Here’s the first in a series of articles I have in the queue about the oncology market. The first is from Greg Pawelski:

Under the new Medicare Prescription Bill (MMA) medical oncologists will be reimbursed for providing evaluation and management services, making referrals for diagnostic testing, radiation therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival.

The fact that medical oncologists received no reimbursement for providing oral-dose therapy to patients had been the principal barrier to the availability of oral-dose protocol. The advent of oral agents ultimately means that medical oncology will need to change its identity, prior to the chemotherapy drug concession. Because oral-dose drugs hold the promise of being more selective, harming fewer normal cells, reducing side-effects and work to improve the quality of life for people with cancer, they will rightfully gain their appropriate share of the marketplace, again.

The new Medicare Bill offers patients benefits they did not have before, mainly some coverage for oral chemotherapy drugs. Since April of 2004, $200 million was available so that some Medicare cancer patients would have transitional coverage for these drugs, until the bill goes into full effect in 2006. Although some benefit was realized, more might have been achieved if the American Society of Clinical Oncology and other groups had lobbied as much for the oral chemotherapy drug issue as they did for office-practice expense reimbursement. They fought long and hard to retain the Chemotherapy Drug Concession.

Increasingly, oral-dose anti-cancer drugs are found to treat cancer effectively and seen as a necessary part of a patient’s cancer care. A number of these breakthrough cancer drugs came on to the market that are only in oral form and previously not reimbursed under Medicare. Patients were being forced to compromise their cancer care due to Medicare not covering many of these life-saving therapies.

The new legislation started the process of providing access to a full range of the latest cancer-related prescription drugs at manageable costs to enhance the quality and standard of treatment for cancer. Medicare recipients were being relagated to treating their diseases with older, more toxic infusional chemotherapy agents at a time when new and more promising cancer drugs were reaching the market.

Compared to infusional therapy, oral-dose anti-cancer drugs can make receiving cancer treatment more convenient for patients by allowing flexibility in taking medication without disrupting work or other activities. They can often result in less time (or no time) spent in office-based oncology practices because of the absence of intravenous administration and its related side-effects.

Targeted cancer therapies will give doctors a better way to tailor cancer treatment. There are a multiple of different cancer drug regimens, all of which have approximately the same probability of working. Treatments may be individualized based on the unique set of molecular targets produced by the patient’s tumor, and these important treatment advances will require individualizing treatment based on testing the individual properties of each patient’s cancer.

What was needed, was to remove the profit incentive from the choice of cancer treatments, which were financial incentives for infusion therapy over oral therapy or non-chemotherapy, and financial incentives for choosing some drugs over others. Patients should receive what is best for them and not what is best for their oncologists.

The new system is clearly an improvement from the standpoint of cancer patients, taxpayers, and advocates of basing drug selection on individual tumor biology, rather than on a least common denominator approach which invites “conflict-of-interest medical decision-making.” I think it is time to set aside empiric one-size-fits-all treatment in favor of recognizing that many forms of cancer represent heterogenous diseases, where the tumors of different patients have different responses to chemotherapy. It requires individualized treatment based on testing the individual properties of each patient’s cancer.

A group of emails from within Merck show that the scientists were questioning the data and the marketing people were telling the sales reps to obfuscate. This is really ugly stuff. Taken on its own the views from the scientists aren’t too bad, as they state the actual truth — that good drugs have side effects. But the trial lawyers will not care about that and Merck’s stock is down another 10% today. And you can just imagine the courtroom scene where the plaintiff’s attorney reads management’s instructions to the sales reps to “dodge” questions from doctors about the safety record of Vioxx versus its competitors.

Merck’s long-term is looking bleaker and bleaker. Even though Arcoxia, its new Cox-2 may make it through the FDA — it got a go slow but positive letter last week — the combination of the settlement for Vioxx and the fractured trust with doctors and patients really spells the end of Merck’s reign as the most trusted of the “scientific” pharmaceutical companies that it enjoyed when Vagelos was the CEO. Expect some other pharma to come after Merck within a few months, but perhaps after it’s got a little cheaper.

I’ve been working behind the scenes with a very talented group led by Dave Gershon, an over-qualified MD/JD who’s spent time on Wall Street. Dave has putting together an organization called The National Institute for Pharmaco-Economics & Healthcare Policy. The goal of the Institute is to start asking and answering the really hard questions that have been hitherto mostly avoided.

