Monday, November 19, 2007

The prescription drug feedback loop

Lately, I've come up against a lot of angst and wringing of hands about advertising of drugs, prescription drugs in general, overprescription, the high costs of medicines. Usually, the finger is pointed at big pharma for all the harm done.
But you know, I don't think so.

Some of the angst I’m reading is just a little skewed. So here's a heretical viewpoint or six:
Not all generics ARE created equal.
Not all new drugs have a counterpart–-yet.
Not all drugs should be prescribed at the level they are currently used.
Pretty much no ad, good or bad, was created by the company who made the drug.
Docs don't always have control over the drugs that are dispensed, but insurance companies do.
New drugs are expensive, but I don't know why some of them cost what they do.

Mike Eades, a bariatric specialist I respect, blogged recently that ‘Any medication you see advertised on television has a less expensive counterpart out there.’ Well, that's not always quite the case. There may be a similar drug out there…and there may NOT be, yet. NDAs (new drug applications) are for a drug which somehow, some way, differs in mechanism of action or effect or is tolerable to different conditions or effective in lower or less frequent doses. There has to actually be a difference for it to qualify as an NDA, and get approved. Sometimes, that difference is the thing that makes taking that med possible for a percentage of the population. And if you really need the med, that difference can be the world.

This was all part of a blog discussing some particularly bad drug company advertising, that laid the blame for the bad ads on the drug companies. My response?

Drug companies don’t make the ads–-they buy them (or rather, the ideas for them.)
Advertising companies make the ads. Drug companies just approve the ads and the campaigns, but most of the time, they are babes in the woods when it comes to judging good work. Richard Jarvik for Lipitor, or 'prostate–-a growing problem' or Cialis ads are all a creative department idea (or failing). It ain’t the science selling that stuff. It’s the people the company pays to think up a way to market it, who sell it to the suits in the front offices of the drug company’s marketing group.

Sure, there are ad and marketing types in every drug company. But they serve mainly as translators to the creatives in the outside world who speak their own language and have their own sets of three-letter-acronyms. Internal media outsources the heavy lifting of creating the campaigns to the bona fide ad agencies. I used to be one of the ad agency people who had to come up with the marketing plan packages and the slogans and then sell it to the suits from whatever company we were pitching. Bibles, durable medical equipment, insurance, industrial washing machines, charitable giving programs–-describe your product and it was my job to sell it. I had to sell it whether I thought it was stupid or not–-which is one reason I am no longer in advertising! If the resulting ad is stupid or insulting, it’s because the drug company bought it, but not because they dreamed it up. So error in judgement for buying it? yes. Bad creation? well, um, no.

One very good series of pharma ads, IMO, is the one promoting pharmaceutical research and Glaxo Smith Kline. It shows researchers, and why they chose their area of research, but none of them promote a specific drug. It reminds me why I enjoyed creating the kind of advertising that makes you think (yes–-there is such a thing!) And it makes me proud to have spent 14 years doing preclin R&D drug safety research, and to now be making that work possible for others. It rings true in the context of the scientists I work with, and it feels real. Hats off to the company that created the campaign, and to GSK for not messing with a good idea.

The first rule of being a smart creative is to never show a client a bad idea-–because even if it’s presented in the context of five or six other amazing ideas, the client will embrace the bad idea every time. EVERY time. So shame on whatever ad company thought up the idea of talking mucus to promote the decongestant Mucinex…but I can’t really blame the drug company for buying it. It’s exactly the kind of cute crap suits from stiff companies love. It was my job as a creative to make sure that kind of bad choice wasn’t even presented to them so they wouldn’t make fools of themselves by choosing it. And clearly, someone in the ad agency dropped the ball the day talking mucus sounded plausible!

I really like the story of Mucinex, an over the counter expectorant/decongestant, which used to be available as the generic prescription guaifenisen and has always been available in liquid form as plain old unglamorous Robitussin expectorant cough syrup and its generic counterparts. The plain expectorant type of Mucinex, which I take daily because I live in the rain-soaked northeast (instead of somewhere like Tuscon), contains 600mg of guaifenisen–just like the old scrip stuff. The company that marketed the prescription version (which cost me about $6 for 60 tabs, versus the 50 cents per tab Mucinex costs), somehow failed to renew the right paperwork and lost the right to sell it about five years ago. Enter Mucinex, at approximately 8 times the price of the prescription drug. After about 12 months on the market, I began to see an unbranded tablet form of the drug that is relabeled and sold on the internet and in Walmart–but it’s a lower dose per tab…and the price for two tabs is just about the price for the branded med…so no payoff in going generic there. The generic is not equal to the branded product–you have to take more of it to get the same effect. And yes, in that case, the company is clearly protecting an investment in name and marketing $$$ with direct to the consumer drug costs.

