Physicians

PHARMA/PHYSICIANS: Attacking the Rx data stream

So perhaps this is getting serious. Doctors Object to Gathering of Drug Data

If the A.M.A effort succeeds, "legislators will turn their attention elsewhere, and the industry can hang on to one of its most valuable data sources," according to an article this week in the industry trade magazine Pharmaceutical Executive, which was co-written by an A.M.A. official and an executive with the leading vendor of prescription data. Even many critics concede that patients’ privacy is apparently not an issue, because the tracking systems identify only the prescribing doctors, not patients. But many doctors find the use of the data by sales representatives an intrusion into the way they practice medicine."These doctors were outraged that people came into their office and talked to them about how many times they prescribed a particular drug," said Dr. John C. Lewin, the chief executive of the state medical association in California, one of the states where complaints about the current system arose.  The California group is beginning its own program under which doctors who do not opt out under the A.M.A. system will get comparisons of their prescribing patterns in 17 classes of drugs from the data companies, said Dr. Lewin, who added that the program was being started as a pilot effort that he hoped would be extended statewide.

This latest dose of outrage is almost hysterical. In both senses of the word.

There are some doctors who are vehement in their opposition to drug companies. They won’t take the free lunch. There are some who take advantage. For most, they have a fairly neutral opinion of drug reps. But the concept of not allowing anyone to know their prescribing patterns doesn’t exactly smack of the transparency that we’ve heard so much about. And frankly if the drug companies don’t know how to detail docs as efficiently as possible (and for that they do need the data) it’s likely that their marketing efforts will get more unfocused and more onerous on the system as a whole. And in general I’m of the belief that useful targeted marketing & sales is better than blanket non-targeted efforts. So unless we are going to ban ALL pharma marketing (which will mean tossing a great deal of useful babies out with the bath-water) and fundamentally change how information about drugs is communicated to physicians, then getting rid of the IMS type data is not helpful.

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  4. Are Drug Reps Really Necessary?
    One of the main functions of pharmaceutical representatives is to provide free samples to doctor’s offices presently instead of authentic persuasion, and these samples in themselves cost billions to the pharmaceutical industry. Yet arguably, samples are the most influential tool in influencing the prescribing habit of a health care provider. Let me be clear on that point: Its samples, not a representative, who may be the top influencer of prescribing habits.
    Yet considering that drug promotion cost overall is approaching 20 billion a year, combined with about 5 billion spent on drug reps themselves, what if there is another way for doctors to get free drug samples, which is what they desire for their patients to initiate various treatment regimens? What if prescribers could with great elation avoid drug reps entirely?
    There is, actually, a way to do this, but it is limited. With some select, smaller pharma companies, doctors have the ability to order samples by printing order forms on line for certain medications through certain web sites associated with the manufacturers of these samples. Some examples are such medications that can be ordered in this way are keflex, extendryl, and allerx. Possibly several more can or are available to prescribers in this way. Others, however, cannot be acquired by this method.
    So in some situations, a doctor can go on line, print off a sample order form, fax it into a designated fax number after completion of the form, and the samples are shipped directly to the doctor’s office with some products thanks to their manufacturers who provide this avenue. There is no review of the doctor’s prescribing habits. No embellishments from reps actually sounds pretty good.
    Usually, this system is available for those smaller companies with very small sales forces to compensate for what may be vacant territories, but can be applied to any pharmaceutical company who, upon discretion, could implement such a system.
    Now, why is this not done more often? Apparently, it is legal to obtain samples in this manner. If samples are the number one influencer of prescribing habits, why spend all the money on reps to deliver samples personally? It’s worth exploring, possibly, since the drug rep profession has evolved into those who become UPS in a nice suit.
    Think of the money that could be saved if more pharma companies offered samples to doctors in this manner. Furthermore, additional benefits with this ideal system are that there is no interruption of the doctor’s practice. And again, there is no risk of bias presented to the doctor by a rep, as they would avoid contact with reps if they order samples through this way- to have the samples directly to be shipped to their office.
    When samples are shipped to doctors’ offices in this manner, prescribing information of the particular med is included with the samples shipped. Doctors can order and utilize samples according to their discretion, and would be free of interference from the marketing elements of pharmaceutical corporations. Patients benefit when this occurs.
    Considering the high costs associated with the pharmaceutical industry, having samples shipped directly to doctor’s offices should be utilized more than it is presently- regardless of the size of the pharmaceutical company.
    Something to think about as one ponders cost savings regarding this issue.
    “The new source of power is not money in the hands of a few but information in the hands of many.”
    —- John Naisbitt
    Dan Abshear

  5. I agree. R&D has become more of a challenge, but the industry is focusing to a greater extent on categories such as oncology, to a great extent based on profit motive. But that profit incentive is based on the fact that payers won’t pay for me too drugs. The market wants real cures for serious diseases and thus goes the industry’s focus. I think you will see cuts in marketing budgets over the next few years, particularly in the bloated sales forces. It’s tough, along the lines of nuclear disarmament. Everybody knows it needs to be done but every company is afraid to unilaterally disarm. Part D has certainly helped seniors (cutting the out of pocket of the previously uncovered by 50%), and I suspect the industry will (for better or worse) slide down the slippery slope of price negotiation the next time the Democrats wield the levers of power.
    I’m no big fan of DTC, to tell you the truth, especially the Dorothy Hamill Vioxx genre. But to the extent that it makes the general public aware of issues like high blood pressure granted not a big DTC category) and even ED (which gets many men into doctors’ offices whose first encounter with the healthcare system would otherwise be the ER, I think it has at least the potential to be a force for the betterment of public health. The industry has wisely moved to a more sober tone and more of a disease awareness approach of late, in my opinion.

  6. Well, Terry, you are disliked by honest physicians because of what drug marketers do. There are some decent drug reps who provide information and drug samples, as requested by physicians. However, the fact is that the drug industry spends more money on marketing than research. The U.S. health care system is the most expensive in the world, but it is falling apart at the seams because of all the non-productive costs. We all pay for drug marketing costs.
    The collection of physician prescribing information is an invitation to corruption. Physicians who prescribe expensive drugs have, in the past, been rewarded extensively by some drug reps. Hopefully, this practice is over, but as long as physician prescribing data are provided to drug co’s, the temptation for various forms of kickbacks exists.
    If you want to subsidize journals and CME’s, fine. But how do you justify spending billions on consumer oriented marketing? You overcharge seniors for drugs, spend millions lobbying Congress so that Medicare can’t negotiate fair prices, and you want to be liked?
    Get back to the business of developing new drugs that are major improvements over old ones, cut your marketing budgets and give the old folks and the taxpayers a fair price and maybe your image will be positive.

  7. Is there anyone out there who would be interested in starting a march on our state capitals to protest our enslavery by health insurance companies. I think the 4th of July would be a great time to do this so that we could ask for our freedom from health insurance companies running our lives.
    All we do is pay rising rates every year for very little if nothing. Then when we get a preexisting condition we can’t even change to another insurance company. We small business owners cannot afford health insurance anymore. Surely there are a lot of other people without insurance at all and those of us who are fed up with paying it and then having our hands tied and being forced to pay ever-increasing rates every year. And also those that can’t even leave their town or job because of needing their existing insurance that must be extremely upset about this. We need to all get together and march to protest this never ending problem. Who out there is interested.

  8. Matt, I scrolled through this whole debate just to tell you that I think you’re spot on regarding prescribing data availability. While it can be misused, it certainly helps marketers operate more efficiently when used properly.
    I was, as always, dismayed by the vitriol directed toward pharmaceutical marketing. I am in the business myself, as a supplier of data to the industry. I can assure the correspondents that pharmaceutical marketers do not knowingly market drugs that kill people. For the more charitably minded, the rationale that they are human beings may suffice. For the prejudiced, the cold hard fact that it’s bad for business may prove grudgingly compelling.
    Pharmaceutical marketing has sufferred its share of malpractice, as has every profession, medicine definitely being far from without sin. However that does not make it inherently evil. To the contrary, it is necessary. If drugs sold themselves, companies would spend zero on marketing. New drugs are risky. Many doctors are cautious, no doubt with good reason. Drugs must be sold. Dr. Tuteur argues that doctors should thoroughly educate themselves at their own expense. Many, if not most, don’t. Many, if not most, journals are funded by drug ads, as is most CME, even that provided by specialty societies. The AMA used to publish a book called Drug Evaluations, unbiased and comprehensive information about drugs. Now it dosen’t, because doctors wouldn’t pay for it–they use the PDR instead, because it’s free. The Medical Letter, another paid subscription (thus unbiased) struggles for the same reason.
    In the real world, doctors are extremely reluctant to pay for information about drugs. If marketing is outlawed, doctors will get their information primarily from their health plans. As a patient, I prefer he status quo.
    As a marketer, it saddens me that some physicians and others have been driven to such extreme hatred of pharmaceutical companies, and particularly marketers.
    I believe the companies have saved more lives than perhaps any other industry, yet they are reviled with opprobrium associated with the merchants of death who market tobacco.
    Clearly, there is a need for reform and rapprochment. Doctors of medicine need medicine, and makers of medicine need doctors.
    As for DTC, again, there is good and bad. I am no fan of DTC, but I believe many lives have been saved as patients see their doctors about diabetes, hypertension and even ED who, absent DTC, would never have made the trip.
    Are there nightmares such as Vioxx? Yes. Is the system perfect? No. But are pharmaceutical marketers murderers? Should marketing be illegal? I think not. Given our Constitution, such extremism is beyond Quixotic. I would encourage the participants in this debate to curb their enthusiasm and work toward realistic reforms that recognize the realities of the situation. Pharma may not be angelic, but it is hardly demonic.

