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1. Righting the Script: Improving Prescription Drug Policy in an Era of Health Reform December 9, 2008 Peter Wyckoff, National Consultant, The Prescription Project Dr. Rupin Thakkar, Washington Coalition for Prescription Integrity Alicia Haywood, Colorado Prescription Drug Coalition

2. Coalitions and Alliances: Building a Prescription Reform Coalition The Washington State Coalition – a leader perspective – Rupin Thakkar The Colorado State Coalition – A staffing perspective - Alicia Haywood Additional State Models & Coalitional Issues - Pete Wyckoff 2

3. The Prescription Project 2008 Annual Meeting State Policy And Action Case Study: Washington Coalition for Prescribing Integrity Rupin Thakkar, MD Co-Chair, WA Coalition for Prescribing Integrity Board of Directors, National Physicians Alliance

4. National Physicians Alliance Founded in 2005 to restore physicians' primary emphasis on the core values of our profession: service, integrity, and advocacy. Physicians must partner with patients in order to achieve healthcare reform. The needs of patients and communities should be the highest priority. Governance structure includes the Council of Consumers- participates in the creation and review of NPA’s policies. Unbranded Doctor Campaign: Refuse all financial entanglements with the drug industry and seek only evidence-based sources for drug information.

5. Rx Data-mining 3 WA docs interested in promoting NPA’s Rx reform proposals at state level…HB 1850, 2007 session, “The Prescription Privacy Act”- failed in cmte. NPA’s position paper on data-mining led to front-page story in Washington Post. RxP informed us of state-based grants and their interest in WA state.

6. A History of Progressive Rx Reforms in Washington Early 1980’s: Therapeutic Drug Substitution Act 2003 Evidence-based Prescription Drug Program and State Preferred Drug List 2004 Pooled Purchasing Act/Rx Card 70,000 people covered, avg discount 30-60% off medications 2005-2007 Several hospitals and clinics ban drug reps from their campuses 2007: Puget Sound Health Alliance encourages doctors to refuse gifts & samples

7. Building Coalitions Primary Goal: When organizations join together they can produce change that they may not be able to deliver individually. They can pool resources, expand their power base, and raise their volume to decision-makers. Secondary Goal: If groups that traditionally have not worked together learn to respect each other’s differences and experience the exciting process of teaming up to achieve a common goal, the coalition can create a lasting base for change. In our case we hoped to spur future partnerships for broader healthcare reform.

8. Criteria for member selection Credible and reputable member of the community Be committed to the coalition’s mission and objectives (sign-on statement) Politically active / strong links with the community and with decision-makers (asked to prioritize issue in their agenda and earmark lobbyists’ time to the issue)

9. WA Coalition for Prescribing Integrity Mission Promote professional and policy change that will: increase evidence-based prescribing in the state of Washington; reduce conflicts of interest between Washington prescribers and the pharmaceutical industry; preserve the privacy of the doctor-patient relationship; and ensure that all patients in our state have access to quality, appropriate, and affordable medicines.

10. WCPI Objectives Educate consumers, healthcare providers, and policy-makers about how and why pharmaceutical marketing drives up the costs of healthcare. Increase awareness of marketing tactics used to promote medicines, and highlight why conflicts of interest often result in increased prescribing of newer, more expensive drugs without proven benefits in terms of efficacy or safety over older or generic alternatives. Educate consumers, healthcare providers, and policy-makers about why commercial use of prescription data increases healthcare costs and can reduce the quality and safety of prescribing. Work to ensure the privacy of patients’ prescription records, and prohibit interference by the pharmaceutical industry into the private doctor-patient relationship. Work to ensure that Washingtonians have access to the prescription medicines that they need at prices they can afford. Promote educational opportunities for healthcare providers that promote evidence-based prescribing.

11. WCPI Members Doctors: National Physicians Alliance, Puget Sound WA Chapter, American Academy of Pediatrics King County Academy of Family Physicians WA Academy of Family Physicians Physicians for a National Health Program- WA King County Medical Society WA State Medical Association

12. WCPI Members Consumers: WA Community Action Network AARP- Washington League of Women Voters SEIU 1199 WA State Labor Council Healthy WA Coalition Large coalition of consumer, labor, faith and business groups seeking to ensure affordable, quality healthcare for all Washingtonians

13. WCPI Members Other Key Stakeholders: Group Health Cooperative WA State Pharmacy Association

14. WCPI Governing Structure Director- only staffperson 2 Co-Chairs (founders) Steering Committee- reps from 6 organizations who were willing to make the largest commitment of time and resources and helped with outreach to other potential members While all appointed, at first meeting of full coalition asked for vote of approval

15. Use of grant funds Staff expenses (salary, travel) Meeting expenses (space, parking, refreshments) PR Firm Logo, letterhead, business cards Fact sheet, Common Myths, Talking Points Earned Media