But, to take this in another direction–-I belong to an employer-sponsored health insurance plan. In those programs, patients frequently HAVE to purchase the generic version of a prescription. The insurance company makes that decision–not the doc, and not the patient. The insurance company can deny coverage of any price in excess of the generic’s cost, and they do. Been there, paid the bills to prove it. On a doctor's scrip pad is a little box at the bottom, with the phrase ‘dispense as written if box is checked’ or something similar over the top. The doc must specifically X that box in order for the patient to get the branded version when an exact equivalent generic is available. Otherwise, the dispensing pharmacy can give out the generic–-per the insurance company branch of the healthcare industry. It would be the insurance companies and health care plans and pharmacies scoring on that one--not the docs, nor the ad agencies, and most days, not the patients, either.

One of my pharmacy benefits is that I am eligible for any med my company manufactures free of charge-–if it can be dispensed by a pharmacy and self-administered. The thing is, we make cancer drugs, so there aren’t a lot of meds my company makes that you’d WANT to be sick enough to have to take. And none of my cancer infusion meds qualified as being able to be self-administered, so no freebies there. But our employee prescription benefit, regardless of the health insurance plan chosen, mandates use of a specific mail order pharmacy…and any scrip for what the plan classifies a maintenance med MUST be written for 90 days, with three 90 day renewals, and filled by mail for a preset minimum copay (which can go up if the med costs more.) If the employee chooses to use the local bricks/mortar pharmacy, all fills after the 3rd one are charged 100% to the employee at the current retail price for the drug. And the prescription benefit for drugs that can’t be filled mail order or for those first three fills while a doc is trying to figure out what med/dose works for you, is a minimum $10 copayment, or 10% of the retail cost, whichever is *greater.* If the doc does a dispense-as-written 90-day scrip and you try to fill it mail order, it will be bounced back to the doc to rewrite if a generic is available. So I can’t just go in and ask to try Ambien unless I’m willing to pay the retail cost of the drug at my local pharmacy. Trust me, THAT gets old fast.

Anti-emetic pre-meds for chemo infusions were $60 for six pills (two infusions), and the low molecular weight injectable heparin I take daily is $100/month for 30 doses (charges for needles and syringes are extra, of course.) Neither med was eligible for mail order, so I had to pay 10% of retail (since it was greater than $10.) I pay for the sharps I need for the heparin out of pocket…it’s 30 cents a setup from my local pharmacist (who thinks it’s possible I have the worst prescription benefit he’s ever seen), versus 28 cents a setup if I were to get them on a maintenance scrip from the mail order pharmacy. The group scoring on this arrangement is not the employees…it’s the mail order pharmacy and the underwriter guaranteeing the policy for the company. I don’t think the company is scoring that well, either…but they wanted to set an example as part of the pharmaceutical industry. My *mother* gets her meds cheaper than I do…and I subsidize her medicare part D plan with my taxes. When she and I are taking the same med (thankfully, that doesn’t happen often, but it did briefly with a couple meds during chemo), I was effectively paying twice…once through the nose for my meds, and once via taxes for hers.

And no, I cannot justify the prices charged at retail for new drugs…even though I do know the average time to approval (it used to be 15 years; I think certain drugs, when fast-tracked, can be brought in under 8 years) and I do know the costs associated with developing a new meds. I am one of those costs, after all (IT support, and before that, the staff that actually compounded the drugs and did the preclin testing). But that is a feedback loop that is bigger than an ad campaign that prompts a viewer to ask a doc about X medication.

I think Saturday Night Live could do a lot with that material…or any of the commercial spoof sites. But I’m not sure the drug companies are the only ones responsible for the ads. I’ve learned first hand that what insurance will approve and what they mandate about scrips plays a huge part in what a doc will write, and what a pharmacy will fill.

As always…to paraphrase Arsenio Hall, it's all something to make you go ‘hmmm’.

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