  9. Matthew writes in response to my question about the manner of prescribing:
    > Therapeutic substitution is not allowed yet
    I can see that what I have in mind will probably fall under this ruberic, but as “therapeutic substitution” is apparently defined right now, it isn’t quite that.
    The doc would not prescribe “Nexium” and leave the patient/pharmacist free to substitute Prilosec. No: the doc prescribes “proton pump inhibitor” or “statin” or whatever, and there is complete freedom to pick one from among the FDA approved drugs in that class. This is not “substitution” — it is “choice”, or “empowerment” or “personal responsibility”. Whatever floats your boat.
    Under this scheme the notion of “prescribing patterns” takes on a completely different hue. Docs would not prescribe brands any more, and pharmacists wouldn’t really do it either. Them that want the advice of a pharmacist or doctor about the relative merits of the various drugs of this class can get it, and in a way they’ll be forced to because they do not have a prescription with the name of a drug on it. Them that want brand names for whatever reason will choose the best-marketed (from their point of view) version. Under a well-constructed benefit design, they’d pay for (most of) the difference out of their own pockets, and who besides Jack Daniels will say there’s anything wrong with that? I bet lots more people would end up with the white pill called omeprazole for 20 cents/dose.
    Here, by the way, is the top 200 Rx of 2004 by $$$
    and here is the top 300 Rx of 2004 by number of fills
    According to this article, generics accounted for 56% of Rx dispensed last year, but only about 10% of total $$$ spent. Pretty stunning.
    My understanding this is pretty much what the original intent behind the FDA was: a regulatory scheme that would make it safe (and effective) for people to medicate themselves. A combination of influences prevented this coming about, but maybe now is a time to reexamine the way drugs are controlled.
    I think this furthers Matt & Barry’s goal of transparency, by forcing people to look at the now translucent glass, and trusting they will demand it be wiped clean.
    t

  10. Arguments are what I’m interested in. There is data every which way you look pointing in any direction you want. Even so, I’m going to cite more in a second.
    Healthcare should be run by the federal government? At all levels? Congratulations, you’ve hit my hottest button. You cannot be serious. Medicare is failing. Medicaid is failing. My previous posts were not unfounded.
    http://hspm.sph.sc.edu/Courses/ECON/CLASSES/Friedman.html
    The fresh pool of ill-managed money available from government programs has hurt us. A lot. Giving control of healthcare to the feds is like giving a bottle of gin and car keys to a pack of hormone-raged 14-year olds. I guess you haven’t been reading any news about the FDA for, I don’t know, about three years.
    Fiscal policy aside, politics will get more in the way of healthcare if you give the government control, and it has no place in research. I don’t think there’s any good response to this fact. Read my AIDs vaccine concern? How naive can you be?
    Sounds like you narrowed your argument to doctor-marketing, I noticed. Do you concede that DTC to consumers is useful? Dr. Amy never responded to that one either. And still, _still_ nothing on fewer drugs getting onto the market and to patients. Or destigmatization. I guess you’ve abandoned these arguments.
    I never said I want more spending on healthcare. Based on what I’ve said so far, that doesn’t seem like something that I would say, now does it? I’m the most fiscally conversative poster here. The wheel of healthcare is spinning too fast for a variety of reasons including overutilization (the tragedy of the commons, as it were), tax benefits, defensive medicine, and a bunch of other reasons.
    A right wing nut, huh? I didn’t know right wing nuts were for Plan B as much as I am.
    Banning doctor marketing (in sales rep details) is not the solution. Should it happen less? Yes. Yes, yes, yes. I agree with you that, as I’ve been saying for some time now. It’s not even cost-effective from the industry standpoint, as I’ve noted. Banning marketing in journals is simply a terrible idea. Banning DTC marketing, is, apparently, something you’re not willing to argue about anymore either, unless you’ve finally decided to respond on that.
    In terms of overall healthcare costs, by far the biggest cost contributor that I see is Medicare and Medicaid. By far. How much? Well, roughly, 1 out of every 3 of our tax dollars is spent transfers of wealth through either Social Security, Medicare, or Medicaid. And the middleman in that equation? The government (and not just any government…ours. The US government. There are differences). We can see how well that’s been working so far. These levels are totally untenable. At these rates, Medicare will be bankrupt by 2015, and insolvent by 2020. Medicare is actually my biggest beef right now.
    I’m a whopping 24 years old (but I’ve been studing healthcare since I was 18). The Medicare money out my pay is likely going to older folks with more twice the wealth that I have. How is that equitable? If I asked my parents if they’d like me to subsidize their medical care when they came of age (and maybe throw 10% of that money out the window from the start to pay for the government to administer it), they would probably say, “But son…you’re poorer than us. That doesn’t make any sense.”
    We need massive, massive reform in these areas. Government programs and transparency are the two hot buttons in healthcare right now, by far.

  11. I agree Berry, which is why drug research should be run by the federal government, not by private enterprise.
    TAke all the money we spend on drugs, and restructure it. Have the NIH fund all drug trials and drug research at all levels, from conception to phase IV clinical trials. Currently the modus operandi is that NIH funds all the basic science research, which big pharma picks up on and funds all the way thru clinical trials.
    Its well documented that the vast majority of truly revolutionary drugs were developed in academia by NIH funded research, NOT by big pharma. We should disband the private sector drug industry and have everything controlled by the NIH/FDA.
    Free markets have failed in healthcare. For people to pretend that MORE free markets will fix the problem is a pipe dream. Healthcare at all levels, including drug research, should be run by the federal government.

  12. I agree with Tom that there is not a lot of gold to be mined here. As he has pointed out more than once, prescription drugs are only about 10% of healthcare spending. DTC advertising is about $4 billion or so out of $200 billion+ spent on drugs. Drug retailers and PBM’s are already incentivized to switch brand scrips to generics if one is available and the doc has not specified DAW. When a me too drug is far more expensive than its competitor for little or no incremental efficacy, insurers can and do either exclude it from their formulary or require an extra layer of approval. Finally, the elderly, who consume 3-4 times as many scrips per person than the rest of the population are not equipped to do a lot of internet research or medical journal reading, especially when there may be interaction or contra-indication issues. And they shouldn’t have to.
    If cutting healthcare costs is the goal, there are plenty of more promising areas to explore. In fact, if we did a better job of reducing utilization whether by malpractice reform (health courts), living wills, QALY metrics, EMR’s in hospitals (to reduce errors), trying to bring about some convergence in practice patterns (like Medicare spending 3 times more per person in Miami than in Minneapolis), we might be able to afford to not only cover the uninsured but increase doctor reimbursement rates as well!

