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active drugs in our society that appeared in Drugs and Health Care, that was cited, I believe, as the 12th reference in my paper.

The essence of the proposal is that society needs a comprehensive record system to efficiently record prescribing, dispensing, and consumption practices. This proposal is based upon the concept of a clearinghouse, and the clearinghouse is best demonstrated if I have access to a piece of paper or even your blackboard which is here today.

Mr. NELLIS. Please go ahead.

Dr. RUCKER. The concept of the clearinghouse includes the introduction of computerized terminals at all points of dispensing, whether these are pharmacies, hospitals, or dispensing physicians. The concept recognizes that it is essential to have a standardized computer terminal introduced in these various dispensing areas. An embellished model might even encompass the introduction of terminals at the level of prescribing-namely, back at the physician's office—but we will bypass that element for the moment.

The concept of the clearinghouse is exceedingly simple. It implies that all prescription orders be transmitted automatically by means of source data automation based upon the computerized terminal from the point of dispensing to a regional central processing unit. These two elements, in essence, represent the clearinghouse. This means that all the cash sales at the pharmacies, all the credit sales, and all the third-party sales are entered into the terminal in the same format. Thus, all prescription records will be received by the regional central processing unit in the same format, regardless of the ultimate disposition of the data. As far as the pharmacist is concerned, or the dispenser, the uniformity of the information system is maintained as indicated.

The primary purpose of this system is to provide the pharmacist and the physician with an opportunity to evaluate, within a professionally controlled mechanism, the quality of prescribing. Given the aggregation of drug records at the regional CPŪ, there may be a number of separate quality assurance mechanisms created for administrative needs. If the local quality assurance mechanism happens to be a PSRO, then the PSRO unit has access to these records. If this responsibility is independent of the PSRO unit, then a new quality assurance mechanism can be accommodated.

Should the pharmacist wish to control inventory through this same system, then the regional CPU can transmit the data to the wholesaler or the manufacturer according to the instructions provided. Consequently, control over inventory level and the source of supply is always maintained by the dispenser.

In addition to the function of the regional clearinghouse which would be replicated throughout the United States and I don't know whether there would be 8 regions or perhaps 58 regions—that's a technological consideration—there would also be the capability of introducing an additional function. That additional element pertains to uses other than professional review of prescription data. One of these purposes might involve the development of third-party programs, not unlike Aetna, Blue Cross, Blue Shield, Paid Prescriptions, medicaid, and so forth. But the data that is required by these thirdparty programs for purposes of reimbursement is obtained independently from the submission of information by the dispenser.

Now, the strategy behind the development of the clearinghouse mechanism recognizes a sharp dichotomy between professional interest and needs, which is controlled by the practitioner at this level [indicating]; that is, the regional level, and those of other interest groups which is recognized here with the development of computers that receive their information from the central processing unit.

If we wish to consider the potential of national health insurance, or the expansion of drug coverage under medicare, we do not concern ourselves with the integrity of the information system made available to practitioners for the simple reason that information network is maintained. If, however, we decide to change the financing mechanism—that is, change the relationship with third parties the only variable involved pertains to the location of computers which are external to the regional clearinghouse mechanism.

Now, one of the major advantages of the clearinghouse is the availability of patient records regardless of the practitioner or place of service. Patients may decide to receive medical services from different physicians. Patients may decide to leave the area. Under both conditions, the data system, the clearinghouse function, still controls patient records which are automatically provided to the vendor as required.

If the patient goes to Florida for 3 months or 3 weeks in the wintertime, then there's simply an exchange or updating of information between the respective regions. If the patient decides to receive care from four or five practitioners simultaneously, the integrity of the data base, with respect to prescribing at least, is assured simply be cause all prescription records are maintained in the system.

Basically, we are talking about a clearinghouse concept to which has been appended techniques pertaining to third-party reimbursement or other controls that may be essential for society, while simultaneously maintaining the integrity of the data base here for professional review and interpretation.

Mr. NELLIS. What about cost and confidentiality?

