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Crawford, 50, has been director of the Oregon Health Plan since 1994. As such, he presides over one of the most innovative Medicaid programs in the country, a program that was developed and promoted by Kitzhaber. The program prioritizes--or rations--medical procedures so that health-care dollars can be stretched further, expanding the number of low-income Oregonians who have access. By applying the concepts of managed care and preventive medicine and identifying some medical procedures that the plan won't cover (such as diet drugs and cosmetic surgery), Oregon has expanded Medicaid enrollment from 250,000 to 350,000 people since 1994. In a time when public frustration with managed care is the norm, the Oregon Health Plan is an example of how managed care can work well. In the summer of 1997, however, Crawford and Bev Castor--the health plan's pharmacy program manager--were presented with startling findings of an in-house study. The study, a random survey of the Oregon Health Plan's mental-health drug prescriptions, revealed that 5 percent of prescriptions that had been filled in the past six months were for doses considered excessive. Fourteen percent of prescriptions involved mixing drugs that could cause dangerous side effects such as seizures. Eleven percent of prescriptions were filled without a diagnosis. Nine percent of all mental-health drug prescriptions involved a patient taking a drug that simply duplicated what he or she was already taking. Behind the stats are some troubling stories. One patient surveyed was a 40-year-old pregnant woman in southern Oregon who had seen four different doctors and received from each a prescription for Xanax, an anxiety drug. Over-prescription of Xanax causes malformation of the fetus. Another patient, a 45-year-old woman from suburban Portland, was refilling her 30-day anti-depressant prescriptions every 14 days--using four different doctors and eight different pharmacies to get the extra supply of drugs. A third patient, a 40-year old nursing home resident, was taking two different brand drugs for schizophrenia. One of the drugs, an anti-psychotic called Clozaril that cost $105 a week, wasn't needed, according to one of the patient's physicians. The Oregon Health Plan's review also found that hundreds of prescriptions to Risperdal (an anti-psychotic) exceeded the manufacturers' own recommended dosages. "Sixteen percent of our claims for Risperdal are dangerous," says Castor. Overall, the report found problems in nearly one in four of all OHP's mental-health drug prescriptions. These problems are not unique to the Oregon Health Plan. One of the best-kept secrets in the medical business is how difficult it is for physicians to stay informed about drugs, proper doses and potential reactions between drugs. "There is no question that physicians need more info from pharmacists," says Dr. Paul Leung, acting clinical director for the department of psychiatry at OHSU. "A lot of anti-depressants are being prescribed by providers who may not have the kind of training that is necessary. There are just no guidelines on how much medication to use and prescribe." These problems plague the entire health-care industry. The Oregon Health Plan, however, has a quirk that compounds the misuse and over-prescription of drugs. Under the OHP, patients don't need to see a primary-care doctor--a gatekeeper--to get mental-health drugs. A patient can seek mental-health medication from any physician he or she chooses--and from any number of different doctors. He or she could, for example, get Prozac from one doctor and Zoloft from another. The problem is exacerbated because patients may be taking other drugs as well--non-mental-health drugs like antibiotics, painkillers or high blood pressure medicine--through their primary care physician. As a consequence, no individual doctor has all the information about a patient's drug prescriptions. Doctors may ask patients about their drug histories before prescribing anything, but patients can forget--or lie. When it comes to pharmaceuticals, the OHP operates like a set of divorced parents monitoring their child's homework. The father supervises the math homework, while the mother is responsible for the history homework. Neither parent knows all the child's assignments. Junior might tell Dad he doesn't have a math test tomorrow, so Dad takes Junior to a movie, then out for ice cream--unaware that Junior has a history test the next day. Short of getting remarried, a weekly phone check-in would probably be the best solution. Crawford had the same thought. In November, Crawford, who has a reputation as a stubborn bureaucrat, presented his solution to the state. The plan wouldn't allow the state to veto drug prescriptions. It would, however, authorize trained clinical pharmacists to call physicians who were prescribing certain mental-health drugs after a patient had been using one of the drugs for nine months. During the phone call the pharmacist, a contractor who works for the state health plan, would alert the physician to other drugs