  13. http://www-rohan.sdsu.edu/dept/schlcomm/-Riskier.pdf#search='most%20commonly%20advertised%20drugs
    Most consumers are successful in obtaining the requested
    drug. Survey data estimate that between half and three-quarters of all requests are approved by a physician (Brody, 1998, ““National Survey,ÏÏ 1998). Moreover, there are indications that consumers who are unable to obtain an advertised drug from their own physician meet the denial with “suspicion and hostility” (Neergaard,
    1999) and “shop around” until they Ðnd a physician willing to prescribe the desired drug (Cohen, 1990 ; She†et & Reece, 1994).”
    The research on big pharma marketing to doctors is clear and conclusive:
    1) It changes script habits of doctors (duuhhh, big pharma wouldnt use it unless it worked)
    2) Changing script habits of doctors has NOT resulted in better patient outcomes or more suitable drug matching.
    3) Changing script habits HAS resulted in increased healthcare costs.
    Now, Holts and others response to this is “well those doctors took an oath, they ought to be ashamed of themselves”
    Being a doctor is a job just like every other job sector. They are influenced by the same nefarious factors that others are influenced by. I dont know where Holt and others got this idea that doctors are all Nietzche-like supermen who are immune to outside pressures.
    McDonald’s advertising affects Holt the same way drug reps affect doctors. So why are we so surprised that doctor-directed marketing changes their script habits?
    Holt’s response is a non-starter. He essentially says “too bad, thats the doctors fault and the doctors problem.” Its really missing the point. I’m not concerned about placing blame, I want solutions. The SOLUTION is to ban doctor-directed marketing and remove the nefarious influences that plague the profession. Apparently Holt is happy with the status quo on doctor-marketing as long as he can wag his finger at the evil doctors. I’m not satisfied with that.
    There is absolutely, positively no UPSIDE to doctor-directed marketing. Removing doctor influences would force them to rely on more appropriate sources of information. Is the scientific literature and professional association guidelines perfect? Nope, but they are damn sure better than outright misleading marketing directed towards docs

  14. “Still no response to the fact that banning DTC marketing would hamper drug development.”
    Ohhh thats rich. You do know that funding to R&D, when adjusted for inflation, has DECREASED since 1997 correct?
    99% of DTC ads are for “me too” drugs, whose value is MARGINAL if anything. DTC ads are NOT about introducing new classes of medications, they are about introducing “me too” drugs that are vastly more expensive than existing drugs and in which healthcare outcomes data shows no improvement over the existing pharmacopeia.

  15. Come on man, that report was written by an extremist right wing republican who believes that free markets are the “cure” to medicine. NOthing more than a long winded, non peer reviewed diatribe, with idiotic logic such as “since advertising reduces costs in other markets, it will also reduce costs in healthcare”
    Do we really think that healthcare is a free market? Only a fool believes that.
    I think this whole debate comes down to a more fundamental debate that comes down to one question: is the US spending not enough, enough, or too much money on healthcare. I believe its obvious to all now that teh answer is that we are spending TOO MUCH on healthcare, for a variety of reasons. What we need is a total revamping of the health care system, and INCLUDED IN THAT IS pharmaceutical reform. Nobody is arguing that pharma reform BY ITSELF will cure american healthcare, but certainly its part of the problem.
    Americans pay up to 10X more for drugs than our counterparts in other nations, yet we have WORSE HEALTHCARE OUTCOMES than those other countries. Yet the right winger free enterprise nuts want to rail on and on about how our massive spending on healthcare leads to a better system, which is just false by any measure.

  16. Jack,
    Restating your argument does nothing. Still nothing on search activity or opportunity costs.
    http://www.ftc.gov/ogc/healthcare/calfeedtcjppm.pdf
    Evidence, and there’s more where that came from. We can quote studies at each other all day long, or we can argue at each other’s responses.
    Still no response on who pays to spread all this drug information. Still no response to the fact that banning DTC marketing would hamper drug development. And the fact that you honestly expect sick people to wade through journal data (many of those studies are paid for by guess-who, incidentally) doesn’t pass the smell test.
    t,
    I think your plan would be a good one, but as Mr. Holt points out, we’re not ready to give the patient that much latitude.

  17. “Because the good outweighs the bad. Oh, and then there’s that pesky civil-liberties thing.”
    What evidence do you have that the good outweighs the bad? The only evidence presented here was by me, showing that DTC and doctor-marketing makes healthcare WORSE, not better. If you’d like to convince me otherwise, then by all means supply your evidence.
    As for civil rights, there is no civil right that guarantees freedom of marketing. If there were, dont you think big pharma would have sued the federal government on those grounds long ago when DTC marketing was nonexistant?
    The US constantly regulates marketing and certainly has the power to ban certain sectors of it.
    We already know for a FACT that marketing INCREASES health care costs. That is absolutely indisputable. Yet I see NO EVIDENCE that patients healthcare is better off.
    We already know that marketing biases doctors prescription habits, and thats definitely NOT GOOD for healthcare.
    So again, where is this evidence you speak of that shows the “good outweighs the bad?”

  18. “Journals have subscription fees. It’s not public domain. The abstracts, maybe.”
    First off, all you need are abstracts, and those are totally free to anybody.
    Secondly, even the full articles are free. All you have to do is go to your local university library. They have paid subscriptions that anybody can access.
    In fact, its even easier than that. Most university libraries set up proxy servers where anybody can use the university’s servers as a proxy and get free access to the full articles.

  19. > Please go back and read the links I posted.
    Here is one of your own summaries:
    > 57% of DTC ads were found to have little
    > or no educational value to patients(1*)
    Which says almost half have more than a little, therefore some, educational value, even on the angelic standards of these researchers, which I am sure they disclosed completely and fully, and which you understand and concur with.
    I don’t have a lot of energy for shouting and feeling OUTRAGED!!!!! over stuff like this. There are bigger fish to fry than some fraction of 10% of healthcare spending, that is spent on actual medicine that indisputably works.
    > Now please explain to me, IN LIGHT OF THESE UNDISPUTED
    > FACTS, as to why DTC and doctor-marketing should be
    > allowed.
    Because the good outweighs the bad. Oh, and then there’s that pesky civil-liberties thing.
    There is one prescribing reform I have thought of, and I’d love to have feedback from the physicians here: instead of the “generic substitution allowed” box, how about a “substitution within drug class allowed” box, and let the decision of which molecule, packaging, price, etc. be decided between the patient, pharmacist, and PBM? What is this likely to hurt? Patient says “I want Nexium”. Doc decides patient can benefit from proton pump inhibitor, prescribes this class of therapy, tells patient “I am prescribing a proton pump inhibitor.” Patient gets to pharmacy and finds out he can have the purple pill for $60/month or something that’ll likely work just as well for $5. Let the pharmacist educate the patient, and let the patient decide. Or maybe you can already do this?
    t

  20. Sorry “I think the costs do not outweigh the benefits” is what I meant to say. The rest is right.

  21. Jack,
    In regard to your response to t’s post, you spend a lot of time on the cost-side of DTC marketing. There are costs. But do they outweigh the benefits?
    I think they do. I’ll go into the costs of not having DTC, again.
    Without DTC, I’m very sure that fewer medicines would be available and that prices would be higher, not lower. Patients would be less informed, because as you’ve stated, it would require additional effort on their part. Patients would be less empowered. There would be a smaller incentive to innovate new products. Forecasts would be more conservative. Less marketing means less R&D money because the potential market is smaller.
    How many drugs undeveloped would be enough to make DTC worth it again for you? One? Two? What indications would you be happy to see untreated?

  22. Jack,
    I will respond line by line.
    I didn’t say that it was only marketing. I’ve been saying it’s the beginning of the decision process for about three posts now.
    Docs are not dispensing pills only because of pharma marketing. There is a correlation, of course, but it’s on the docs to, I dunno, adhere to the oath they took maybe? Again, banning DTC is not the answer. Take a look at t’s excellent post about the environment of prescribing.
    “The vast majority of the time,” you need an idea of what treatment options are available to make a sound decision with your doctor.
    If patients are motivated enough, they can understand journals as well as doctors? That’s an incredible claim. I was under the impression medical knowledge was cumulative. Maybe they can…after the equivalent of 2 years of med school. But is that really what they should have to do?
    Journals have subscription fees. It’s not public domain. The abstracts, maybe. And then there’s the time spent reading them.
    Isn’t engaging in all of that search and research activity forcing the patient to give something up? Isn’t that an opportunity cost that is presently avoided, or at least lessened? Are you still in favor of banning DTC? And who do you think pays for a significant portion of the ad space required to run WebMD and similar sites? Take a closer look at the sidebar next time.

  23. “I do not have so much faith in the ability of clinical practitioners to wade through, interpret, and apply scientific information.”
    Separate issue. The bottom line is that the scientific info is the MOST RELIABLE DATA we have. Your conclusion that we should allow ADMITTEDLY AND DEMONSTRABLY BIASED MARKETING as a substitute for scientific information is just outrageous. If you think docs cant understand scientific info, then lobby for changes in that respect; dont throw in another source which by ALL MEASURES is nowheere NEAR as reliable as scientific data.
    “At the very least, marketing to doctors seems useful. Maybe even necessary if it is a goal to drive adoption of useful therapies.”
    NO, its not useful, study after study has PROVEN this. Health outcomes DECLINE when doctors are biased by marketing. Patients get more expensive drugs, are subject to more side effects, and
    Studies have also shown that the “usefulness” of the drugs shown in DTC ads is grossly overhyped. 99% of the DTC ads are about “me too” drugs which show NO BENEFIT above existing treatments. However, they happen to be MUCH more expensive.
    “Whether valid or no is a value judgement of your own. Whether useful or no is testable.”
    You are sticking your head in the sand. STudies have ALREADY SHOWN DTC NOT TO BE USEFUL. Please go back and read the links I posted.
    “Jack Daniels spends a great deal of time rebutting things that are not in dispute.”
    If by “not in dispute” you refer to
    1) DTC ads drive up overall healthcare costs
    2) Marketing biases doctors
    3) Marketing results in REDUCED HEALTHCARE OUTCOMES WITH INCREASED COST
    4) Doctor/patient visit efficiency is reduced because of wasted time debating DTC ads.
    then I’m glad we agree that these are not in dispute. Now please explain to me, IN LIGHT OF THESE UNDISPUTED FACTS, as to why DTC and doctor-marketing should be allowed.

