A doctor who sits on an advisory board that helps decide when Medicaid patients can be prescribed certain drugs in Colorado has received thousands of dollars in payments and benefits from pharmaceutical companies whose products come before that board for review.
Members of the state’s Drug Utilization Review Board are supposed to tell state officials about any conflicts of interest they have and take themselves out of discussions when those conflicts could be an issue. But The Colorado Sun found that board member Dr. Alex Reish continued to participate in conversations about at least one drug — and argued in favor of that drug — despite having received more than $1,000 in reported free food and drinks from the drug’s maker.
There is no indication in board minutes that Reish disclosed the benefits he received related to that drug, an opioid called Nucynta. Reish also wrote an opinion article for the Drug Utilization Review Board’s newsletter last winter arguing for greater use of Nucynta. Despite the benefits he received from Nucynta’s manufacturer, Reish — using Nucynta’s generic name of tapentadol — wrote, “I do not have any disclosures nor speak for tapentadol, but have strong clinical experience utilizing it in my practice.”
“With the new Medicaid policy of prescribing opioids in the naive, please strongly consider tapentadol as a superior and first line option compared to all other Schedule II opioids,” he wrote, referencing a policy designed to keep those who haven’t been exposed to opioids before from getting hooked on them.
All told, Reish has received about $10,000 in payments and benefits from drug companies in the previous five years, The Sun found. Most of that — about $6,700 — came in the form of free food or drinks, according to federal reports.
Reish, who is based in Boulder, specializes in treating severe headaches and other kinds of pain. In an email, he defended his actions, saying he meets with representatives from the pharmaceutical industry to learn more about their products and to stay current in his practice.
He said the compensation figures may be inflated because meals for his staff may also have been reported as payments to him in federal records. Regardless, he said the benefits did not influence his actions on the board, so he said he did not believe he needed to tell state officials and fellow board members about them.
“The pharmaceutical industry is a part of our practice whether we like it or not,” he wrote. “Pharmacists, physicians, NPs, PAs, medical students, residents, RNs, MAs, LPNs — we all deal with them to varying degrees. Hopefully we all learn to understand early how they can benefit our patients or harm them and in this case indirectly or directly influence the (Drug Utilization Review) board. I clearly understand this and feel that I do not have any conflicts of interest.”
State reviewing board disclosure rules
Cathy Traugott, the pharmacy section manager for Colorado’s Medicaid program and who helps oversee the Drug Utilization Review Board, said she could not comment on Reish’s situation specifically. But she said the state Department of Health Care Policy and Financing — which administers Medicaid in Colorado — is reviewing its rules for conflict-of-interest disclosures for board members and will have more information at a board meeting Tuesday evening.
Board members — who are all volunteers — are required to fill out a conflict-of-interest form when they apply to sit on the board, she said. They are expected to update those disclosures as needed prior to the board’s quarterly meetings.
The form refers mostly to direct financial relationships that a board member may have with a pharmaceutical company — holding shares in it, for instance, or serving on an advisory board or being paid a retainer. But Traugott said state officials view the disclosure requirement more broadly.
“We basically consider if you’ve received anything, you should be disclosing it,” she said. “And then it is determined whether that is of a sufficient amount to constitute a conflict.”
If there is a conflict, she said, officials must decide whether board members should recuse themselves from a specific decision or whether the conflict is so large that members shouldn’t serve on the board at all.
Those are rare steps.
“It hasn’t come up a lot,” she said.
How Colorado’s DUR board stacks up against other states
The Colorado Sun began looking into drug company payments to Drug Utilization Review Board members following a story by National Public Radio and the Center for Public Integrity that found members of some states’ DUR boards had received hundreds of thousands of dollars in payments and benefits from pharmaceutical companies.
Federal law requires each state to have a DUR board to ensure their state’s Medicaid program is administering drugs in the most safe, efficient and cost-effective way. Medicaid is the joint state and federal health insurance program for people with low incomes.
In Colorado, the DUR board has an extra responsibility — one that gives it some authority over which drugs have an easier path onto doctors’ prescription pads.
Colorado’s Medicaid program maintains a preferred drug list that spells out which drugs are considered the first-line treatment option for Medicaid patients and, thus, can be prescribed without preauthorization from state officials. That list is set by a different board.
Colorado’s DUR board then sorts through all the drugs that aren’t on the preferred drug list, making recommendations for when those drugs can be prescribed and, thus, potentially moving drugs up or down in the order of treatment options. Medicaid officials make the final call.
In NPR and CPI’s reporting, Colorado’s DUR board fell somewhere in the middle of the pack nationally for drug company payments to doctors who serve on the board. Most of those payments are connected to Reish. Another board member, Dr. Mary Wilkerson, received about $150 in food and drinks last year. A third member, Dr. Michael Noonan, received $14 in food and drinks in 2015, while a fourth member has not received any payments, according to federal records.
“I do not consider this a conflict of interest”
Reish, in emailed answers to questions, said he is in a unique position among his colleagues because he is an independent private-practice physician. In addition to the educational opportunities, Reish said meeting with pharmaceutical company representatives provides him with drug samples or coupons that he can give to his patients to lower their costs and that he wouldn’t otherwise get.
He said he often declines drug company overtures when he thinks they won’t be useful to his practice. When he does meet with representatives, it is typically over lunch in his clinic or at dinner lectures, and no alcohol is involved, he said.
Reish said he was aware, when he wrote his article in support of Nucynta, that the company’s manufacturer had reported providing benefits to him, but he said he doesn’t believe that created a conflict. He said Nucynta, which he called an “atypical” opioid with lower potential for abuse and overdose, is safer than more traditional opioids like Oxycontin, and he said he joined the DUR board because he wanted to educate doctors and stem the opioid epidemic.
“Again, when I learn more about a medication that I use and find helpful and safe in my practice, I do not consider this a conflict of interest,” he wrote in his email.
Reish said he has reported one conflict to state officials — after the pharmaceutical company Amgen last year named him to an advisory board for a new drug to treat migraines. He said he will recuse himself from DUR board discussions about that drug. And he said he agrees there should be transparency in pharmaceutical payments in order to root out bad actors.
“[B]ut the data probably does not get reported accurately,” he wrote, “and just because you see data for a physician and pharma company does not immediately translate to a bought and sold puppet physician for the pharma industry.”
Traugott said state officials from now on will proactively check federal records to make sure doctors on the DUR board are disclosing all payments and benefits.
HOW WE REPORTED THIS STORY
The Affordable Care Act — the health care law also known as Obamacare — requires drug companies to report payments and benefits they provide to doctors. These are collected in a federal database called Open Payments, which is searchable by anyone online. The investigative news organization ProPublica has compiled Open Payments data into an easier-to-use format in its Dollars for Docs database. The Colorado Sun used both databases to report this story.
Because the disclosure requirement only covers payments or benefits given to doctors, The Sun couldn’t look up every member of Colorado’s Drug Utilization Review Board. Of the board’s nine members, only four are doctors. Four are pharmacists, and one is a non-voting representative from the pharmaceutical industry.
WHAT YOU CAN DO
We plan to aggressively investigate the inner workings of the health care industry — and you can help. If you have a story to tell about a medical bill, a doctor or a hospital, email us at tips@coloradosun.com. And if you want to do some digging of your own, ProPublica also has databases on surgical performance and prescribing patterns. Let us know what you find!
This story first appeared in The Colorado Sun’s newsletter, The Sunriser. You can subscribe here: cosun.co/thesunriser