On one of my recent blogs, I was quite critical of television news coverage, but now feel compelled to eat some crow due to the story about drug prices on 60 Minutes the other night. This is a subject that has been dear to my heart for years, and I found myself cheering the physician who was being interviewed with an enthusiasm usually reserved for my grandson’s basketball team.

The Cost of a Hope

The focus was on a new drug for the treatment of colon cancer (Zaltrap).   According to clinical studies, this drug offered no advantages over other similar acting drugs, such as Avastin. However, the cost for an average person was $11,000 per month, even with health insurance, compared to a piddly $5,000 per month for Avastin.

The return on average Joe’s investment is that he gets to live four and a half months longer than he would without the drug.  Of course this is an average result and it is possible that there may be some few people who are actually cured.  This pinpoint ray of hope in many cases would persuade Joe to give it a try, and who could blame him.  In addition to the financial burden, if Joe chooses treatment, he will also be forced to deal with whatever side effects occur.

It does seem unconscionable to me that a man facing a probable terminal illness must choose between treatment and leaving his family in poverty. Cancer alone is stressful enough and I know whereof I speak for I am a cancer survivor (see The Big C and Me). Unfortunately this is not the only case in which outlandish prices are charged for medications. For example Gilead pharmaceuticals recently received a great deal of unwanted publicity about their new drug Sovaldi.  It has proved to be remarkably effective in the treatment of Hepatitis C with a 90% success rate in an illness previously deemed incurable.   The only problem is that it costs $ 1,000.00 dollars per day and must be taken twice daily for six weeks.

Will Government Intervene?

I was aware that not long ago our Congress in their infinite wisdom issued the pharmaceutical industry a license to steal by passing a law forbidding Medicare to negotiate drug prices. In return, we were given assurances that the industry would do their best to hold the line on prices.  I recall hearing of this agreement on my car radio and expecting there would be a furor over this boondoggle, but there was hardly a ripple of discontent.  When citizens sent their prescriptions to Canada, whose negotiations had resulted in significantly lower costs,  the FDA warned that Canada’s drugs might not be safe.  Never mind that almost all U.S. medications were manufactured off shore beyond their purview.  The fact that drugs are sold to other countries for from 20%-50% less than in the U.S. would seem to indicate that either we are being ripped off or we are subsidizing these other countries.

Physicians Dance with the Devil

Although disgusting, none of this was new to me. The big shock was to learn that physicians could be a party to this rip off.  The 60 Minutes story revealed a creative marketing gimmick, where the makers of Zaltrap sold their product directly to the attending physician, and discounted it 20%. To paraphrase Senator Everett Dickson “20 thousand here and 20 thousand there and pretty soon you are talking real money.”

In the past Medicare had taken great pains to avoid conflicts of interest among doctors.  For example, guidelines were established to limit a doctor’s ability to refer patients to facilities in which they had a financial interest, and for a physician to bill for medications dispensed in his office would be fruitless.  Medicare has used its big stick very effectively.  Physicians and their organizations also have traditionally been active in removing the temptations of situations in which their choice of treatment could be influenced by financial incentives.

Nevertheless the big drug companies continue to get their nose under the tent, and this cancer drug thing smacks of big bucks.  I am reminded of one of my favorite semi-raunchy stories about the guy who approaches a beautiful young lady and asks her if she would be willing to go to bed with him for $ 1,000,000.  After some hesitation she says yes.  The guy then asks if she would go to bed with him for $ 10.00. The woman indignantly replies “What do you think I am?” He responds “We have already established that, now we are just negotiating the price.”

Full Disclosure: My Dance with the Devil

In the interest of full disclosure, I must confess that I have taken advantage of some of the perks provided to physicians by drug companies. A few years ago I agreed to become a “consultant” to one of those companies.  One of my first duties was to attend a conference in Palm Springs to relate my experience with one of their Psychiatric drugs.    The conference consisted of a one-hour presentation about the drug and we were free to spend the rest of the long weekend being wined and dined in the luxurious resort. I returned home ashamed that I had sold my integrity for such a small price.   That incident marked the onset of my reformation; though I must admit I have not bought a pen in fifty years.

Self Regulation + The Other Side of the Coin

Pharma has cleaned up their act in recent years, I suspect in response to some unfavorable publicity. There are no longer free trips to exotic places, and gifts are forbidden unless they can be proven to be of educational value. They no longer give out writing instruments with their logo,  but feeding seems to be OK for there are still frequent invitations to  exclusive restaurants for “educational “ activities, and bringing in food for an entire office staff is now the norm.  The restaurant meetings usually feature a so called expert who will present a program with the help of the company’s slides which are of course totally unbiased.  Of course the presenter receives a generous fee for his effort, the audience gets a superb meal, and everyone is happy.  Physicians would insist they are not influenced by these gimmicks, and I respond that these marketing folks are not stupid and such strategies would not be used were they not effective.

None of this is meant to disparage the pharmaceutical industry for they are a very key component in our medical system. They have done much to alleviate suffering, and to prolong life.  During my career I have witnessed amazing advancements in the medications available to us physicians.  Their research facilities are the envy of the world.  They are also involved in a highly competitive business with significant risks.  It takes a huge amount of money to bring a new drug to market, and if not approved by the FDA, the research and clinical trials representing hundreds of millions of dollars is lost.  Nevertheless, first and foremost, they are a business. As such, pharmaceutical companies exist primarily to make a profit.  Their first responsibility is to their stockholders, and I suspect any feelings of humanitarianism must be secondary.

