Thank God for the tobacco and oil companies for without them the health care industry’s reputation would be bottom of the heap. Harris Interactive is out with its latest scores on reputations and the pharma industry continues its fall from having 79% of the public thinking they’re doing a good job for consumers to 44%. Managed care companies fell to 30% from 51% in 1997. Only the oil, tobacco and health insurers rate worse than pharma.

So the tale of managed care’s woes is well understood–once they were well known they were despised, and probably will be better off trying to get themselves known as health insurers (which is sort of what they are anyway). The pharma case is a little more curious. Americans love medical technology and the pharma industry has delivered great new technology in spades. And although the pricing of drugs is well known to be out of control, not that many people have to bear those high prices directly.

My suspicion is that this means that the Democratic rhetoric about the Medicare bill and the stonewalling on the reimportation issue are really getting through to the public. It’s been in the past 18 months that the pharma industry’s reputation has really gone into freefall.

Ernst and Young (hattip to Don at BusinessWord) seem to think that the pharma companies really need to fight their corner on reimportation and pricing. They seem to be doing so via the Administration in their negotiations with the Australians at least. (Thanks to the Industry Veteran for that link). I disagree. Imports are and will remain a small part of the market. The pharma industry can afford a drop in revenues and pricing and keep pretty decent margins(hint to CFOs: there’s a ton of fat in sales and marketing to be taken out), and this short-term thinking increases the likelihood of price controls and greater government intervention in the future.

Sidebar: The Aussies went to Iraq despite the opposition of 90% of their population because they were promised a free-trade deal to get their agricultural products into the US. They continue to be horrified that free-trade according to the US means that the Australian government has to give up its role as monopsony for drugs in that country! Meanwhile, what did Bushco offer the UK government go to war in Iraq with it? Guesses on a postcard to me please, as I have no clue and my British friends are now being fingerprinted at US immigration.

(Hat-tip to Sydney at Medpundit for this one). The FDA late last week issued a new advisory for Crestor, Astra-Zeneca’s blockbuster statin. THCB readers not suffering from medium term memory loss might remember a series of articles from various interested contributors late last year that were started mostly by the British medical journal The Lancet. That journal was highly critical of Astra-Zeneca’s stance in getting the drug through the FDA. I’m not enough of a pharmacy expert to interpret the FDA’s latest advisory, but the key section says:

FDA has received reports of rhabdomyolysis in association with Crestor, as it has with other drugs in the statin class. In ongoing fashion, we are evaluating these reports of adverse muscle effects with regard to clinical severity and apparent relationship to the drug. FDA is comparing the frequency of reporting of muscle injury with Crestor to that with other statins, given differences in prescribing rates for the different drugs. Pending the evaluation of the recent Crestor safety experience, FDA is not proposing to change the US labeling for Crestor, but does want to re-emphasize to physicians to the importance of carefully following the recommendations in the current product label. Analysis of accumulating safety data in the U.S. and worldwide will be considered in any future labeling changes for Crestor, and to make recommendations on risk management plans for Crestor.

Crestor’s removal from the market is still an extremely unlikely wildcard, and those who suggested shorting AZ’s stock last year have seen it stay in a tight $45-50 range since the Crestor launch. I’ll try to raise more information about the statin market, but given that in 2003 Lipitor and Zocor had $16 billion in sales between them, you understand that developments like this in the statin market are very serious business. But like everything else these days you can bet on it in an online idea futures market.

Meanwhile, if you were concerned that high cholesterol may not be a sufficiently nebulous condition to demand all this attention, don’t worry. Metabolic syndrome has been pushed by the pharma press for a year or so now and it makes its first appearance (at least first one that I’ve noticed) in a mainstream business publication (Forbes)today. The article is appropriately enough called Inventing a New Heart Disease.

It’s for long been a somewhat dirty little secret of the pharma world that not all drugs work for not all patients. That goes for statins too, despite the best medical advice saying that we should all be on them. Forbes has an interesting little article showing some developments in the combination of genomic diagnosis with therapy to figure out which statin works best for which genome. Some farsighted pharma professionals (notably Kim Slocum at Astra Zeneca) have been preaching for years that the combination of genomics, information systems and better targeted pharmaceuticals will not only improve health, but also improve the financial health of big pharma.

Of course the corresponding fear of many within big pharma is that as a result of this trend there will be no such thing as a blockbuster, because genomic testing will show that most drugs should be restricted to a smaller segment of their target population. So instead of 3-4 leading statins, we’ll need 20-30 — each with their own need for clinical trials, $800m development costs and expensive outreach programs.

Whether Kim’s right or the nay-sayers are right, it looks like we’re going to a world where genomic testing, drug delivery and outcomes information will be better linked. And that will be a different world for pharma and doctors, and hopefully a better one for patients.