• What pharmaceutical and medical technologies and processes work best in the real world?
• What costly new technologies are justified in terms of savings elsewhere in the system and improvements in health and the economy?
• How can the right therapies at the right time be made available to those who need them?

To answer these questions is to provide a guide to some of the most important questions that will be facing us as we create the health care system for the next ten to thirty years. In my view, saying that we can do everything is not realistic, but saying that we can’t do anything is equally untrue. Anyone reading THCB (or the newspaper) has seen far too many articles about unnecessary care variation, marketing-driven prescribing, and unevenly applied medical technologies.

We can do better and we can do it with integrity. And we can advise decision makers in the public and private sectors how to cooperate on doing the right thing, while maintaining innovation.

That’s the underlying concept of this new Institute, and I encourage you to go take a look at the web site, at http://www.healthcare-economics.org and give me your feedback.

There’s a pretty long article by Malcolm Gladwell in the New Yorker called High Prices in which he essentially places much of the blame for big pharma’s current state on the other actors in the system being too dumb to stop them. To quote his conclusions.

For sellers to behave responsibly, buyers must first behave intelligently. And if we want to create a system where millions of working and elderly Americans don’t have to struggle to pay for prescription drugs that’s also up to us. We could find it in our hearts to provide all Americans with adequate health insurance. It is only by the most spectacular feat of cynicism that our political system’s moral negligence has become the fault of the pharmaceutical industry.

There is a second book out this fall on the prescription-drug crisis, called "Overdosed America", by John Abramson, who teaches at Harvard Medical School. At one point, Abramson discusses a study that he found in a medical journal concluding that the statin Pravachol lowered the risk of stroke in patients with coronary heart disease by nineteen per cent. That sounds like a significant finding, but, as Abramson shows, it isn’t. In the six years of the study, 4.5 per cent of those taking a placebo had a stroke versus 3.7 per cent of those on Pravachol. In the real world, that means that for every thousand people you put on Pravachol you prevent one stroke–which, given how much the drug costs, comes to at least $1.2 million per stroke prevented. On top of that, the study’s participants had an average age of sixty-two and most of them were men. Stroke victims, however, are more likely to be female, and, on average, much older–and the patients older than seventy in the study who were taking Pravachol had more strokes than those who were on a placebo.

Here is a classic case of the kind of thing that bedevils the American health system–dubious findings that, without careful evaluation, have the potential to drive up costs. But whose fault is it? It’s hard to blame Pravachol’s manufacturer, Bristol-Myers Squibb. The studys principal objective was to look at Pravachol’s effectiveness in fighting heart attacks; the company was simply using that patient population to make a secondary observation about strokes. In any case, Bristol-Myers didn’t write up the results. A group of cardiologists from New Zealand and Australia did, and they hardly tried to hide Pravachol’s shortcomings in women and older people. All those data are presented in a large chart on the study’s third page. What’s wrong is the context in which the study’s findings are presented. The abstract at the beginning ought to have been rewritten. The conclusion needs a much clearer explanation of how the findings add to our understanding of stroke prevention. There is no accompanying commentary that points out the extreme cost-ineffectiveness of Pravachol as a stroke medication–and all those are faults of the medical journal’s editorial staff. In the end, the fight to keep drug spending under control is principally a matter of information, of proper communication among everyone who prescribes and pays for and ultimately uses drugs about what works and what doesn’t, and what makes economic sense and what doesn’t–and medical journals play a critical role in this process. As Abramson writes:

When I finished analyzing the article and understood that the title didn’t tell the whole story, that the findings were not statistically significant, and that Pravachol appeared to cause more strokes in the population at greater risk, it felt like a violation of the trust that doctors (including me) place in the research published in respected medical journals.

The journal in which the Pravachol article appeared, incidentally, was The New England Journal of Medicine. And its editor at the time the paper was accepted for publication? Dr. Marcia Angell. Physician, heal thyself.