  24. Matt,
    why do you assume that the ONLY way patients can find out about drugs is thru biased DTC marketing?
    Thats absolutely NOT the case. Multiple books have been written, in a layperson, down to earth format, sort of like a “mini-PDR” if you will.
    There are many many internet sites where you can find lists of drugs for each medical condition.
    You say doctors cant be trusted becaues they are biased, the reason they are biased is BECAUSE OF PHARMA MARKETING! Talk about speaking with double tongue. PHarma marketing in all its forms should be banned, whether it be to docs or DTC. You do that, and the docs will no longer be biased about drugs.
    There is no standard resource where patients can type in their symptoms and find a list of treatments, because those systems are unreliable. The vast majority of the time, you need a doctor for a diagnosis.
    Patients have access to the same info that doctors do, thru peer reviewed scientific journals. So if patients are self motivated enough, they can do their own literature search for best treatments. You make it sound as if doctors hold on to some kind of “secret” stockpile of info. Thats just not true. The doctors sources of information are ALL IN TEH PUBLIC DOMAIN, which means the public has ready access to the same info.
    If hte scientific literature is too complex for patients, then they have other resources such as WebMD, other interent sites, or a MULTITUDE of books which give “dumbed down” information about each drug, sort of like a “mini PDR” as I said earlier.

  25. Dr. Tuteur:
    > Marketing is not a valid, useful or necessary
    > way to educate consumers about health options.
    Whether valid or no is a value judgement of your own. Whether useful or no is testable. Whether necessary or no is a matter of prioritizing — I can’t see the concept “necessity” in this context as categorical.
    > No one ever marketed penicillin and it became
    > extraordinarily popular.
    Penicillin was discovered in 1928. It was not produced in clinically-useful quantities until 1941, and only then because the government was losing too many soldiers to infection. Haven’t you made the claim that doctors read scientific literature, evaluate it, and use it to treat their patients? So why was penicillin not adopted? How many lives were lost because penicillin was not marketed until after 1941?
    After 1941, your assertion is factually incorrect. Pharmas went on a binge of antibiotic discovery and heavily marketed their successes. The first patented antibiotic I think was streptomycin in 1948, quickly followed by chlortetracycline, chloramphenicol, erythromycin, tetracycline… who knows what else? They were all marketed to consumers and doctors alike.
    I do not have so much faith in the ability of clinical practitioners to wade through, interpret, and apply scientific information. At the very least, marketing to doctors seems useful. Maybe even necessary if it is a goal to drive adoption of useful therapies.
    Jack Daniels spends a great deal of time rebutting things that are not in dispute.
    t

  26. Mr. Holt,
    Sadly, I don’t have a TV. But maybe I’ll download it from iTunes for $2.
    Well said. I agree on this issue. What happened in NH today made me irritated.

  27. I hope you all saw the Daily Show last night. I’m waiting for the video but it was SO on point.
    And Amy, all I’m saying is that bribery takes two parties.
    My point is
    a) we have to disseminate genuine improvements in medical science somehow, and sadly the Rx detail teams are basically all we’ve got. I’d love to see extensive reform there too, but even the single payer systems have detail reps everywhere, and I see this as a reform that only physicians can impose on themselves.
    b) given the staus quo, it’s better that the marketing from the Rx companies is more targeted and less wasteful than it would be if they had no data and no idea what doctor was prescribing what drug, and were just throwing mud at a all to see if it stuck up there. I think (given the huge margins on drus) that they’d throw MORE mud, not less in that situation.

  28. So, once again, the doctor has to be the one that knows about the drug, even though, as you said, this is not about doctor control. So the onus is on the patient to find out about what drugs are available without any marketing informing them of what drugs are available?
    So let’s say a patient is sick with a runny nose in this world. They type in their symptoms (they have no way of knowing drug brands) into Google and get maybe 1,000 hits of various molecules. Is that how they are supposed to research their options? Seems not very efficient. I guess they’d have to rely on word of mouth or some other means. Or are they once again in the all-controlling hands of the (again, you admitted it) not-so-trust-worthy physician?
    You did not address the issue of marketing lowering social stigma of certain diseases. Depression, herpes, and a slew of other diseases come to mind. Care to respond?

  29. Matt:
    “The part about the marketing of drugs sometimes helping patients. My Aspirin example, smoking patches, etc. Agree or not?”
    I think you are confounding two different issues. Yes, the drugs are beneficial. No, they would have become popular with or without marketing for two reasons. One, they work! Two, doctors know that they work and they recommend them. No one ever marketed penicillin and it became extraordinarily popular.
    Marketing is not a valid, useful or necessary way to educate consumers about health options.

  30. Amy,
    The part about the marketing of drugs sometimes helping patients. My Aspirin example, smoking patches, etc. Agree or not?

  31. Mr. Holt,
    I’m not sure which company will be first to cut properly, actually. But I’m sure there will be an adjustment eventually. At most of these companies, budget dollars rain down from above, and everyone wants as much as they can get, especially DTC marketers, and (not unlike other inefficient systems) everyone spends every cent they have to get more budget next year. An old story, but a true one.
    I for one think that eventually the good money will chase out the bad. It will take time, though; we’re fighting a sort of twisted corporate version of a ratchet effect. And, in reality, there are a lot of places businesses will turn to cut costs before going after the sales reps. There was a lot of buzz about this last year, and yet here we are.
    In addition, Big Pharma are becoming more “marketing machines” because they are buying the rights to drugs developed at smaller feeder companies. This sort of consolidation has been happening for years. So the actual number of reps can be misleading; I’d prefer to examine reps per drug for sale. Even so, I’m sure there are too many.
    It will be the affect of transparency that fuels major changes in the way people buy drugs. Consumers can’t have too much information on prices. If it were up to me, I’d come up with a raio that measured how often doctors preferentially prescribed the drugs they were detailed and sell it to a large insurer. I’m sure they’d be more than happy to mine that data…

  32. My little contribution to a great discussion.
    http://www.citizen.org/publications/release.cfm?ID=7065
    “The drug industry’s top priority increasingly is advertising and marketing, more than R&D. Increases in drug industry advertising budgets have averaged almost 40 percent a year since the government relaxed rules on direct-to-consumer advertising in 1997. Moreover, the Fortune 500 drug companies dedicated 30 percent of their revenues to marketing and administration in the year 2000, and just 12 percent to R&D. (See Section X)”

  33. Matt:
    “I could have sworn you were taking more of the decision making from the patient and giving it to the doctor, even though there’s no evidence this has helped. (http://www.nytimes.com/2006/02/22/business/22leonhardt.html?ex=1146888000&en=d1ed781a415cd827&ei=5070)”
    The reference you quoted is a newspaper story and it’s not even about the topic in question.
    “As for you doctor-income bit, you do know that oncologists can make more than 1/2 their income administering drugs, right?”
    This is a loop hole that is about to be closed. It is an exception to the general rule. Again, I am puzzled though. It does not surprise you that doctors would mark about the price of a medication to increase profit, yet you are reluctant to acknowledge that drug companies do the same thing all day, every day. They call it gouging. There are quite a few legal prosecutions of drug companies who attempted to partner with doctors to gouge patients. The drug companies would provide the doctor with reduced costs drugs so the doctor could make an even greater profit. That’s another loss leader; artificially increasing the doctor’s profit induced the doctor to prescribe the particular drug even more, so the drug company made up the discount on volume.
    Jack Daniels has already provided a tremendous amount of referenced material to demonstrate that dtc advertising benefits only the drug company and not the consumer; I don’t think that any more evidence is required on that point.
    Matt Holt:
    “But that they don’t proves that their sales forces can change physician behavior. So I’m not sure that if it’s as bad a picture as Amy et al suggest, that America’s MDs should be looking a little closer in the mirror.”
    I thinks it’s pretty obvious that Big Pharma believes it can change physician behavior. Otherwise, why would they send out drug reps? Surely it is not out of an altruistic desire to spread knowledge throughout the land.
    You can’t have it both ways. You can’t assert, on the one hand, that physicians and consumers can only be motivated by economic incentives, and then, on the other hand, seriously suggest that drug companies spend massive amounts of money on marketing (more than they spend on R&D) to “inform” consumers. They spend massive amounts of money because it is successful in deforming prescribing patterns to render profitable drugs that would not otherwise be prescribed.
    The little dig at the end of your comment (“America’s MDs should be looking a little closer in the mirror”) is a case in point. You simply cannot credibly claim that America’s doctors are falling for drug company bribes, while also claiming that the drug companies are not bribing doctors.

