdis of ever increasing advertising-fueled patient demands will only add to the overburdened state we have already put them in.

Good medical ethics requires a robust system for making appeals about insurance limits. But a viable health care system requires a robust primary care sector. If we continue to drown our PCPs the sector will vanish.

It is possible to create processes that protect patient interests in access to medications that are “needed” rather than simply “desired” and at the same time protect physicians from unreasonable “hassle.” Kaiser Permanente’s approach to managing Selective Serotonin Reuptake Inhibitors (Prozac and its cousins) shows us how to do this. Our discombobulated health system needs to learn from exemplary practices like the one Kaiser Permanente offers.