The Center for Public Integrity began investigating the influence of the pharmaceutical industry on state Medicaid programs eight months ago. Prescription medications under those programs cost states tens of billions of dollars annually. And the cost has been increasing, nearly doubling between 2008 and 2016.
To better understand this, reporters Liz Essley Whyte and Joe Yerardi dug into how states decide which prescription drugs Medicaid programs will prioritize — and whether pharmaceutical companies influence the process. NPR health policy correspondent Alison Kodjak later joined in the project, adding her expertise.
Reporters married data analysis with information from interviews of more than 50 people and from hundreds of pages of court records, financial disclosure reports and other documents.
The code and data behind this story's analysis is publicly available on GitHub. A summary follows below:
Collecting data on the state boards
State boards often known as pharmacy and therapeutics committees or drug utilization review boards typically prioritize which drugs Medicaid patients should receive. The boards are composed of volunteer pharmacists, doctors and sometimes drug company representatives. Often, Medicaid officials must approve the boards’ recommendations. The investigation refers to the boards as List committees because they help decide how the Preferred Drug List system works in each state, though in many states their duties are divided between two committees: One committee decides which drugs to include on the List, while the other sets the rules for when the state can pay for other drugs.
No central repository listing the membership of the boards exists. So Center for Public Integrity reporters called state Medicaid agencies, scoured websites, reviewed meeting minutes or filed public records requests for all 50 states. We entered details about those individuals — more than 1,000 in all — serving on such boards from January 2016 through June 2018 into a spreadsheet. We were unable to obtain information on the members of two out of the four committees in Illinois and South Carolina; Illinois Medicaid did not respond to repeated inquiries, while South Carolina was reorganizing one of its committees and did not supply past information in time for publication.
Analyzing drug company payments to doctors
One potential avenue of influence is drug company perks given to the doctors serving on these boards. Drug companies are required to report such payments — which may include free dinners or travel, consulting fees, speaking honorariums or research grants — to the federal Centers for Medicare and Medicaid Services, which is published as the Open Payments dataset. Our analysis did not include research payments.
To determine the extent of those payments to doctors serving on Medicaid drug boards, we matched the first names, last names and states of board members with those of doctors in the Open Payments data.
The CMS data covers payments made from August 2013 through 2017 to doctors specializing in medicine, osteopathic medicine, podiatric medicine, dental medicine or dental surgery, optometry, as well as chiropractors, but does not include pharmacists or other health professionals who serve on List committees. Center for Public Integrity reporters recorded degree information, where available, for Medicaid drug board members to determine the pool of doctors on such boards.
Some states have multiple doctors with the same name. To find potential duplicates for each matching board doctor, we used both the Open Payments data and the National Plan & Provider Enumeration System, a national database where all physicians, not just those taking drug company payments, register. Doctors with potential duplicates — more than one doctor with the same name and state — were excluded when calculating the extent of payments among doctors serving on Medicaid drug boards if the NPPES data indicated one or more of the doctors did not receive any payments. In cases where multiple doctors existed but Open Payments indicated they all received payments, we calculated the payments using the doctor taking the lowest amount.
The analysis revealed that of the 455 physicians covered by Open Payments and serving on such boards, at least 283 received money or equivalent freebies from drug companies, with at least 103 receiving more than $1,000 and at least 34 receiving more than $10,000. Forty-eight states had one or more doctors on a board who accepted payments, while 38 states had at least one doctor who accepted more than $1,000.