  34. Thanks Amy, Matt, Tom, and Jack Daniels for all of the informative comments.
    It seems to me that, from the consumer perspective, DTC marketing can inform and spread the word about treatment options that are available for various conditions. However, there are questions about both the objectivity of the information and the impact of marketing costs on both per pill cost to the consumer and aggregate cost to the system.
    From a patient perspective, I think it would be helpful if there were a trusted, objective source to go to for information in plain English about specific drugs — their efficacy, side effects, how they stack up against similar drugs to treat the same condition, whether there are generics available, and pricing information for all of the options.
    Whether that source is an organization like Consumer Reports, Mayo Clinic, WebMD, or a medical and drug version of Yahoo Finance, I don’t really care. I don’t know what it would cost to assemble a team of people with the expertise to make these judgments and translate them to everyday language, but I suspect it would be a relative pittance compared to the cost of drug industry DTC advertising.
    Perhaps the industry could be convinced to fund such a group or the NIH could provide a grant. I am a firm believer in the power of information, but it has to be credible, objective and understandable.

  35. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16291421&query_hl=1&itool=pubmed_docsum
    CONCLUSIONS: In these privately insured patients using PPIs, product switching was associated with increased treatment costs. DTC advertising and patient cost-sharing were important predictors of product switching.
    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12867225&query_hl=1&itool=pubmed_DocSum
    CONCLUSIONS: The present findings reinforce the perception that the pharmaceutical industry invests heavily in promoting its products and demonstrates that promotional expenditures are concentrated on a small number of medications.
    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11284378&query_hl=1&itool=pubmed_DocSum
    Evidence is growing that DTC promotion of prescription drugs is: (i) alerting consumers to the existence of new drugs and the conditions they treat; (ii) increasing consumer demand for many drugs; (iii) contributing increasingly to the recent sharp increase in the number of prescriptions being dispensed; (iv) raising sales revenues; and, thus, (v) contributing to the higher pharmaceutical costs of health insurers, government and consumers

  36. But that they don’t proves that their sales forces can change physician behavior. So I’m not sure that if it’s as bad a picture as Amy et al suggest, that America’s MDs should be looking a little closer in the mirror”
    You’re joking right? Of course doctors behavior is influenced by drug reps and marketing. Everybody knows that.
    IN fact, multiple studies have shown that patient care DECLINES precisely because marketing pressure on doctors.
    Doctors are humans, not robots. All humans are influenced by marketing, including health policy analysts. Nobody is immune to that.
    the fact that patient outcomes and treatment decisions are made WORSE by doctors under marketing influence is direct and damning evidence that DTC and doctor marketing should be BANNED.

  37. But that they don’t proves that their sales forces can change physician behavior. So I’m not sure that if it’s as bad a picture as Amy et al suggest, that America’s MDs should be looking a little closer in the mirror”
    You’re joking right? Of course doctors behavior is influenced by drug reps and marketing. Everybody knows that.
    IN fact, multiple studies have shown that patient care DECLINES precisely because marketing pressure on doctors.
    Doctors are humans, not robots. All humans are influenced by marketing, including health policy analysts. Nobody is immune to that.
    the fact that patient outcomes and treatment decisions are made WORSE by doctors under marketing influence is direct and damning evidence that DTC and doctor marketing should be BANNED.

  38. Direct rebuttal:
    1) USA spends more on drugs than any other nation, with no benefits in outcomes to show for it
    2) Since DTC regulations were “clarified” in 1997, drug spending has increased on average 17% PER YEAR, again no data to support improved outcomes
    3) DTC marketing promotes only “me too” or “blockbuster” drugs which have been PROVEN TO HAVE ONLY MARGINAL VALUE TO PATIENT CARE. The increased numbers of blockbuster prescriptions have increased overall health care costs.
    4) Europe has banned DTC for drugs. They use price controls, which I also advocate for the USA. There is zero evidence that price controls reduce availability of drugs. In fact, in many cases Europeans have access to drugs that Americans do NOT have access to (Euro regs are softer for bringing new drugs to market)
    5) 57% of DTC ads were found to have little or no educational value to patients(1*)
    6) Patients viewing a DTC in which both benefits and side effects were presented had difficulty understanding either type of information (2*)
    7) Increased doctor/patient visits due to DTC have resulted in 10% rise in healthcare costs since 1997, with no data showing improved outcomes.
    8) Multiple studies show that the drugs featured in DTC ads are OVERPRESCRIBED, and are NOT meeting any aggregate patient care need. Meanswhile, there are some drugs that never show up in DTC ads that are underprescribed.
    9) Efficiency studies show that efficiency ratings of doctors visits have declined since DTC ads were introduced in 1997. Other studies revealed that increased doctor/patient visit time devoted to talking about DTC ads were proven to be of NO BENEFIT in patient care.
    1* Berndt, Ernst R. “The U.S. Pharmaceutical Industry: Why Major Growth in Times of Cost Containment?” Health Affairs 20 (2001): 100–14
    2* Prevention Magazine. “National Survey of Consumer Reactions to Directto-
    Consumer Advertising” (report). Emmaus, Pa.: Prevention Magazine,
    1999.
    3* Rosenthal, Meredith B., et al. “Promotion of Prescription Drugs to Consumers.”
    New England Journal of Medicine 346 (2002): 498–505.

  39. Great discussion gang.
    So given all that, which will be the first Rx company to get rid of its sales force (the biggest chunk of the 35% of its revenues that go on sales and marketing)? After all that will triple its profits assuming that sales stay constant.
    But that they don’t proves that their sales forces can change physician behavior. So I’m not sure that if it’s as bad a picture as Amy et al suggest, that America’s MDs should be looking a little closer in the mirror

  40. I think that, all factors included, you make a compelling case for the “environment” that currently exists. Willingness to pay is an important aspect, but is informed by the overall healthcare structure.
    Stimulating demand in this environment can lead to higher prices. But, as you point out, marketing alone is not what does it. It depends on the environment in which those dollars are spent.
    However, I think (and hope) that DTC marketing will fall as a % of marketing dollars spent in Big Pharma. The DTC marketing tactic has created a “swollen” marketing environment.

  41. Matthew writes:
    > The fact that more has been spent on marketing
    > and drug prices have gone up do not imply a causal
    > relation.
    In isolation, no, the correlation does not prove causation. But there is indeed a causal relationship between higher prices, higher utilization, and DTC marketing, which is why DTC marketing continues. It just isn’t what most people apparently think it is: “bewitching” the patients.
    Prices have gone up because there is no “correct” price for anything except what people are willing to pay for it, and people value the drugs more highly because of the marketing efforts than they would without them.
    Without DTC and insurance, the pharmas must:
    1) Wait for the consumer to become sufficiently annoyed with his physical ailment to go and ask a doctor whether there is something to be done about it, and then
    2) Convince the consumer to spend $45/month instead of $9/month for a generic
    People do not value “cures” they do not know about.
    With DTC and insurance:
    1) they tell the consumer there is something for it, and it’ll really make them smile. They can smell flowers and play with kitty-cats again. You couldn’t let down your grandkids, could you? And your S.O. will be oh so supportive and (best of all) appreciative.
    2) Convince the consumer this benefit is worth a trip to the doctor and $15/month. Because of insurance, pharmas can double the price to $90 and maybe realize $60 of that after the PBMs get through with them.
    People do value “cures” they do know about, at least a little.
    It is expensive for a person to go see a doctor. First, it usually requires missing a couple hours (at least) of work, and everything that goes with that. Then there’s whatever out of pocket. Then you have to go tell another human being where it hurts. You don’t even know whether anything can be done about it. It might be worse than you ever imagined. And so on. So patients don’t go.
    DTC advertising overcomes two things:
    1) Now we know there really is something for it so our trip probably won’t be wasted, and
    2) They’re talking about it on TV with non-embarassing language, proving that I’m not all alone and if they can talk about it on TV and Leno can joke about it then I guess I can talk to my doctor about it without feeling shame.
    This considerably reduces the “cost” of seeing my doctor. But the only reason I’m seeing him is because I want this drug — the only “cure” I know of.
    Patients get no benefit whatever from doctors they do not go and see. This means they do not value these doctors. Doctors, for reasons utterly beyond my comprehension, do not market either themselves or Modern Medicine itself to their patients. This leaves a huge opening for pharmas to market drugs to their patients. And so the patients have come to value the folks they hear from (pharmas) more highly than they value the folks they don’t hear from (doctors). I think lots of patients consider drugs, devices, and (especially imaging) equipment as being Modern Medicine, and primary care docs are like gas-station attendants. Surgeons are still Gods . There is no surprise here.
    The value of a “cure” is going to be split somehow. A “cure” has two components: the doctor’s component and the pharma’s component. What DTC has done is capture the great majority of that value for the pharmas by doing the work required to get the consumer to act. We can’t claim there is anything underhanded or unfair about this. The passive won’t capture much of the value, and I don’t think they should whine about it, or try to suppress by force activity that does capture it. And that goes for everyone.
    t