the patient was taking, discuss potential drug overlaps or health risks and go over any alternatives. That was the extent of Crawford's plan: providing doctors with complete information about the drugs they were prescribing and the patients they were prescribing them to. The plan exclusively covers mental-health drugs because, under the Oregon Health Plan, these are not managed by a primary-care physician. Crawford chose to monitor the 10 most widely prescribed mental-health drugs. The list, including drugs like Prozac, Zoloft and Risperdal, makes up one third of OHP's budget for mental-health drugs, about $27.6 million a year. Burt Kwitzky, executive director of the Oregon State Pharmacist Association--which represents pharmacists, as opposed to pharmaceutical manufacturers--backed the OHP proposal. "Physicians need to be educated," he says. "There is definitely a lot of over-usage. You have one doctor writing for an explicit condition and then another physician prescribes something that may antagonize that. Hersh was going in the right direction." OHSU psychiatrist Leung agrees. "A review process is necessary to look at prescribing trends to watch for potential problems," he says. Kitzhaber, a former emergency room doctor, also gave the plan a thumbs up. The 10 drugs included in the case management proposal, he said in a letter to legislators, are "powerful drugs with significant side effects which in some cases can be life threatening. They are also a rapidly growing part of our Medicaid expenditures. These factors combined create a clinical and fiscal rationale for carefully monitoring how these drugs are being used." Considering the support the plan was getting, it's no wonder Crawford was startled by the unprecedented campaign against it--a campaign that culminated at the Feb. 11 ambush in Salem, where Crawford was hung out to dry by legislators, health-care advocates and a lobbyist named Jim Gardner. The common denominator used by fellow lobbyists to describe Gardner--who once served as a liberal Democratic state senator from Portland and now lobbies for corporations like Philip Morris and Enron--is "he's bright." Gardner is a graduate of Yale Law School. He clerked for Supreme Court Justice Potter Stewart in the 1970s. Gardner once had ambitions to run for governor, but they were derailed when he lost a run for secretary of state against Barbara Roberts in 1984. (Roberts went on to become governor in 1990.) Shortly after his electoral defeat, Gardner became a lobbyist. In the past decade he has represented the insurance industry, auto manufacturers and tobacco companies. Since 1986, Gardner has also been the Oregon point man for PhRMA, the Pharmaceutical Research and Manufacturers Association. PhRMA, which represents drug giants like Merck, Glaxo Wellcome and Eli Lilly, is one of the most powerful lobbies in the country. Its members spent more than $8.5 million in lobbying expenses in 1996, according to the Associated Press. PhRMA's members also donated $12.1 million to federal candidates in the 1995-96 election cycle, according to the Center for Responsive Politics in Washington, D.C. The pharmaceutical industry has become very uncomfortable with a growing trend in managed care: letting insurers regulate or even advise doctors on the use of drugs. As a consequence, in October 1997, PhRMA, led by Gardner, set out to bury Crawford's proposal. "This was one piece of fine lobbying," a Salem health-care advocate told Willamette Week. "Gardner knows how to take advantage of a situation when one presents itself. A stubborn bureaucrat like Hersh Crawford gave him a great opportunity. He's kind of this arrogant bureaucrat. Gardner sent Crawford down in flames." Gardner says his effort was no big deal. "I just got on the phone and called all the relevant legislators," he says. "That's my job." Gardner's associates at PhRMA also did their jobs. Nate Miles, the vice chairman of the Oregon chapter of PhRMA and a lobbyist for Eli Lilly, contacted Castor of the Oregon Health Plan when the proposal was announced in October. Two of the 10 drugs that the plan recommended monitoring were Eli Lilly's Prozac and Zypraxa, the $8.5 billion drug manufacturer's best-selling and fastest-growing drugs, respectively. Miles arranged a meeting with Castor and Bill Sutherland, PhRMA's Oregon representative and the Oregon lobbyist for Glaxo Wellcome, the second-biggest drug company in the world. Glaxo manufactures Wellbutrin--another one of the drugs on the proposed monitoring list. At the meeting, the two drug lobbyists outlined their objections to Crawford's plan. PhRMA also called in reinforcements, hiring Pac/West Communications, the lobbying firm run by former Republican state legislator Paul Phillips. Gardner and PhRMA were also responsible for lining up health-care consumer advocates against the proposal. "The beauty of it was," a health-care insider told WW, "and this is how you know good lobbying, Jim stayed in the shadows. He brought out all those people, surrogates, but when you peeled back the onion, it was all PhRMA." Nelly Fox Edwards of the Alliance