Now Gladwell may have caught Angell out here, albeit at a remote distance, and I haven’t always been too kind to her on the pages of THCB. But there is a battle going on for the soul of big pharma with one side urging the best pharmaceutical be used at the best time, creating the real information behind that, and accepting that a generic may be more cost-effective than a brand. On the other side is the decision to beef up the sales force, fudge the details of the science at the marketing margins, and financially smother physicians and politicians. The disinterested observer would not incorrect in noticing that whenever big pharma has had the choice to go down the former road, they’ve almost always taken the latter. The Industry Veteran, it may not surprise you to know, has limited time for Caldwell’s analysis:

It’s ostensibly a review of Marcia Angell’s book but it’s actually a New Yorkerized version of the PhRMA boilerplate. His major argument rests on his assertion that volume of drug usage (due to an aging population and greater awareness) is the principal driver of increasing pharmaceutical cost, not unit pricing. The reason this Gladwell fellow is a shill is that he completely ignores the malevolent DTC advertising by the drug companies and their role as the principal provider of continuing therapeutic education for physicians. It is Big Pharma’s propaganda that drives patients and physicians toward the ever more costly, branded me-too’s and away from the vastly cheaper generics.

Gladwell then takes a flying leap into the arms of the Bush ideologues when he defends the me-too’s, claiming that their proliferation drives down prices. Perhaps that obtains in an ideal world or in some Friedmanite wet dream, but in reality the oligopolistic behavior of product competitors in a therapeutic drug category almost never restrains prices.

Next, Gladwell gets all dreamy eyed and rhapsodic over PBMs and how their role in the Bush Medicare scheme, starting in 2006, can restrain prices by pushing people to generics and less costly brands. Were it only so. In his eagerness to exculpate Big Pharma, he completely ignores the fact that they try to subvert the very algorithms and step formulary approaches he suggests through mutli-therapy bundling, volume incentives and rebates that require the exclusion of competitors.

Gladwell then finishes with a minor anecdote, claiming that the sleight-of-hand conclusions that appeared in a journal article on Pravachol were not the fault of Bristol-Myers Squibb. Instead he blames the investigators and the journal’s editor: Marcia Angell. Someone’s got to take this guy out back and beat the crap out of him.

In general I agree with The Veteran although probably not about the crap beaten out of him part. There’s almost no evidence to show that multiple "me-too" drugs in a class lower the overall costs. Lipitor is much costlier than Crestor, and bang for the buck wise, much much much costlier than Mevacor which is now generic. So which one is the most prescribed drug? I don’t have to tell you. PBMs have been co-opted by pharmas and made far too much of their money by playing favorites among brand-managers, with their rebates from manufacturers exceeding their income from medical management. Finally, while the NEJM article might have been in dispute, that’s not how doctors really get their news. I’m sure that the BMS detail babes gave a fair and balanced discussion of what was in effect quasi off-label use for Pravachol in the few minutes they got in front of a doctor, but let’s face it, that session rather than academic probing of journal articles is where doctors get their information, and what drives the prescribing decisions.

But, and I’m sorry to harken back to this, I think that there is both a middle ground here, and the inevitability that pharma must change in and of itself, whether the health care purcasing market demands it or not. Atlas, who is on the other end of the political spectrum from The Veteran comes to much the same conclusion in this article in which he bashes Angell and all those socialists, but more importantly notes that the party can’t go on forever.

Marcia Angell and her Harvard/Martha’s Vineyard/New England Journal of Medicine fellow travelers live in a worker’s paradise that is in permanent denial of the evident failures of socialism and communism. For years, they have been pushing for a national healthcare system to no avail, because, thankfully, most Americans are not fooled by their well meaning naivete into believing that there is a free lunch. We all wish we could get something for nothing but we can’t so we work. This sort of commonsense eludes the overeducated hothouse flowers who promulgate such wishful thinking on the unsuspecting electorate.

All that having been said, is there room for improvement in the pharmaceutical business? You bet. And it will come soon. The next decade will be then Gotterdamerung for the deities of big pharma. It will not kill them (hopefully) so it will make them stronger. Bye bye DTC. Bye bye salesforce. Bye bye CME. Bye bye sampling. Hello efficient, effective marketing like real businesses do–direct marketing, business to business advertising,and al the good old fashioned stuff that has been replaced by six figure deliverymen bearing so much free product that the typical group practice sample cabinet is better stocked than most Wal Mart pharmacies.

The recent Rx marketing orgy isn’t sustainable and nobody knows that better than its perpetrators. Somebody has to blow the whistle and fill the penalty box, and it will be surely be Kerry if he’s wearing the striped shirt. But even a Bush II administration will be giving big pharma a buzz cut, although they may use a scissors instead of a razor.

So it’s a fair bet that many of the bad excesses will be driven out by a combination of regulation and market forces. I agree here too, which yet again puts me in the wishy-washy political middle ground! And at that point the system (hopefully prodded by some sensible bodies acting something like the UK’s NICE) will begin to determine what drugs really work at what cost overall, and those with the desire to play the "full cost of care" argument within the pharmas will take over from those who’ve been running the "marketing orgy".

