Opinion ID: 857137
Heading Depth: 4
Heading Rank: 1

Heading: But-For Reliance Evidence

Text: Kaiser presented ample evidence of the ways in which its reliance on Pfizer's misrepresentations regarding the effectiveness 14 Kaiser has argued that the district court did not actually use the Rosenthal report as evidence of causation, but rather used it only to quantify damages. The district court's findings are not clear on this point. Compare Kaiser Findings, 2011 WL 3852254, at  (To meet its burden of proving causation, plaintiffs offered the testimony of Professor Meredith Rosenthal . . . .), with id. at  (describing causation question as what misrepresentations and omissions Kaiser and DIS relied on[,] . . . whether that reliance caused Kaiser to suffer injury[, and] . . . whether or not PMG physicians would have nonetheless prescribed Neurontin to their patients if DIS had not published monographs recommending Neurontin or if the P & T Committees had added guidelines or restrictions to Neurontin's formulary status). The jury charge on causation and damages did not mention the aggregate evidence one way or another. We will proceed on the understanding that the aggregate evidence both went to causation and set the basis for damages. -37- of Neurontin for the four relevant off-label uses met the but-for causation requirement. Kaiser received Pfizer's misrepresentations through Pfizer's contacts with Kaiser's DIS, which disseminated information throughout the Kaiser organization. See Kaiser Findings, 2011 WL 3852254, at -4. The DIS also relied on publicly available information about Neurontin, id. at , which, because of Pfizer's publication strategy, omitted important information about negative study results, see id. at -8. A reasonable factfinder could readily conclude that misinformation received by the DIS would be widely disseminated, utilized, and relied upon throughout the Kaiser organization to cause but-for injury. Kaiser specifically presented evidence that the DIS shared with all regions at least two monographs that recommended Neurontin for bipolar disorder and that recommended removal of any formulary restrictions on Neurontin. See id. at -29. These monographs were compiled without Pfizer having disclosed certain adverse material information. Id. In making formulary decisions, P & T Committees rely heavily on DIS's monographs, id. at , and PMG physicians comply with the formulary at a 95 percent rate, id. at . There was also evidence that PMG physicians received and acted upon Pfizer's misrepresentations, both through information sent through the DIS and information provided to them at Pfizer- -38- sponsored events. For one, when DIS answered physicians' questions through its inquiry service, DIS relied on half-truths communicated to it by Pfizer. See id. at . Second, after PMG physicians attended a medical education conference in May 1999, new Neurontin prescriptions increased by 62 percent. Id. at . And significantly, when Kaiser conducted the DRUG and DUAT campaigns to reduce Neurontin usage after the negative information about Neurontin came to light, new prescriptions of Neurontin fell by about 33 percent. At the same time, such prescriptions continued to rise nationally. Id. at . From this evidence, the district court concluded that [t]he publication strategies and the other communications between Pfizer and Kaiser directly affected decisions about Neurontin's placement on formulary without restrictions. In addition, the direct communications to PMG physicians caused Kaiser injury because it reimbursed for Neurontin rather than less costly alternatives. Because Kaiser has a 95% compliance rate with its formulary, formulary restrictions necessarily affect the number of prescriptions written for any given drug. I find that Kaiser was injured as a result of its reliance on Pfizer's intentional misrepresentations and omissions. Id. at . This finding was not clearly erroneous. Further, a reasonable jury could have reached the same conclusion. Pfizer argues that Kaiser's DRUG and DUAT campaigns to reduce prescriptions of Neurontin were not evidence of but-for causation because they were motivated by the desire to contain costs, not by concerns about Neurontin's efficacy for off-label -39- uses. Pfizer also argues that once evidence of the DRUG and DUAT campaigns is properly discounted, there is no evidence that the Kaiser PMGs took steps to restrict Neurontin on their formularies, which falsifies Kaiser's causal theory of direct reliance. Pfizer did present evidence that Kaiser continued to permit and even recommend the prescription of Neurontin for certain off-label uses after it became aware of Pfizer's fraud, as well as evidence that Kaiser's efforts to limit Neurontin prescriptions were driven in part by its cost. But Kaiser presented evidence that it did not learn the full scope of Pfizer's fraud until November 2009, Kaiser Findings, 2011 WL 3852254, at , and that its efforts to limit Neurontin prescriptions were motivated by concerns about its efficacy for off-label uses. It was within the factfinder's province to weigh this evidence. Pfizer's evidence did not, as a matter of law or of evidence, falsify Kaiser's theory of reliance upon Pfizer's misrepresentations.