for the Mentally Ill, Jim Davis of AARP and Ellen Pinney of Health Action all threw their weight into helping PhRMA sink Crawford's plan. Pinney acknowledged that PhRMA's lobbying power was able to put the issue on the map. "I know our concerns got so much attention and play because of the enormous resources and lobbying expertise of PhRMA," she says, "but I'm glad it did." AARP's Davis, a longtime liberal consumer advocate, said he worked closely with PhRMA on the campaign. In October, the Oregon Health Plan made its first public presentation of the drug proposal in front of the state's drug utilization review board. (Federal regulations require state Medicaid programs to have such boards.) The room was packed with health-care advocates. Castor says in the four years she's been going to the quarterly drug utilization review board meetings, the room has always been empty. "When we presented the monitoring proposal there were 40 or 50 people there," she says. "I've never seen anything like that before." Castor was soon bombarded with calls, letters and e-mail messages from health advocates like Pinney as well as groups she'd never heard from before. PhRMA, Castor says, was always hovering in the background. "All the calls and letters echoed the exact same complaints I originally heard from PhRMA," she says. "The wording was exactly the same." The organized opposition to Crawford's proposal pivoted on one finely tuned concept. Opponents of the proposal used what is known as a "dirty word" strategy. Crawford's plan was consistently labeled "prior authorization." Prior-authorization programs--common in privately run HMOs like Kaiser Permanente--require physicians to get approval from insurers before prescribing certain drugs. The term "prior authorization" has come to take on ugly connotations to health-care advocates who don't want any barriers put up between consumers and doctors. But Crawford's plan did not involve prior authorization. Prescribing physicians would have had sole power to say yay or nay to medication. The state would've had zero authority to veto any prescription; its role was purely advisory. Nevertheless, PhRMA's message persisted. That was enough to topple the plan. At the Feb. 11 interim legislative committee hearing--which was packed with opposition to the proposal--Gardner trashed the program as "prior authorization." Pushed to explain exactly how the OHP plan was a "prior authorization" plan, Gardner told WW, "It's very subtle, but I saw it for what it was. They've tried to institute a prior-authorization program before. This was prior authorization in disguise." After the meeting, Crawford fumed. "I can't believe Gardner just got up there and said this was prior authorization," he said. "It was frustrating that the plan got characterized that way. I guess Gardner has different morals than me." Mark Gibson, policy advisor for Kitzhaber, agrees that PhRMA was disingenuous. "They called it prior authorization and it wasn't," he says. Crawford retreated, though he says he will return in six months with a revised version. Given the pharmaceutical industry's financial interest in opposing the plan, it's not surprising that Crawford would question Gardner's motives. It's tougher, however, to question the motivation of consumer advocate Ellen Pinney. Pinney is hardly a PhRMA puppet. She is a longtime health-care advocate for Oregon Health Action. In the current environment of managed care, she acts as a watchdog for the bureaucratic gatekeepers who prioritize cost cutting over care. Though Crawford's plan would not have instituted prior authorization, Pinney's unwavering support for total access to health care made her a perfect spokeswoman for PhRMA's misleading mantra, "prior authorization." "Put yourself in the position of someone who needs their medication to be productive. To do their job. To interact with their family," Pinney says in her defense. "Now put yourself in the position of having some bureaucrat whose only role is to make health care cheaper challenge your access to that medicine." Pinney's concern cuts to the heart of the current--and legitimate--national debate over health care. Concerns about managed care's cost-cutting mentality even found their way into President Clinton's State of the Union speech last month as he blasted "drive-through deliveries of babies" and "drive-through mastectomies," calling for a health-care consumer bill of rights. "Politics make strange bedfellows," Pinney says. "Consumer advocates and industry lobbyists don't usually have overlapping interests, but our interests do overlap when there's an effort by bureaucrats to step in and question your right to health care." Dr. Joseph Intile, the Oregon Health Plan's medical director, says the drug-monitoring proposal hardly fit Pinney's fears. He views the opposition to any interference in health-care decisions by insurers, no matter how advisory, as short-sighted. "This became a political debate rather than a medical one," Intile says. "It's unfortunate that absolute fear of control made people have negative, knee-jerk reactions." |