Given the controversy over Vioxx, big Pharma’s PR and The Lancet‘s fight with Crestor last year, this headline from a British government enquiry is pretty explosive stuff. Doctor says drug firms ghost write medical articles. And the articles that are being discussed are ones that are peer-reviewed and in major journals including The Lancet:

Professor David Healy, of the University of Wales, told the House of Commons health select committee on Thursday that as many as half the articles published in journals such as the British Medical Journal and The Lancet were written by members of the industry who had a vested interest in selling the drugs involved. Respected clinicians were then paid to have their names put at the top of the articles, he said, even though they had not seen the raw data on which they were based.

Whether there’s much truth in these allegations remains to be seen, but given what’s gone on in the scandal plagued relationship between doctors and pharma….well let me give you an analogy. I’m a San Francisco Giants fan, and I hope that Barry Bonds wasn’t using steroids, but when his personal trainer says he was I’m starting to believe that smoke and fire connection.

Of course, it might only be those British and Austrian academics and European drug companies who behave like that!

UPDATE: The Industry Veteran, who has more than mild opinions about the behavior of pharma companies and that of the doctors they work closely with, suprisingly enough has something to say about this story and THCB’s mealy-mouthed moderation:

Your hints of qualification and skepticism in “Doctor says drug firms ghost write medical articles” require admonition. After the last few years, how can anyone seriously entertain doubts that a substantial portion of research articles authored by key opinion leaders (KOLs in industry shorthand) are actually written by the pharmaceutical companies? We’re not talking here about cases where these superwhores conduct a study that the sponsoring company then writes up; what Professor Healy and others describe are the numerous instances where the KOLs never even get involved in the study. The sponsors and their investigators who lack any national recognition frequently conduct studies and then pay a superwhore for attaching his name as the lead author. The sponsor can conduct the study far more cheaply because they needn’t pay for the KOL’s retinue of postdocs, administrators, data coordinators and the rest. The KOL gets compensation for the use of his name and a publication that embellishes his expertise in a cutting edge area, thereby raising his speaking fees and consulting credentials. The practice has actually created an entire, parasitic industry of “medical ommunications companies” that write journal articles and create PowerPoint slides that KOLs present at conventions. I find it amusing that pharmaceutical marketers will express high indignation that they have paid a KOL hundreds of thousands of dollars for articles, speaking fees, train-the-trainer sessions and so forth, only to find that after a year or so, the slime bucket trades upon this burnished expertise to collect higher fees from another manufacturer with a competing, new product. Imagine that, refusing to do business on a bought-and-paid-for basis! Well, I guess that is the market at work, that holy of holies according to your physician contributors and the Bush ideologues.

This is brutal, but USA Today reports that equity analyst David Peterson from Bank of America Securities has a report out suggesting not that pharma spends more on marketing and gets more in profits than it spends on R&D, but that in recent years it’s spend more paying out dividends and on stock buy-backs than it’s spent on R&D. I’m not entirely sure these numbers are right. They seem to be comparing the entire health care sector’s R&D spend (at around 8%) with its use of dividends and buy-backs, whereas the sector’s R&D spend is heavily concentrated in big pharma (commonly 12-13% in R&D). But in any event it’s not great publicity for the industry, and Merck and Pfizer–the two biggest American companies–both had much more spending on dividends and buy-backs than on research:

Pfizer, the world’s largest drugmaker, spent $22.2 billion on stock buybacks and dividends, or 210% of what was spent on research. Merck returned $7.3 billion, or 143% of research spending. Merck spokeswoman Anita Larsen would not comment on the Bank of America report, but she said the company’s R&D budget grew 19% in 2003 to nearly $3.2 billion. Pfizer did not respond to a request for comment.

Some years back when I did a lot of business with a large pharma, the strategists there use to joke about the “bank in New York” that owned them, and how it restricted what they could do. My sense was that the people there wanted to do the right thing, in terms of spending money on improving their products and improving health care delivery. But it seems that they weren’t joking too much about the influence of the “banking” side of their business. And the resulting PR fallout continues to make pharma’s life harder.

UPDATE: Dave Schuler from The Glittering Eye tells me that:

I reported this six months ago It’s obvious to anyone who can read an annual report. But even more interesting is the behavior over time. Year-to-year increases in R&D spending vary with the rate of inflation NOT with profits. The conclusion that leaps to mind on this behavior is that Big Pharma sees their core business something other than developing new drugs.

