March 5, 2008

USAToday Says Drug Ads Are Smarter Than Doctors

There's an article in USA Today which says, essentially, that drug ads cause patients to ask for medications which they don't need, which are then given to them by their doctors. The key is that the doctors would not have given them these or any medications had the patient not asked.

The first question that can be asked is, ok, sure-- ads make patients ask for these medications. Why are the doctors succumbing to this pressure? It's a loaded concept, and I'm confident USA TODAY hasn't thought it through: are you suggesting that the doctors are prescribing a medication which is not indicated for the problem the patient describes? Or are you saying the doctor is a moron and doesn't think to recommend it in the first place? Or, are you saying the medicine isn't really needed, but the doctor is pressured to give it anyway?

Which brings us to our semiotics lesson for today: what do we mean be "need?"


The article's secondary point is that the ads drive up medication spending. Wrong: doctors do. If medication spending goes up, its because doctors are prescribing more. Leaving aside the appropriateness of this prescribing, if you want to reduce costs, you target the doctors.

The point is that the doctors' prescribing shouldn't be so fickle and malleable that it responds to either ad pressures or, in this case, removing ad pressures. If the only reason you gave the Nexium for reflux is that the patient pressured you into it after seeing an ad, then the ad has more power over you than the existence of the condition. The problem isn't the ad.

Let me clarify: if you notice reflux and give Nexium, that's fine. But if you didn't notice the reflux at all; or see the reflux and don't give Nexium-- but then sometime later give it because the patient asks for it, you're fired. The ad was smarter than you.


It's a logically inconsistent to say "doctors prescribe drugs people don't need" and also "people can't afford their medications." Perhaps they don't need the drugs they can't afford?

What these articles are unable to state clearly is the idea that medications can be valued differently-- blood pressure med more valuable than reflux med-- but that price is no longer a reflection of this value.

Why not? Well, price controls and 3rd party payers, thank you very much Comrade. There's no incentive for Pharma to reduce prices, and no economic incentive for the doctor or the patient not to take more pills. Why not add Nexium?  No reason not to.  So Nexium becomes priced like tamoxifen-- in some cases, is more expensive than tamoxifen, even though it is less valuable.


So, bottom line, you want the doctor to use the medication "budget" intelligently.  Ok. Here's the solution: give the doctor control of the pharmacy budget: every patient gets $20/day. Go.

Prices will fall. Pharma will be incentivized to create drugs people need, as opposed to yet another Viagra. Subspecialists will confer with one another to decide what's needed and what isn't. No more Zyprexa + Lipitor. Get it?

Doctors hate this, because it's another thing they have to worry about, along with drug-drug interactions, side effects etc. Well, if they were actually worrying about these things in the first place we'd have some room to argue. I think it's tremendously awesome that doctors, the AMA, the NEJM spend journal space on the government's position on torture and gay rights. How about saving some pages for pharmacology and economics?

Bottom line: someone has to be accountable. It makes no sense to have the spender of the money be separated from the money itself. Under the guild system of medicine, doctors have to be in charge.


Adding Nexium to a tamoxifen script increases the total expenditure on meds, but it does not drive up the price of tamoxifen.  You "need" tamoxifen, so you pay for it; but you could forgo the Nexium.

The problem is that in many cases, the patient could not possibly make these value distinctions. The presence/absence of generics complicates it further (brand Actos for diabetes, or two generics for blood pressure?)

Which is why, again, it falls to doctors. But to make these value calculations, they must hold the wallet.