  42. Marketing results in increased competition:
    http://www.duke.edu/~mkyle/Deregulating%20Direct-to-Consumer%20Marketing_JLE_October2002.pdf
    As for lowering drug costs, I can tell you that when there is information about two similar products to treat the same indication on the market, they each cost less than if there was only one…the effect is even more severe if one of the products is generic or OTC. Remember Claritin and Allegra duking it out on our TV sets? “Clearly” Claritin and that wheat-wind-surfing Allegra woman?
    Glad we agree on Plan B. We should talk about a potential AIDS vaccine next (even though it’s years away, I think that in this country, it’s not going to be made readily available for fear that it will increase promiscuity. Disgusting, no? Mark my words, it’s going to happen.)
    People killed in car crashes while driving a Ford Explorer with Firestone tires can’t vote either…but the rest of us can, thanks to advertising informing us of alternative vehicles that are similar, yet safer.
    Patients have no idea who makes each drug because at present, companies don’t identify themselves in drug ads. Remember when you saw an ad and heard the company name at the end? It doesn’t happen as much anymore. Take a look. It’s noticeable. That, my friend, is a problem that I think is worth acting on because it hurts transparency. I think if you make something, you’d sure as hell better put your name to it. I wouldn’t fly in a plane made by Hindenburg.
    As for you doctor-income bit, you do know that oncologists can make more than 1/2 their income administering drugs, right? And don’t get me started on marking up implantables or lab or path fees. Giving the doctor more power to prescribe what is not known about is asking for the patient to be gouged. Yes, by everyone, but the doctor is part of everyone.
    As for the last bit, howabout Aspirin? Bayer Aspirin? It’s the oldest, most successful pharma marketing story in history. Invented in the late 1800s, if I recall correctly, right after Bayer was finished inventing heroin to treat the cough and morphine addiction. But I digress. All aspirin is the same, and yet Bayer holds on to the lion’s share of the market to this day. The word “aspirin” is tied to the word “Bayer” in most people’s minds. Bayer spread the word about taking aspirin during a heart attack. Patients are helped. People at risk for a heart attack carry aspirin around in their pockets. Some even have to use it. And lives are saved.
    On the lesser end of the spectrum, how about the Claritin / Allegra example I cited above? Or “sensitive topic” drugs like NuvaRing or Androderm, that help reduce social stigma about a condition or need and thereby help patients (through marketing)? And let’s not even get started in the chemo and pain management indications. These are drugs that cater to a specific population in terrible pain, that wouldn’t be able to even navigate the vast sea of molecules without a few brand names to guide them. And herpes drugs, that reduce chances of transmission? And what about AZT, and other reduced-transmission drugs? Smoking cessation drugs / patches / gum? I can keep going. And we first learn about these drugs through marketing.
    Some drugs _do_ make our lives better the same way some companies make our lives better. And the marketing (yes, even DTC marketing) of these drugs helps spread the good word, which helps patients more than if it were not there. Explicitly, do you agree or not agree?

  43. Matt:
    “I did not say that consciously pharma is acting to lower costs. I said that marketing resulted in lower costs.”
    I might possibly believe that if you offered some compelling data. Is there anything that I can read that would confirm your assertion?
    “I am, as you can tell, very much in favor of OTC Plan B.”
    I am in favor of it, too, but I don’t think it’s going to do much to prevent unintended pregnancy. The same women who can’t remember to take one pill a day, are not going to rush out and get Plan B in a timely fashion, and it doesn’t work very well if you don’t take it immediately.
    Moreover, the plaintiffs lawyers are going to have a field day with it. Lawsuits for ineffectiveness, lawsuits for birth defects that lawyers will assert are caused by Plan B, it’s going to be a bonanza.
    Neither of these are reasons not to make it available, though.
    “Let’s switch to game theory for a second. If it was shown that a certain company (specific examples spring to mind) was DM in its marketing, patients would vote with their feet and avoid those drugs (as they have).”
    Dead people can’t vote (with their feet or otherwise).
    Patients have no idea who makes each drug. Sure they’ll avoid any drug that has killed other people; but by the time they know the drug is killing people their doctor knows, too and is not going to prescribe it. Afterall, how do you think people find out about dangerous medications? It’s because doctors report them. Unfortunately, no one is about to boycott specific medications because they are manufactured by a drug company that has previously committed egregious actions.
    “As for whether or not doctors would make more money if marketing was banned, you did not respond.”
    I don’t think that doctors make more or less money either way. It is the patients who suffer from marketing because they are enticed to take drugs they don’t need, money is diverted from R&D to marketing, and consumers bear the increased cost of free samples.
    “There are good drugs out there. There are even good marketing campaigns out there, that have helped patients. Do you concede this point?”
    Well, give me an example. I can’t thing of any campaigns that have helped patients.

  44. Amy,
    Well said.
    “The thing that really puzzles me here is that you are so quick to believe that physicians are only motivated by financial considerations and can only be moved by financial penalties and incentives, yet you suggest that Big Pharma is pushing expensive patent protected drugs to inform consumers and to lower the overall cost of drugs. That’s really, really tough to believe. It is so counter intuitive, that I’d have to see some really good data before I would believe it.”
    I did not say that consciously pharma is acting to lower costs. I said that marketing resulted in lower costs.
    I, on the other hand, cannot imagine how you think marketing has nothing to do with informing consumers. I don’t think we’re going to overcome that issue.
    I did not argue that we need more marketing. Just some of it. I did say I was alarmed by the level of DTC marketing. I think we agree that journals are a better bet.
    Sounds like we weren’t understanding each other on the medical information bit. I could have sworn you were taking more of the decision making from the patient and giving it to the doctor, even though there’s no evidence this has helped. (http://www.nytimes.com/2006/02/22/business/22leonhardt.html?ex=1146888000&en=d1ed781a415cd827&ei=5070)
    We agree now. I am, as you can tell, very much in favor of OTC Plan B. Except about the part where doctors don’t act in their own financial interests. I’m not going concede that just yet, especially since you admitted this was why drug reps were banned from you hospital earlier, thereby contradicting yourself.
    Consumers have nothing to do with marketing? Explain.
    I think our fundamental issue is over the phrase “deliberately misleading.” I’ll just call it DM from now on. You think DTC drug marketing should be banned because it is DM, and I think that drug marketing is not DM.
    Let’s switch to game theory for a second. If it was shown that a certain company (specific examples spring to mind) was DM in its marketing, patients would vote with their feet and avoid those drugs (as they have). As such, there is an incentive not to be DM; you can gain patients that way.
    You also seem to think that all drug companies are DM. There’s no evidence to support this blanket generalization. There is lots of evidence against it, however. _You should be careful when you call an entire industry murderers_. These are scientists, doctors, researchers, business people, ordinary folks. And you’re demonizing them. Why should I respect such an argument?
    As for whether or not doctors would make more money if marketing was banned, you did not respond.
    There are good drugs out there. There are even good marketing campaigns out there, that have helped patients. Do you concede this point?

