How to think about prescription drugs.
October 31, 2004 9:03 PM   Subscribe

How to think about prescription drugs. Malcolm Gladwell's latest piece in The New Yorker
The emphasis of the prescription-drug debate is all wrong. We've been focussed on the drug manufacturers. But decisions about prevalence, therapeutic mix, and intensity aren't made by the producers of drugs. They’re made by the consumers of drugs.

posted by trharlan (20 comments total)
On a related note, CATO pegs the cost of health care regulation at $169mm. (.pdf)
posted by trharlan at 9:06 PM on October 31, 2004

Patients do not write prescriptions.
posted by ilsa at 10:09 PM on October 31, 2004

The cost of drug advertising is much higher...

$ According to industry estimates, drug companies spent $15.7 billion dollars on promotion in 2000, up from $13.9 billion in 1999.

In fact, In 2000, Merck spent $161 million on advertising for Vioxx. That is more than Pepsico spent advertising Pepsi. ($125 million), and more than Anheuser-Busch spent advertising Budweiser..

posted by drezdn at 10:24 PM on October 31, 2004

AstraZeneca is being sued for its deceptive promotion of Nexium.
posted by euphorb at 11:04 PM on October 31, 2004

I did it myyyyyyy waaaaaaaaaaayyy!!
posted by Hildegarde at 2:49 AM on November 1, 2004

Go read Jerry Avorn's book: Powerful Medicines

good stuff
posted by knutmo at 2:55 AM on November 1, 2004

A big part of Gladwell's thesis here is that an educated consumer (patient) will lead to a more rational market. But let's be real here - is a 75 year old woman suffering from arthritis going to learn the difference between COX-2 inhibitors and NSAIDS?

Some of this comes down to the assumption on the part of a patient that a "more expensive" drug means a "better" drug, and that a doctor or a health care provider's attempt to prescribe something cheaper is an attempt to cheat the patient - to save costs by prescribing something inferior. "No, I want the real stuff," is likely to be a patient's reply.

And this stands in the face of drug companies deliberate attempts to confuse consumers so that they can't make rational choices. The trick that AstraZeneca pulled with Prilosec reminds me of what Scott Adams (of Dilbert) called the "confuseopolies" - companies who use marketing power to confuse consumers so they can't tell which product or package is best for them. Adams was talking of phone companies and cell phone plans, but it seems applicable here, too.
posted by Chanther at 4:02 AM on November 1, 2004

The emphasis of the prescription-drug debate is all wrong. We’ve been focussed on the drug manufacturers.

I disagree with Gladwell.
posted by nofundy at 4:30 AM on November 1, 2004

It baffles me that the US HMOs are not breaking out the thumbscrews over this.

Think of it: an HMO that can offer the same heath outcomes using generics rather than reformulations. They save bundles and pass (some of) that onto consumers as lower premiums. They make billions! And fight crime! Isn't that how a free market is supposed to work? Why isn't it?
posted by bonehead at 5:38 AM on November 1, 2004

Why isn't it?

Because the HMOs treat their members as liabilities rather than assets and turn the thumbscrews on them as a result.

For instance, I recently went in for surgery (to repair a hernia) and buried deep in the pre-op paperwork was a warning that I should decline all hospital-provided lab work because my HMO was having a dispute with the hospital's lab. Their suggestion was for me to get the lab work done at their sanctioned lab and bring the results in before the surgery. When I got to the hospital, there was a similar sign (also badly placed) which suggested it was my insurer's fault and, if billed, I should take it up with them.

Had I not been an intelligent consumer, I would have gotten billed for the full cost of the lab work at the hospital, and if I had brought this grievous error to my insurer, they would have told me to pound sand because I had been duly notified by both parties.

My story isn't about drugs, but it shows that my HMO wasn't willing to go to bat for me, despite the fact that I and the other members of their plan make up the buying power they are supposed to use in my favor.

Our healthcare system is screwed up in so many more ways than just the drug companies pricing practices, it's not even funny.
posted by tomierna at 6:41 AM on November 1, 2004

This is a very good article, but it leaves out the fact that most insurance plans (and especially medicare/medicaid) do not pay for over the counter drugs. As more and more drugs go OTC, this is a potential source of huge savings. Also, I got the impression that the article pointed as much of a finger at physicians and their prescribing as at anyone. Physicians are the major target of the marketing dollars spent by big pharma (often disguised as education) and the generic companies, on the other hand, spend almost nothing on marketing.

Patient demand is also important, though, and that is why drug companies also market directly to consumers. It is part of the physicians job to educate the patient as to what is the most appropriate drug for them rather than give them the drug they have seen on TV, but that takes time and effort, which can be difficult when you are expected to spend only 5 minutes with each patient in order to see everyone who has an appointment (based on HMO reimbursement schedules)

Our healthcare system is screwed up in so many more ways than just the drug companies pricing practices, it's not even funny
posted by TedW at 6:58 AM on November 1, 2004

I disagree with Gladwell.