My quarrel is with my fellow physicians and a system that does not recognize the uniqueness of the medical profession. Ted Kennedy is alleged to have once said that: “Medicine is too important to be left in the hands of physicians.”

There was a time when I would have violently disagreed with that statement, now I am not so sure.   Many of the big names in my specialty of psychiatry profit from  relationships with drug companies. Even major universities appear to have cozy relationships with big pharma.  In recent years it has become fashionable to publish so called “head to head” studies comparing one medication to another in order to determine which is the most effective.  Surprise, surprise in over 95% of these studies authored by physicians and financed by a drug company,  the sponsoring drug company’s product won.  Some experts in study design point to built-in biases; others have noted that unfavorable results are never published.  I feel that physicians may sometimes be complicit in this type of misinformation, although I grant that sometimes they may be duped.

My Experience with Sales Reps from Pharma

During my years in practice I have enjoyed visits from drug company representatives. I have found them to be well trained and knowledgeable.  The brief periods of time spent with them was often a welcome break and I always enjoyed the repartee.  Their job of course was to promote their product, which was usually done in a very professional manner, and they often provided useful information.  One notable exception was when a rep blatantly said to me that she would arrange for me to attend any meeting in the country at her company’s expense if I would write ten new prescriptions for her company’s product by the end of the week.  Of course my wife’s travel and expenses would be included.  I should have told her my soul was no longer available because Ii had already sold it for a trip to Palm Springs.

During the last few years of my career I decided to do some research by exploring the attitudes of some of these reps with whom I had developed a close enough relationship that they were able to share with me some of their most disagreeable experiences. When pushed most would confess that they resented the role of food delivery  person to various offices.  Most disgusting to them was that there were offices where the physicians would only see them if they would bring in lunch for them and their staff.   My favorite rep told me of an episode in which she was taking a group of doctors to dinner.  Since one of them fancied himself a wine connoisseur, she asked him to order the wine.  He ordered a four hundred dollar bottle.  You can imagine her opinion of that presumptuous jerk.  Another told me that she had delivered lunch to the office of one of her more demanding clients when she was asked to also deliver food to the doctor’s house for her child and the Nannie.  One of the best of all times however was the story of a major academic figure who I had previously held in great respect until I heard the story of how he had asked the rep to get him more dinner talks at seven hundred bucks a clip because he had kids in college and needed the money.  Previously I had violated my rule to abstain from these dinner charades, but attended one at which he was speaking due to the respect I held for him then.  I was actually embarrassed  as he made no attempt to be objective and was a blatant shill for the drug company.

Is the Cost of Ethics and Integrity Too Great?

The sad part about these stories is that it apparently works. The rep who offered me the payola for writing prescriptions of her product subsequently was promoted to a very responsible position in her home office.  Even sadder is that physicians are so easy, and do not see the value of maintaining a respectful but arm’s length distance from big Pharma.  I know the good old days were not always that good; however I am convinced these things would not have occurred back when I was a young buck.  In those days I thought some of those ethical standards espoused were ridiculously strict.  Now, they don’t seem so crazy after all.

My major concern is that we now have a system in place which permits and even encourages what I consider to be transgressions.   In spite of all my complaints, I do believe in the capitalist system.   The promise of fortune and the fame which accompanies it are powerful motivators which have resulted in much that is good in our society.   Profit is necessary for people and companies to succeed; however I believe that there are instances where the admonition to set prices based on “what the traffic will bear” is not always appropriate.  Medication is one of those instances: for when it is a matter of life or death, the traffic will bear almost anything which makes for fertile ground for those willing to take advantage,

The Economics of Drug Research

Another problem is that in order to profit or even break even, one must have a large demand for a medication. Blockbuster medications, as Wall street calls them, are those which are used by large  segments of the population.  Zocor (a cholesterol lowering drug ) is a good example as millions of people are taking this or similar statins.  The problem with this is that there can never be enough sales to recover those huge costs of development.  Consequently; those afflicted with uncommon illnesses are neglected.

What Does It All Mean for the Future + Ebola?

So, knowing all this, where do you suppose this puts the quest for medications to treat the uncommon and rare diseases?   You’ve got it: at the very bottom. Since companies are averse to losing money, research will be limited to academic laboratories that lack the structure or finances to market medications.  They are largely dependent upon advocacy groups or NIH for financing.  Our forward looking Congress has virtually eliminated the second option with their draconian budget cuts.   Our current Ebola crisis is a case in point.  We have known about this virus for nearly 45 years but outbreaks were mostly limited to cases in small isolated villages in Africa, and received little attention.  Now there is a frantic search underway for a cure or at least a treatment of some kind.  Although the epidemic in the 70s was localized, it was found to be highly contagious with a mortality rate of 90 percent.   Still the epidemic was contained and as the saying goes “out of sight, out of mind”.   There have been some academic virologists who have worked with the virus, but as nearly as I can tell no big push to develop a vaccine or even to determine if that or any other treatment might be possible.  Now that there is the potential for a big market, so I am sure the drug companies will become interested.   I have my own concerns about this Ebola thing, but that is another story about which I hope to write next blog post.