  45. Barry:
    “First, if drug detailers and pharma marketing were banned, where would that leave the lazy doctors who were relying on the detailers and would their patients be even worse off than before? Second, Peter, on another thread, cited KFF data from 2004 that put the retail value of samples given to doctors at $15.4 billion. To the extent that many of these samples find their way to patients who are either uninsured or have less than adequate insurance, wouldn’t this be a significant loss?”
    Bad doctors would still be bad and the patients will not be worse off than before. The reps give bad advice, mainly because of ignorance. They have no idea how their drug really compares to others. They are trained simply to identify clinical situations in which they can promote the drug. A bad doctor is a problem; a bad doctor plus a self serving drug rep only makes the situation worse.
    As far as free samples are concerned. The drug companies could use the money saved to lower the cost of the drugs. It’s really a vicious circle. The drug companies give free samples of expensive drugs in order to get people started on them. If the expensive drug works, people will want more of it and the drug company will have greater profit. It’s equivalent to a “loss leader” in retail. Free samples hook the consumer on a product that he or she may never have needed.
    Matt:
    “Can you say that the rise in price was due to increased marketing? Yes. But not entirely. And I would say marketing more than offsets the higher price we would pay if it were not present.”
    I agree that correlation is not necessarily causation, but it doesn’t rule out correlation, either. Considering that marketing now accounts for a greater amount of pharma spending than R&D, it certainly suggests that we are heading in the wrong direction.
    The thing that really puzzles me here is that you are so quick to believe that physicians are only motivated by financial considerations and can only be moved by financial penalties and incentives, yet you suggest that Big Pharma is pushing expensive patent protected drugs to inform consumers and to lower the overall cost of drugs. That’s really, really tough to believe. It is so counter intuitive, that I’d have to see some really good data before I would believe it.
    “People _are_ being informed to make a certain choice by drug companies; that is the point.”
    No, no, no. Drug companies publish propaganda, not information. They want to inform consumers of the existence of a medication in order to drive demand for it. They are not interested in whether it is actually beneficial for the patient. Matt, these are the same people who advertise drugs that they know will kill people and go so far as to suppress the scientific information that would allow doctors to make good judgements. I cannot imagine why you think informing consumers has anything to do with marketing.
    “I do not believe that no one should make a decision about medication without reading medical literature. That’s simply false. There are OTC meds that are much more dangerous than prescribed meds, and people take them and seem to do fine by them. I suppose you oppose Plan B as well.”
    You are setting up a false dichotomy. The choice is not between learning about medications from your doctor OR the drug company. There are consumer publications about medications. Pharmacists are knowledgeable about medications. Heck, Consumer Reports has gotten into the health information business.
    I do not mean that the patient personally has to read the medical literature. I mean that the patient can consult with a number of sources that explain the medical literature and then make an informed decision. However, as between the doctor, who has no financial stake in prescribing a particular medication, and the drug company, who can only profit if that medication is prescribed, I’ll take the doctor every time.
    “Information will out; it cannot be contained.”
    Matt, no one is suggesting that information should be suppressed. I am saying that deliberately misleading information published by drug companies hurts patients and drives up costs. As mentioned above, there are many alternate sources of information.
    “What you are proposing is placing the entire decision about healthcare in the doctor’s hands, and that the layperson should have no part in their own health. I do not hold to that, although it should not be surprising to hear a doctor argue that they should have more power than the patient.”
    I already know that you are hostile toward doctors, but that isn’t the subject of this particular discussion and I find it surprising, and revealing, that you are interjecting it here.
    All decisions ultimately belong to the patient and patients do quite a bit of research. Every doctor I know is confronted daily by patients brandishing information they found on the web, or in the New England Journal of Medicine (some of my patients brought in articles), or read in a magazine or newspaper. There’s an entire publication called “Doctor, I’ve Read” which is devoted to updating doctors about medical news in lay publications so they will be prepared to discuss it intelligently with their patients.
    This is absolutely, positively not a control issue on the part of physicians. Marketing by Big Pharma has hurt patients by pushing drugs they do not need on them, by raising the cost of the drugs themselves, and by distorting or suppressing information about the drugs that could have life threatening consequences.

  46. I will respond to each of your comments in turn.
    Jack,
    The information available about generic drugs has been provided by the marketing for the relevant prior branded versions. That’s why so little marketing is needed: the information is already out there. I have worked on generic drug forecasts, and generic companies do not allocate much money to advertising, since the job has already been done.
    A drug ad is not the end-game of the decision-making process for a consumer. It should be the beginning. I agree that no one should be choosing drugs based on what they see on their television. But the ad _does_ serve to educate the consumer initially.
    Banning DTC marketing _will_ result in higher prices. Advertising informs us of alternatives. It does try to steer us to a particular good, but there are many people advertising at a given point in time, all of them competing with each other. If X and Y both treat the same indiction, X will cost more if Y is not around or not known about. Competition is increased by advertising, and competition drives lower prices.
    To be sure, the effect is greatly blunted in the pharma industry because of high prices due to patent protection, the fact that the consumer does not bear the entire burden of paying for their drugs, tax exemption, and a slew of other price-transparency issues. But it is there. Sometimes lowering price increases revenue (the Laffer Curve).
    In addition, branding gives companies (especially pharma companies where the cost of making a shoddy product is high) incentives to maintain high quality and safety. Advertising feeds quality control, and visa versa. We all are painfully aware that the FDA isn’t perfect.
    I myself am a strong advocate of evidence-based marketing in journals instead of DTC advertising. And the data bears this out: the cost effectiveness of marketing in a journal is higher than marketing DTC in nearly every case across nearly every indication.
    Unfortunately, drug companies do not learn this lesson very quickly, because internally the metric used to measure marketing effectivenss is SOV (Share of Voice), or some other market share metric, not an efficient, absolute metric (like, oh, I don’t know…cost effectiveness?). We’ve seen the backlash this has created in terms of layoffs at major pharma companies. It is a fairly obvious miscalculation.
    Finally, imagine a consumer that was not aware of different brands of a drug. They get prescribed a molecule, and they take it. What if something goes wrong? Who is left responsible? Would there be a clear place to turn for compensation? Even better, where, specifically, did that pill come from? Branding has fueled amazing advancements in tracking pills via the drive for marketing data, among other things.
    Amy,
    The fact that more has been spent on marketing and drug prices have gone up do not imply a causal relation. A lot of things have been driving the price of drugs up, not the least of which is the 20% of the population that consumes 80% of healthcare, the increased demand for such drugs, the awareness of the populace, better diagnostic tools, and the list goes on and on. The price of education has outpaced inflation as well, and colleges are marketing more than ever. Can you say that the rise in price was due to increased marketing? Yes. But not entirely. And I would say marketing more than offsets the higher price we would pay if it were not present.
    People _are_ being informed to make a certain choice by drug companies; that is the point. But it is not the end of their choice. It should be the beginning. In this age of information, patients and doctors should have the presence of mind to listen, weigh, and consider. Doctors especially: “First do no harm.”
    I do not believe that no one should make a decision about medication without reading medical literature. That’s simply false. There are OTC meds that are much more dangerous than prescribed meds, and people take them and seem to do fine by them. I suppose you oppose Plan B as well.
    Marketing materials _are_ an alternate form of information. Consumer exists as a flow of various forces. If it’s not in an ad, it will be by word of mouth. If it’s not by word of mouth, it will be by in print. If it’s not in print, it will be on the internet, etc. Information will out; it cannot be contained.
    Even in the USSR, where certain goods were only state-made, consumers found out which plants made the best stoves or toasters, and preferentially bought those. You can’t stop the market for information. People like to make informed choices.
    Social reforms in healthcare have lead to a terrible system. Data clearly shows that since the advent of Medicare and Medicaid, we’ve been spending more per patient and getting less and less over time. Bans, caps, quotas, and price ceilings (or floors) will only increase scarcity. Now is the time for more information in healthcare (the buzz about hospital transparency, for example). Not less.
    What you are proposing is placing the entire decision about healthcare in the doctor’s hands, and that the layperson should have no part in their own health. I do not hold to that, although it should not be surprising to hear a doctor argue that they should have more power than the patient. Historically, doctors are not to be trusted; you yourself raised this point. If marketing ended, it would place a substantial amount of power in the doctors hands to set the price seen by the patient (this already occurs in oncology), and doctors would make more money, just as hospitals make more money when they increase their chargemaster, since consumers don’t see that, either.

  47. “I have two questions regarding your most recent post. First, if drug detailers and pharma marketing were banned, where would that leave the lazy doctors who were relying on the detailers and would their patients be even worse off than before?”
    No, it would force the docs to actually read the scientific literature regarding medicines instead of accepting at face value what the evil drug reps say. This would be a good thing.
    Actually, the docs probably dont even have to read the literature. They can use their professional organizations guidelines for drugs. For example, if its an ob/gyn doc, they can use the American College of Obstetrics/Gynecology recommendations. These recs are based on surveys of scientific literature.
    “Second, Peter, on another thread, cited KFF data from 2004 that put the retail value of samples given to doctors at $15.4 billion. To the extent that many of these samples find their way to patients who are either uninsured or have less than adequate insurance, wouldn’t this be a significant loss?”
    The loss of free samples should not be used as justification of our current system. This is a separate topic, however I favor national price controls on drugs. There is no reason that American citizens should have to support 100% of the research burden for medical drugs. Other nations are getting a sweet deal at the expense of us. They pay bottom barrel cost for drugs and the pharma companies make Americans pay inflated costs to cover their ridiculous marketing campaigns.