Dr. RUCKER. If I could summarize in one sentence. I would like to suggest that the major problems with development of this network are not in the area of economics or technology. If McDonald's hamburger stands can develop a system to serve their needs, it seems to me we have demonstrated enough ingenuity in society to maintain a system for drugs that might be useful for professional and social purposes.

In my view, the major problems lie in the area of concept, coordination, and catalyst, while the confidentiality problem is one where there's a fair amount of work already done. In fact, there are some instructors at Ohio State University who are preeminent in this particular field. Nevertheless, it is an area of concern in a number of different groups and ought to be recorded as such.

In my view, the major problems are in trying to get the professions together, the third parties and the Government and other interested individuals, to delineate and work on these critical problems of concept, coordination, and catalyst.

I don't have a firm estimate for you pertaining to the overall cost of the system. Several years ago I made an estimate that this might be under $600 million a year. However, if we recognize that our society is now approaching—some time in the early part of 1980—the volume of 3 billion prescriptions a year written in both ambulatory and institutional settings-private and governmental—we must consider that we are going to be able to amortize the cost of this system over some 3 billion records.

My initial estimates indicated that the average cost of processing these records within the total system could probably be accommodated in the area of 13 cents per claim. If you compare this cost of some 13 cents, and let's say I'm off by 100 percent, 26 cents or even 30 cents, if you compare that

expense to the traditional expense of insurance carriers which is sometimes in the neighborhood of $1 to $2 or more, I think there's significant cost-effective advantages inherent in a system of this nature.

Let me conclude just this brief explanation by citing a statistic generated by the Journal of the Royal College of General Practitioners in Great Britain, I believe in June or July of 1973. This study indicated that psychoactive drugs represented the single most important area within drugs for hospital admissions. The model clearinghouse system, though, controlled by professional standards and review, represents a mechanism for minimizing those instances of hospitalization. Thus the whole cost-effective parameters of this system must be evaluated in that broader context and not exclusively within the model of how much would it cost to buy so many terminals or so many computers.

This is a very complex subject and I have simply made this reference hopefully to stimulate others to do more intensive work in the area. I'm sorry to say that since I have published these ideas, to the best of my knowledge, nothing has happened. Mr. NELLIS. Thank you, Dr. Rucker.

Mr. PEKKANEN. We will reserve questions until the committee members return, Dr. Rucker.



Mr. PEKKANEN. My name is John Pekkanen. I live in Bethesda and for the past 6 years I have been an independent writer specializing in drug and medical subjects.

Thank you for extending me an invitation to appear before this committee today. I will make a brief statement and then respond to any questions you might have for me.

I will begin by stating my bias, and that is I believe we live in an overmedicated society. In my opinion, Americans indulge in an excess of drug taking—from alcohol to prescription drugs. My area of special concern has long been legitimately prescribed psychoactive drugs, commonly called mood altering drugs, such as amphetamines, barbiturates, and tranquilizers. I have written a book on the subject, as well as shorter articles.

I will offer you some of my views regarding the reasons I think that Americans take too many of these psychoactive drugs and what I think some of the consequences might be.

To begin, these drugs of which I speak, barbiturates, amphetamines, and tranquilizers, are all habit forming and all can have extremely

serious consequences when misused. Barbiturate withdrawal is considered by drug researchers to be the most serious and life-threatening withdrawal of any drug, licit or illicit. Tranquilizers, often blithely referred to as "happy pills," can also create extremely serious withdrawal problems when taken in high doses, and abruptly withdrawn. The point I am trying to make is that I do not believe the American public generally respects the potency or potential hazards of these drugs. I think the public by and large holds illicit drugs such as heroin and cocaine with the proper respect, but that does not extend to these legitimate mood-altering drugs. I think part of the reason is the way in which the public gets these drugs, and that is through their doctor. These drugs, from the outset, have medical sanction and approval. Thus, the public accepts these drugs as “medicine” and all too often is not properly apprised of the potential problems they may create.

To understand this, and to understand why we as a nation purchase in excess of 275 million psychoactive drug prescriptions each year, it is necessary to understand the crucial role the medical professional plays. This has been part of my special interest in this problem.

The doctor is in a unique position of directing the consumer/patient to a specific drug. Because of this special role, the physician has been the object of intense promotion and advertising by the drug industry. The drug company courts the doctors, and attempts to persuade them to prescribe its product.