Given that pharma spends two and half times on sales, marketing and GA what they do on R&D, and that the model successful company over the last decade has been Pfizer which did it by hiring the biggest and best sales force, I agree.

I thought that my HSA post from Friday might stir one of my noted contributors into action. Not so; instead The Industry Veteran thinks that in a recent post where I’ve been a little critical of Marcia Angell, I’ve misinterpreted her and, worse, been overly cosy-ing up to big Pharma. He writes to me:

The fact that you printed a reasonable exchange of views on single-payer vs. HSAs is not what leads me to second the suggestion that you sit down and apply old compresses. It’s the fact that twice earlier this week you showed signs of developing Bush-Cheney patellar reflexes. First you throw your two cents into the Vioxx scandal by admonishing people not to be too hard on Big Pharma. I suppose that, in essence, THCB is a promotional site for your professional services, but I was still astonished by such a bald-faced plug. Then you proceeded to review Marcia Angell’s radio talk by claiming that the logic of her argument must inevitably lead to a misguided nationalization of the pharmaceutical industry. I half expected that you would then start calling her a flip-flopper and push your surrogates to claim she never really edited the New England Journal of Medicine.

Now after all, it is your Blog so I won’t dispute your right to use it for cozying up. It’s just that I had always considered you a man of advanced Fabian persuasions, one who reminded me of my former LSE prof, Richard Titmuss. It was disappointing, for that reason, to see you adopting the postures normally taken by those who favor a “competitive, materialistic, acquisitive society based on hierarchies of power and privilege.” as for Dr. Angell, I know that she explicitly disavows the idea of a nationalized pharmaceutical industry. Her position parallels that of Merrill Goozner, Sid Wolfe and an ample number of other industry critics who merely seek greater transparency (disclosing actual R&D costs, publishing the results of all trials, et.al.), the strict removal of marketing concerns from continuing medical education, greater supervision and penalties concerning conflicts of interest, and an allocation of R&D resources based more on medical needs and less on the profits from exploiting fetishism. This last goal, for example, can be readily accomplished by maintaining patent and tax benefits for company efforts to develop products that genuinely advance the standards of medical care and by denying these advantages for products that create four-hour erections, smooth wrinkles by paralyzing facial nerves or act as high-tech versions of Spanish fly. In fact I don’t know any experienced industry people who would favor a nationalized system. In a government-managed system we might still be waiting for penicillin while your AWOL-playboy President would forbid potentially fruitful areas of research in an effort to appease his base constituency of self-righteous, religious morons.

I am of course expecting Fred Hassan and Hank McKinnell to drop the bribe money off any day now….

So Marcia Angell’s talk at the commonwealth Club was all that I expected. She is witty and charming and she really laid into big Pharma. Big pharma to her has no redeeming qualities. Everything they do is wrong and all they do is run biased clinical trials, and pay off the doctors (majority) and the politicians (minorly). A review of her book in the NEJM(BTW you can go to BugmeNot to break into these password protected sites, shh!!) from a Canadian Medical Association doc echoes her points, even though rational people (i.e. me) think that she was a little over the top.

I hope that there is a middle ground. Drugs save huge amounts of other health care costs and they do keep people alive who would otherwise be dead. If you read on in the review you get to this passage.

Angell’s concluding chapter, the least convincing one in an otherwise fascinating and penetrating book, contains the solutions, all of them predictable (and probably unattainable): control me-too drugs, re-empower the FDA, oversee Big Pharma’s clinical research, curb patent length and abuse, keep Big Pharma out of medical education, make company financial statements transparent (so we can tell what the costs of research really are, as distinct from marketing), and impose price controls or guidelines. Granted, the problems are so prevalent and the corporate tentacles so entwined with our way of being that it is hard to see what else to recommend.

But perhaps Angell is right. We must change the way we manage research and the development and distribution of new drugs. Not only are health and health care at risk, but so are the research enterprise and the reputations of universities and governments. The integrity of scientific research is too important to be left to the invisible hand of the marketplace.

The problem is that this logically leads to the idea that the only solution is heavy government regulation or even the total nationalization of the pharma business. Realistically, that’s not going to happen. So if you go to that extreme, all you can expect from pharma is a circling of the wagons and an attempt to keep paying off their servants in Congress and the Administration.