  48. Amy, I always appreciate your comments because I learn something virtually every time. I have two questions regarding your most recent post. First, if drug detailers and pharma marketing were banned, where would that leave the lazy doctors who were relying on the detailers and would their patients be even worse off than before? Second, Peter, on another thread, cited KFF data from 2004 that put the retail value of samples given to doctors at $15.4 billion. To the extent that many of these samples find their way to patients who are either uninsured or have less than adequate insurance, wouldn’t this be a significant loss?
    I am not arguing for or against pharma marketing but just trying to understand the pros and cons. For doctors who stay up to date on new developments in their field and consider themselves perfectly capable of making their own judgment as to what drugs to prescribe regardless of what the detailers say, as long as it doesn’t take up too much of their time, it seems worthwhile to meet with the detailers just to get the free samples which, presumably, do benefit patients.

  49. Barry:
    “drug detailers must provide some useful information to docs. If they didn’t, why wouldn’t the doctors just refuse to meet with them?”
    They meet with them for two reasons, both of them bad for patients. The most common reason is for the goodies that they give, like free dinners, payments for speaking engagements and various other incentives that may be good for the doctor, but do nothing for the patient.
    The other type of doctor who meets with the drug reps is one who is out of date. He doesn’t know about the latest drugs and (rather than read about them), takes advice from the drug reps. As you might imagine, this is very dangerous for patients. The drug reps push their own drugs without regard for how they might compare with other drugs. Most drug reps are not knowledgeable about contraindications; they just pressure the doctor to use the drug, telling him that it’s the latest and the best and everyone is using it.
    The hospital where I trained banned drug reps about 20 years ago. The reasoning was that there was no benefit for patients and a significant possibility that doctors’ judgments would be skewed by the chance of monetary gain.

  50. Since the large drug chains like Walgreens and CVS actually make more gross profit dollars on a generic scrip than they do on the equivalent drug in brand name form, they have an economic incentive to switch branded scrips to a generic automatically as long as the doc hasn’t checked off the DAW box on the scrip form. They have the information systems to do this as do the PBM’s. This must happen quite frequently as approximately 50% of all scrips are generic, though brands probably account for 80% prescription drug spending.
    Regarding situations like Prilosec vs Nexium, many insurers will exclude it from their formulary or make the patient and doc jump through a few extra hoops to get it approved and paid for. I know my insurer does this with Allegra, since Claritin works OK for many people.
    I believe insurers have a right to know what they are paying for, and drug detailers must provide some useful information to docs. If they didn’t, why wouldn’t the doctors just refuse to meet with them?

  51. Matt:
    “Marketing actually reduces costs, be it for drugs or toasters, because it increases the information available to the consumer, allowing them to make informed trade-offs. Banning marketing of drugs would hurt the patient and increase healthcare costs.”
    That is like saying that lobbying reduces the cost of government.
    I simply cannot believe that assertion. Are there any data to support that contention? Over the last two decades, pharmaceutical companies have spend progressively more on marketing, and drug prices have risen faster than inflation, and much faster than they rose before the advent of marketing.
    Marketing, as it has been used to date, drives demand for higher cost, less effective alternatives. That’s the point of marketing. Take Nexium and Prilosec as just one example. When patent protection ended on Prilosec, the drug company introduced Nexium, a “me-too” drug that is not more effective for patients, but is much more profitable for the company.
    Anyone who gets their drug information from pharmaceutical companies, be it doctors or patients, is being deliberately misinformed and mislead. Doctors should know better (even though they don’t always appear to) but patients cannot possibly make an informed decision by perusing the marketing materials produced by drug companies.
    NO ONE should make a decision about medication without reading the medical literature. That’s the way to be informed. Marketing materials are not an alternate form of information; they are not medically accurate information at all.
    It is difficult to fathom the unrelenting faith that market forces can fix healthcare, even though that has failed time and again. What will it take for administrators to realize that healthcare is not a market like others, and cannot be improved solely by market forces?

  52. Matt,
    I dont follow your logic. First off, the generic drugs are NOT marketed heavily, its ONLY the brand spanking new “me too” drugs that make the TV airwaves. So patients are getting exposed to ONLY the drugs that are LEAST LIKELY TO BE IN THEIR BEST INTEREST.
    There have been several studies on this, showing that drug marketing does NOT educate the consumer as to the best drug for them. It “educates” them on the MOST EXPENSIVE drug for them, period.
    You are the first person I’ve heard argue that pharma marketing allows patients to choose better drugs. There’s just no evidence to back that up, while multiple studies show the opposite.
    I agree with Amy. Ban ALL PHARMA MARKETING, to doctors and direct to consumer. Eliminate the nefarious influence of marketing on doctors.
    Doctors should be choosing drugs based on the data that comes out of journals such as the NEJM or JAMA, not what comes out of a drug rep’s filthy mouth.

  53. Dr. Tuteur,
    There are _definitely_ economic reasons.
    Marketing actually reduces costs, be it for drugs or toasters, because it increases the information available to the consumer, allowing them to make informed trade-offs. Banning marketing of drugs would hurt the patient and increase healthcare costs.
    Imagine a patient is stuck in the office of a doctor who loves to prescribe the one drug that gets him the most free lunches. How would this patient protect themselves if they didn’t know about the alternatives available? Without information distributed via marketing, they could not. Marketing gives companies that have the best-in-class product incentives to spread the word.
    Not only that, the drug companies could be able to charge more for a given product, not less, since the ability of the consumer to find good substitutes for that product would be greatly hampered, which increases health-care costs and inefficiency in terms of resource allocation.
    Our hypothetical doctor would be able to prescribe an antihistamine-decongestant-heartburn-me-too newly patented drug, just to treat an allergy, and the patient would have no recourse whereas now, they can simply ask for an ordinary generic antihistamine.
    I think your beef is primarily with the lack of symmetrical information. If there was some way of balancing the power more towards the consumer (like, for example, empowering the _consumer_ with the information of how their doctor prescribes using the data above), then it sounds like you’d be for it. Correct?
    Either way, this data is very useful. What we really need is more transparency on the physician side. This is a problem of information.

  54. I know why drug companies want to know physician prescribing patterns. They want to lobby them, either with visits, gifts, free samples, etc. They want to push physicians to prescribe medication based on what is good for the drug companies, not based on what is good medicine. Why on earth should we allow that?
    What is the value for patients, physicians or healthcare administrators? I can’t see any value at all. It is the exact opposite of what so many have been saying about best practices and cost effective practices.
    Anyone who claims to be serious about improving healthcare and saving money could not possibly support making that information available to pharmaceutical companies.
    Matt, why shouldn’t we ban pharma marketing? There may be free speech concerns that prevent us from doing so, but there are certainly no medical or economic reasons to ban it. No one needs it but the pharmaceutical companies.

  55. Actually, they dont know as much about the drug side as they’d like to, and the end clients (the employers) are continually being bamboozled by the PBMs.
    However the data is generally coming from different places. Most data used in pharma marketing comes from chain drugstores via IMS. other sources are the “switch” (Now part of WebMD and NDC/Wahlers Klowters (sp?) and the PBMs.

  56. > if you think that the data, once widely available,
    > will not be looked at by insurance companies
    ?!?!?!?!?! The data is already looked at by the insurance companies: who do you think is paying for the non-Medicare population’s drugs? You think they don’t (or shouldn’t) know what they’re paying for?
    I don’t quite know what to think of “information privacy” in the context of “controlled substances” which are “paid-for by third parties” and whose “manufacturers face huge potential legal liabilities” for misuse and other issues. Should pharma marketing groups have access to prescribing records at the doctor level? Gee, I don’t know. There is a good argument for it. What is the argument against it?
    t

  57. Tom- if you think that the data, once widely available, will not be looked at by insurance companies, then …
    Information privacy and its implications are a big issue, not necessarily because of the initial stated goal of a policy, but rather the logical extension of to whom the information will become available once there is an established market for it.

  58. > The concern is that prescribing habits will directly
    > translate into selective credentialling of physicians
    > by insurance plans
    Then the concern is misplaced. The article (and Matthew’s comment) is about the provision to and use of prescribing pattern data by pharma marketing, not by credentialling departments at insurance companies. The payers will have this information, period.
    t

  59. The issue is not one of information gathering per se. Your (and mine) purchasing habits are bought and sold all the time.
    The concern is that prescribing habits will directly translate into selective credentialling of physicians by insurance plans– based purely upon who is the cheapest.
    The information (like credit scores) ought to be available to the physicians (just like you know what you buy), and the factors that insurers use for credentialling ought to be transparent.
    This, by the way, should also hold true for ‘pay for performance’, which has also become an industry buzzword for rewarding for the cheapest care, not the ‘best’.

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