16. WCPI Earned Media Public Radio Coverage of Senate Hearing, 1/17/08 Op-EDs: “Give Doctors & Patients Privacy,” Seattle Post Intelligencer, 2/7/08 Support Bill to Halt Drug-Record Mining, Bellingham Herald, 2/21/08 Editorials: “Data-Mining should get the shaft,” The Seattle Times, 2/25/08 “Opening Eyes,” Spokane Spokesman Review, 2/22/08 Articles The Olympian, 1/22/08 & 2/25/08 Tacoma News Tribune, 2/26/08

17. Legislative outcomes HB 2664/SB 6241, “Prescription Privacy Act” (Datamining) Prohibits the sale or use of prescriber’s identifiable prescription data for marketing or promotional purposes. Governor’s endorsement Passes state senate (26-22) Fails by 1-2 votes to make floor of State House Gifts Disclousre: Fails to pass out of committee in both house & senate Academic Detailing Program: Fails to pass out of committee in both house & senate

18. Accomplishments Education: Professional Societies Publications (FABLES- Journal of WCAAP, WA Family Physician) Presentations (WSMA, WCAAP, WAFP, KCAFP, KCMS, PNHP) Action alerts to members throughout session Policy-Makers State Senate Consumer Protection hearing (Nov ‘07) House and Senate Health Committee hearings (Jan ‘08) Follow-up education during off session Public Coalition Materials Earned media

19. Accomplishments Change: Professional Clinics banned drug detailers Doctors register with PDRP. KCAFP: Opt-Out Day WAFP holds 1st “Pharm-Free” annual meeting Patient/Consumer “Newer is not better” and “The Unbranded Doctor” Consumer Reports Best Buy Drugs

20. Accomplishments Building a base for broader healthcare reform: Before WCPI no physician organizations belonged to the Healthy WA Coalition (state’s largest group dedicated to healthcare reform). Now NPA-Puget Sound and WSMA are active members. Governor Gregoire & Rep Pedersen vocalized that the data-mining bill was a necessary step towards reducing costs and improving quality so that we can cover all Washingtonians

21. Future plans of WCPI Continued outreach / educational efforts Expand membership. Wish list: Clinics & Hospitals Non-Physician Prescribers (i.e. NPs, PAs) Legislative activism Protect Patient Privacy Close loophole in HIPAA that allows patient’s private prescription histories to be sold for use in direct marketing Enable Academic Detailing Mandate state to apply for federal funding for the development of a program if they become available with passage of S3396: "The Independent Drug Education and Outreach Act "

22. Contact Us: Rupin Thakkar, MD Co-Chair, WA Coalition for Prescribing Integrity Email: [email protected] Joana Ramos, MSW Director, WA Coalition for Prescribing Integrity Email: [email protected] Thanks to my co-chair, Jeff Huebner, MD, our tireless coalition, The National Physicians Alliance, and The Prescription Project

24. CPC Origin Prescription Project visits Colorado in December of 2007 to meet with key organizations and assess the landscape in the state. Dr. Mark Earnest, Vice-President of the Board for the Colorado Coalition for the Medically Underserved (CCMU) submitted a grant and convened a group. CCMU agreed to serve as the fiscal agent for the state-based grant.

25. CPC Origin Grant money primarily used to hire project staff and facilitation for the Coalition. The Adams Group provided facilitation and support for the six month start-up phase and continues their work with Coalition today. Coalition worked together over six months to develop a name, set up ground rules and membership agreement, and establish a mission, short and long term goals and policy priorities.

26. Start Up Phase Successes Name: Colorado Prescription Coalition Established ground rules, membership agreement and regular meeting schedule. Mission: To increase evidence-based prescribing in the state, reduce conflicts of interest between Colorado prescribers and the pharmaceutical industry, and ensure patients have access to quality, appropriate, and affordable medications. Coalition organized around two ideas: public policy options and academic detailing.

27. Key Organizations at the Table AARP Colorado Rural Health Center Independent Pharmacies Association Kaiser Permanente University of Colorado medical doctors and students Many fantastic individuals 27

28. Benefits of Process Gives participants the chance to learn together and create a shared understanding of the issues Establishes history in order to work together on solutions 28

29. Benefits of Project Staff Serve as point person for the project Provide facilitation skills Available for technical research Collect and organize feedback Draft ideas into concept paper Develop the strategic plan and work plan with input from the Coalition Provide outreach to current and new members Search for additional funding sources   29

30. CPC Process Challenges Involvement of consensus in ground rules Agreement upon policy priorities Membership requires sign on Policy components UPSIDE Coalition process allowed for time to learn together and build trust, which was essential when facing challenges. 30

31. CPC Accomplishments Secured sponsors to support bill in the 2009 legislative session. Bill to include: Data mining Gift ban and disclosures Conflict of interest in committees Development of a funding proposal for an academic detailing pilot program.