Gee, that's convincing. Did you actually read the article? Do you have information proving that Gladwell is wrong about the rise in medical costs being due to more medicines being prescribed rather than increases in the prices of drugs, or are you just proclaiming your belief in your own preconceptions?

ilsa: He's not primarily blaming patients, he's blaming doctors and insurers.
posted by languagehat at 7:12 AM on November 1, 2004

bonehead: because "free market" is just a meme used to sell the concept that less or no government regulation on market is a good thing (curiously enough many of so called "free market" supporters are quick to forget patent system is a significan obstacle to free market, a virtual barrier for new companies).

As we hear "free" we think of freedom and "getting something without paying" so we think that anything that comes with "free" is good but that's total bullshit. (example, you get flu for free, but is it good ?). Problem is "free market" is a meme also used in perfect competition market model's an interesting and sound model..unfortunately it's very hard to have "reality" meet that model.

For instace take India's pharmaceutical market.. some interesting info here. Apparently, as far as I learned, indian patent system disallowed recognition of foreign drug patents in 1970..which allowed indian drug producers to just copy foreign patented drugs ; to avoid litigation some indian company devised new ways (probably new delivery methods too, pharmaceutical mefites ?) to produce the drugs.

This is -pure competition- in which Indian company X manufactures drug "BLAH" owned by another company without:
1. taking the cost and risk of research and developement
2. exploiting the advatange coming from comparatively cheaper indian workforce

The fruit of this -unrestricted pure competition- is that indian companies can (if they so wish) pass along some of the savings to the customers, poor and sick people probably benefiting the most.

Obviously patent owners cry wolf at such a behavior and call it -unfair competition-..but as the New Yorker articles leads me to believe, some of them are only good preachers of -fair competition- while they exploit loopholes in the patent system exactly like the indian did, kind of criminals pointing fingers and namecalling other criminals "criminals" ! Pot meet kettle, I guess ?

The biggest difference being the following: indians exploited their own patent system to produce more of "good" at a cheaper price while making good profits, while the others are apparently exploiting patent system in a effort to (indirectly) challenge generic drug producers out of market : which in turn could lead to reduced production of unexpensive, "good until marketing said no" drugs.
posted by elpapacito at 7:36 AM on November 1, 2004

Gladwell points out that health insurers are trying to promote rational decisions through the use of formularies. The copays for drugs in my previous health insurance plan were $10, $30, and $50 according to the formularies--pretty big differences to me.

But my doctor does not have my health insurer's formulary sheet in front of her when she prescribes medicines, and while I griped about the high copays of some drugs, I don't take the formlary sheet with me to the doctor's office to ask my doctor about the relative efficacy of the different drugs (though I might do so in the future, after reading Gladwell's explanation of formularies!).

Seems like formularies are not a bad idea in principle, but I don't see them actually changing people's behavior much in practice.
posted by tippiedog at 8:16 AM on November 1, 2004

Malcolm Gladwell always delivers provocative reads, and this article is no different. The most surprising insight to me was when he reported that Americans pay less for generic drugs than other countries do, which is interesting. That said, I think the article lacks balance.

First, his hymn to PBMs leaves out a few of their problems, such as their lack of transparency (which leaves room for massive fraud). Many of the largest PBMs are owned by pharmaceutical companies, which has some pharmacists wary.

Also, how can Gladwell let the drug companies completely off the hook when their billion-dollar hype and misinformation campaigns are the principal source of ignorance about the drugs' effectiveness? Even the book he approvingly cites in his tried-and-true end-of-article "gotcha" moment blames drug manufacturers for many of the problems plaguing the industry.

Gladwell has a good point -- we need to look beyond the ads to ferret out real, affordable drug solutions, but there's a lot more to the story than what he writes.
posted by grrarrgh00 at 8:20 AM on November 1, 2004

how can [we] let the ____ companies completely off the hook when their billion-dollar hype and misinformation campaigns are the principal source of ignorance about [product] effectiveness?

plug in industry of choice, statement remains true.
hey! let's all go to the movies!
posted by quonsar at 8:32 AM on November 1, 2004

I disagree with Gladwell.
Gee, that's convincing. Did you actually read the article?

Why, thank you! Yes, I did. The article only rates a very brief response. There are way too many well paid defenders of Big Pharma to respond fully to each and every one. This one doesn't rate among the best. The flaws are so obvious in his arguments that I leave it to others to deconstruct yet again. But thanks for caring.
posted by nofundy at 11:59 AM on November 1, 2004

Go read the best response to Gladwell's article.

OK, I read it. "The reason this Gladwell fellow is a shill is that he completely ignores the malevolent DTC advertising by the drug companies... Gladwell then takes a flying leap into the arms of the Bush ideologues... Next, Gladwell gets all dreamy eyed and rhapsodic over PBMs... In his eagerness to exculpate Big Pharma..."

Sorry, but if this is the best the other side can do I'll stick with Gladwell. Somehow, facts are more convincing to me than shrill rhetoric. If you have to use words like "shill" and expressions like "takes a flying leap into the arms of the Bush ideologues" and "gets all dreamy eyed and rhapsodic," that suggests you don't have anything else to offer. Gladwell is not trying to "exculpate Big Pharma," he's saying everybody's blaming them without looking very hard at the rest of the picture, and that seems to me unquestionably true. But if all you want to hear is "Big Pharma bad, very bad!"... well, there's lots of places you can get it.
posted by languagehat at 4:44 PM on November 1, 2004

posted by dancingbaptist at 3:49 PM on November 22, 2004

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