There needs to be a middle way, and I gave some ideas earlier this week about what that looks like. I don’t think Angell’s approach will get us there, even if 90% of what she says is true.

It’s all true and HHS Secretary Thompson has appealed to the general public not to take a Botox shot away from someone with a film role or major awards cermony coming up.

So it’s become apparent to THCB readers and anyone else following the reimportation issue that Pharma is, as the Christian Science Monitor puts it, the new corporate villain. And it isn’t playing its hand very well. The one person in big pharma who has gone off the reservation is the Pfizer exec Peter Rost. Here’s his very positive review of Marcia Angell’s book on Amazon. (BTW before they start I can dispel the rumors–Peter Rost is not The Industry Veteran!). But Pfizer’s lawyers have already visited Rost in a way that really didn’t show much subtlety.

To be fair, those attacking the pharma industry are also being a little over-aggressive. Marcia Angell was on a NPR radio show last week in which she attacked the pharma business over the creation of me-too drugs. (The drug discussion is about 5 minutes into the show here). Rost makes a cameo appearance and a flack from PhRMA also defends their touch position. The show is well worth a listen, but it’s worth trying to distinguish among the “me-toos” that Angell is attacking.

There are “me-toos” that are second to market for whatever reason, but usually because of the research process (e.g. Crestor developed later in the race after Lipitor). It may or may not be OK to have another statin on the market, but that type of competition in development is the American way. Furthermore, as the Vioxx mess shows, not all “me-toos” have identical clinical effects (or at least Pfizer is hoping like hell that that’s true!)

The thing that Angell should be going after is the set of other “me-tooisms”, such as

• creating an extended release version to extend the patents (see here for the AFL-CIOs version of the Glucophage XR story)
• delaying the introductions of generics by paying off generic companies (Lilly and Aventis were both known for paying generic companies to not market generic competitors to Prozac and Cardizem)
• And it wasn’t too long ago that the NY Times was reporting on some really naughty stuff on the marketing side from Schering in the late 1990s.

While much of this bad behavior is in the past, it doesn’t exactly help that DCI, a lobbying group for pharmaceutical companies (and by the way the publisher of the supposedly academically neutral Tech Central Station) was reported by The Hill a few days back to be “offering healthcare consultants almost $4,000 each to find senior citizens who are willing to speak out in favor of the Medicare drug discount card and write letters to Congress thanking members for saving them money on pharmaceuticals.” So I think it’s helpful to try to distinguish between the bad behavior and the market failure. My problem with Angell is that she sees no good in the industry at all, and that leads to the industry just circling the wagons and saying “screw you” to other approaches.

However, there are some vague signs that calmer heads may be able to prevail, even if they aren’t close to doing so yet. Most of this really bad behavior on the pharma industry’s part is in the past. Meanwhile, an interesting but very small survey being conducted on the Pharma-Marketing List-Serv suggests that a big section of that pharma audience realizes that reimportation is a) inevitable and b) not likely to be that harmful. Last week the NEJM had an article that more or less agreed with the CBOs analysis that reimportation won’t have that big an impact on prices. The author, Richard Frank a Harvard health economist, argues that:

The Congressional Budget Office has also suggested that direct negotiations would have a “negligible effect on federal spending.” But direct government negotiation may realize savings on brand-name drugs that have little competition — cases in which prescription-drug plans would be unable to negotiate lower prices by taking advantage of competition among similar products for positions on drug formularies. Paying VA prices for the drugs used by Medicare beneficiaries would benefit the federal budget. Of course, lower prices would also affect the revenues of pharmaceutical companies. For drugs that are unique, prescription-drug plans will have little ability to negotiate prices. Thus, higher prices would most likely be paid for the most innovative products. Yet it would not be politically acceptable simply to let the industry name its price. Thus, at a minimum, some direct price negotiation by the government is likely to occur regardless of which candidate is elected.

He goes on to suggest that as a consequence of re-importation prices will lower here and increase sharply in Europe, but that we’ll get to a place where we can have a rational discussion about how to fund the research for innovative products.

So is it too much to see if we calmer heads can start that conversation, as after the election it’ll have to happen anyway? Well tonight I’m going to see Angell talk live, so I can report back as to whether there is any middle ground. I actually have a spare ticket, so if any locals are looking for a hot date, let me know quick. (You think I jest? I actually took a date to see my colleague Paul Saffo once. It was pretty much our last date!)