32. Next Steps for CPC Obtain funding for lobbying and advocacy of bill Grow coalition Provide education to targeted groups Support bill through the legislative process in 2009 Solidify support for academic detailing pilot program 32

33. Contact Alicia Haywood The Adams Group [email protected] Chris Adams The Adams Group [email protected] 33

34. RxP Coalitions and Technical Assistance Massachusetts Minnesota Maryland Wisconsin Technical Assistance Maine Vermont New Hampshire D.C. New York New Mexico 34

35. Keys to Success Broad Coalition Active Issues with Buy-In of Stakeholders Role of state RxP coalitions in national health reform effort Media Strategies Funding & Support - RxP Reform Campaigns 35

36. Massachusetts Prescription Reform Coalition Diverse group of community organizations, local and national non-profit organizations, healthcare advocates, private insurers, and healthcare providers dedicated to making affordable prescription drugs available to everyone. AARP Massachusetts; AIDS Action Committee; Blue Cross Blue Shield of Massachusetts; Commonwealth Care Alliance; Commonwealth of Massachusetts Group Insurance Commission Community Partners; Health Care For All; Leukemia and Lymphoma Society of Massachusetts; Massachusetts Council on Aging; Massachusetts Senior Action Council; MASSPIRG; National Physicians Alliance; Neighborhood Health Plan; The Prescription Project; United Auto Workers, Massachusetts State Community Action Program Council  36

37. Massachusetts Prescription Reform Coalition – Compelling story The Coalition is committed to promoting evidence-based, unbiased prescribing.  Why We Have Come Together Massachusetts’ healthcare access expansion can only be maintained if healthcare costs are controlled.  The cost of prescription drugs is among the fastest growing segments of health care spending.  Between 2000 and 2007 the price of many of the most commonly prescribed brand name drugs rose by nearly 50%, far exceeding inflation.  These rising costs threaten the stability of health care reform and the Commonwealth’s budget.  The costs also threaten people's ability to access the medications that they need to maintain their health.  37

38. Massachusetts Prescription Reform Coalition Mass Prescription Drug Legislation Comprehensive cost and quality legislation Academic Detailing Gifts Code of Conduct and disclosure– (transparency & ban) The Message  The Coalition is joining with state leaders to highlight the importance of taking action against pharmaceutical industry marketing practices that contribute to high and rising prescription drug costs, threatening the success of Massachusetts health reform. The end goal of this Coalition is to ensure that all people are able to afford the medications that they need to maintain their health. 38

39. Maryland Led by the Health Care for All Part of broader Maryland Coalition on Comprehensive Health Care Reform Working on Academic Detailing 39

40. Minnesota Led by the Minnesota Senior Federation Coalitional efforts around evidenced based prescribing began in 2005 Consumer Reports Best Buy Drugs Neurontin Settlement – Attorney General Consumer & Prescriber Education Grant Program 40

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43. Minnesota RxP Coalition Began in 2007 Around key issues Data Mining Strengthening Minnesota Pharmaceutical Gift Ban Legislation PBM Transparency Legislation Academic Detailing 43

44. “Drug Companies influence should worry public, docs” “We are adamant that a physician's recommendation to a patient must reflect best medical evidence and be without influence from his or her relationship with a drug company.” 44 Physician Leadership Policy Forum, a group of physician leaders from Allina Hospitals and Clinics, Children's Hospitals and Clinics, HealthEast, HealthPartners, Hennepin Faculty Associates, Fairview Health Services, North Memorial Medical Center , Park Nicollet Health Services and University of Minnesota Physicians Physician Leadership Policy Forum, a group of physician leaders from Allina Hospitals and Clinics, Children's Hospitals and Clinics, HealthEast, HealthPartners, Hennepin Faculty Associates, Fairview Health Services, North Memorial Medical Center , Park Nicollet Health Services and University of Minnesota Physicians

45. “Drug Companies influence should worry public, docs” Minnesota Physician Leadership Policy Forum Member organizations are: Requiring physicians to disclose conflicts of interest and income from industry relationships and in some cases seek prior approval for industry relationships. Prohibited or restricted the longstanding practice of pharmaceutical "sampling" (handing out free drug samples) within our facilities. Other steps 45 Physician Leadership Policy Forum, a group of physician leaders from Allina Hospitals and Clinics, Children's Hospitals and Clinics, HealthEast, HealthPartners, Hennepin Faculty Associates, Fairview Health Services, North Memorial Medical Center , Park Nicollet Health Services and University of Minnesota Physicians Physician Leadership Policy Forum, a group of physician leaders from Allina Hospitals and Clinics, Children's Hospitals and Clinics, HealthEast, HealthPartners, Hennepin Faculty Associates, Fairview Health Services, North Memorial Medical Center , Park Nicollet Health Services and University of Minnesota Physicians