There are three main avenues of drug promotion to physicians. They are direct mail, personal solicitation by drug company salesmen, called detailmen, and advertising in medical journals. Precise figures are difficult to obtain, but the drug industry spends about $5,000 a year on each and every one of the approximately 200,000 practicing physicians in this country.

If we are to accept the word of the doctors themselves the most effective method of promotion of psychoactive drugs is through the detailmen. Nationally, the detail force numbers about 20,000.

In a survey conducted by the American Medical Association in 1973, 17 percent of the physicians surveyed said they regarded direct mail advertising as a major influence in their prescribing habits, 25 percent regard journal advertising as a mjor influence; and 52 percent regard the detailmen as a major influence. Furthermore, an additional 11 percent said the detailmen had a marked influence on their prescribing habits, or a total of 63 percent who said these salesmen greatly influenced their drug prescribing.

The survey method was submitted to a representative number of physicians and we may infer that it represents the sentiments of physicians nationwide.

It is my view that most physicians are ill prepared to resist the promotion and advertising of the drug industry for a number of reasons. The first, and most important, reason is that despite what the public rightfully expects of doctors, most of them in fact have not had adequate education or training in the use of psychoactive drugs.

Let me cite you some specifics. Pharmacology, which is the science of the actions of drugs on the human body, generally has little emphasis in medical school. In interviewing at medical schools for a study I did on this subject in 1975, the general consensus was that the average


medical student is exposed to 3 to 6 hours of pharmacology, formal pharmacology, and this is in the classroom, and I think this has inproved since 1975 but not to a significant extent. Psychopharmacology, the science of the action of drugs on the human mind, has a lesser priority, often being offered in a seminar or two during medical school. I should add that I did not do an exhaustive study of medical schools, however, I did visit Columbia and Harvard, which certainly rank among the best medical schools in the country.

The quality of pharmacology training a young resident receives is very dependent on the senior residents and physicians he trains under, and this is obviously in the second phase of his training, and their training is more crucial than his formal classroom education. However, it is very idiosyncratic. If he trains under a doctor who administers drugs promiscuously, he is likely to adopt that attitude, and vice

My point is that the practicing physician has little reliable objective information to guide him in his drug prescribing. Add to this fact that a number of his patients come to his office either demanding a prescription for a mood astering drug or have no complaint other than loneliness or depression and I think these kinds of complaints, although often masked in semantic complaints, can range from 50 to 60 percent in the surveys I have seen. That is, there is little mystery as to why drugs are so widely prescribed. In one sense, I see the practicing physician in the middle of this process. On the one hand, he is not equipped with solid information on psychoactive drugs and the specific indications for their use. He is also faced with drug industry promotion and salesmen who attempt to persuade him, through a series of strategems, to prescribe their drug. And finally, he is often subjected to the pressure

of his own patients who feel a "need” for a mood altering drug and who, if they are not prescribed one, may leave him and go to another doctor, and I don't think that this economic pinch that the doctor can be put under should be dismissed. Thus, we frequently find psychoactive drugs prescribed for little or no medical indication.

In my interviewing of medical school students, teachers and administrators, I found a recognition of this fact. One medical school teacher found clinical training in the use of psychoactive drugs "an overwhelming failure." I do not think he was exaggerating.

I will conclude by noting three studies which I think have some bearing on the overuse of habit forming psychoactive drugs. In three separate studies by Drs. Blum, in California; Smart, in Toronto; and Louria, in New Jersey; the message is inescapable: The use of legitimate psychoactive drugs by parents greatly increases the chance of their children's abusing illicit drugs. In some cases, the children have a five- or tenfold greater chance of abusing illicit drugs than children whose parents are not users. The studies also point out that parental use of tobacco and alcohol are also influences which increase the chances of their offspring abusing drugs.

Thus, we cannot view the use of illicit drugs by our young people as an isolated phenomenon. It has a strong relationship to a number of larger concerns : The way drugs are promoted; the way our physicians are trained and educated; the public's lack of appreciation for the potential hazards of these drugs; and the way this society has arti

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