46. Combating Marketing to Doctors 46

47. Minn. Health System Purges Its Buildings of Drug Company Trinkets “baubales, bangles and beads” 47

48. Combating Marketing to Doctors 48

49. Dr. Kenneth Irons, MD - Chief of community clinics for SMDC… 49 Minn. Health System Purges Its Buildings of Drug Company Trinkets

50. Minnesota RxP Coalition RxP Funding ended in Sept 2008 – RxP Technical support continues Organizing Issues MN State Senate Interim Hearing -Friday, December 12th Gift Ban Expansion Academic Detailing 50

51. Wisconsin Became RxP project in Fall of 2008 Led by the Coalition of Wisconsin Aging Groups Major 2009 issues will be Academic Detailing Broadest potential coalition in the country 29 groups currently considering membership Medical and Hospital Organizations Labor and Consumer Organizations Business Organizations Insurers and Payers 51

52. Wisconsin – Potential Coalition Members Medical & Pharmaceutical Organizations Wisconsin Medical Society Wisconsin Nurses Association Pharmacy Society of Wisconsin UW Population Health Services 52

53. Wisconsin – Potential Coalition Members Consumer Organizations Coalition of Wisconsin Aging Groups (CWAG) Citizen Action Wisconsin Wisconsin State AFL-CIO Wisconsin Education Association (WEA) Wisconsin Retired Educators Association Wisconsin Farm Bureau Milwaukee Committee on Aging AARP 53

54. Wisconsin – Potential Coalition Members Health Plans & Systems & Payers Aurora Health Care United Health Care - WI Humana - WI Marshfield Clinic Dean WPS Insurance Wisconsin Association of Health Plans Hospitals Groups Ministry Health Care Wisconsin Health and Hospital Association Medical College of Wisconsin UW Hospital and Clinic 54

55. Wisconsin – Potential Coalition Members Other Stakeholder Organizations The Alliance – “Employers moving healthcare forward” Fond du Lac Area Businesses on Health (FABOH) Wisconsin Collaborative for Healthcare Quality (WCHQ) Wisconsin Association of Healthcare Underwriters Rural Wisconsin Health Cooperative Nation Federation of Independent Businesses – Wisconsin (NFIB) Milwaukee County Committee on Aging Brodrick/Barr Lab (Generic drug manufacturer) Trust Wisconsin Catholic Conference Wisconsin Education Association Trust (WEA Trust) 55

56. RxP Technical Support Technical Assistance Maine Vermont New Hampshire D.C. New York New Mexico West Virginia 56

57. Keys to Success Broad Coalition Active Issues with Buy-In of Stakeholders Role of state RxP coalitions in national health reform effort Media Strategies Funding & Support - RxP Reform Campaigns 57

58. Media Strategy and Outreach Key vehicle for delivering your message to stakeholders and for galvanizing support Have an objective and a strategy Objective is to place 3 favorable stories in 2 key print and one radio media outlet Strategy is to announce filing of legislation at State House press conference Before you start: What’s the story – the hook? Timeliness, local and/or human interest angle, conflict/crisis, relevant within context of other big news, relevant to publication’s audience (trade vs. mainstream press) What isn’t news 58

59. Media Strategy – First Steps: Identify a primary spokesperson Develop key messages and train spokesperson; repeat, repeat, repeat Identify appropriate type of media (print, TV, radio, online, dailies, weeklies) Do your homework: identify appropriate reporters Proactive tactics proactive: press releases, media alerts for events, op-eds, ed board meetings, story pitching for hard news and features, reporter touch base Reactive tactics: statements, op-eds, Ed Board, letters to the editor, story pitching 59

60. How to use press to advance the campaign: Engage coalition members in outreach Engage legislators in outreach (use quotes, co-author op-eds, joint ed board meetings) Disseminate positive press coverage to legislators (State House drops) 60

61. Funding and Support for RxP Reform Campaigns Technical Assistance The Rx Project & Community Catalyst NLARX – National Legislative Association on Prescription Drug Prices - www.reducedrugprices.org PPC – Prescription Policy Choices - www.policychoices.org National funding efforts & coordination Goal: leverage and support state work Local Funders Local & State Stakeholders 61

62. Righting the Script: Improving Prescription Drug Policy in an Era of Health Reform December 9, 2008 Peter Wyckoff, National Consultant, The Prescription Project Dr. Rupin Thakkar, Washington Coalition for Prescription Integrity Alicia Haywood, Colorado Prescription Drug Coalition

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