How "direct to consumer" marketing inflates health care costs

http://www.npr.org/templates/story/story.php?storyId=113675737

CorrectionThe audio and a previous Web version of this story mistakenly said that between 1992 and 2008 the average number of prescriptions that Americans get increased by 58 percent. The actual increase was 71 percent.

Part 1: Doctor Decisions All Things Considered, Oct. 8

In the mid-1970s, an unconventional health researcher named Jack Wennberg discovered an unusually high rate of hysterectomies in a small town in Maine. If the rate continued, nearly 70 percent of Lewiston women would be without their wombs by age 70. That was just one of a series of studies conducted by Wennberg that led him to a very surprising conclusion about health care: A large portion of the medical care Americans get is unnecessary, and the structure of the health care system is the reason why. The system can push doctors to prescribe care that doesn't improve patient health.Read this story.

Part 2: Patient Behavior Morning Edition, Oct. 12

The behavior of patients in the U.S. health system has changed dramatically over the past couple of decades. We've been transformed from passive patients who almost blindly follow doctors' orders into active and aggressive consumers of health services. A look at how that change came about, and how it affects the behavior of doctors. Read this story.

Part 3: Marketing Sickness Morning Edition, Oct. 13

Prescription drug spending is the third most expensive cost in the U.S. health care system. The average American gets 12 prescriptions a year, and this number only seems to grow larger. There are more medicines on the market today than in 1992, with Americans now spending $175 billion more per year. A look behind these numbers and what drove the increase in prescription drug consumption in America.


October 13, 2009

David Couper went to his doctor after watching a small green creature jump up and down on the nail of an infected toe.
For Anne Nissan, a 17-year-old in Prescott, Ariz., the image that stayed with her was of a party. Women were on a roof in a city, pimple-free and laughing, utterly unbothered by the cramps that immobilized her once a month.
And then there is Samantha Saveri, a transportation planner in Baltimore. She remembers bunnies and the promise of digestive regularity.
Three different people in three different places were all driven to contact their doctors after watching an ad for a prescription medication on television. Each walked into a doctor's office with a specific request, and walked out with a prescription for exactly the medication he or she desired.

The Rise Of Prescription Drugs In America
Prescription drug spending is the third most expensive cost in our health care system. And spending seems to grow larger every year. Just last year, the average American got 12 prescriptions a year, as compared with 1992, when Americans got an average of seven prescriptions. In a decade and a half, the use of prescription medication went up 71 percent. This has added about $180 billion to our medical spending.
While there are more medicines on the market today than in 1992, researchers estimate that around 20 percent of the $180 billion increase has absolutely nothing to do with the number of medications available, or increases in the cost of that medication.
To understand this change, one place to look is Wilder, Vt. There, in a tasteful housing complex on the side of a mountain, is the home of Joe Davis.
Davis is retired now, but in his speech and manner it's easy to hear the breezy salesmanship that made him so successful. Davis was an adman: "I was trained — or I was toilet-trained as we like to say — in packaged goods," Davis says. "General Foods, Procter & Gamble — that kind of thing."
Until the 1980s, the kind of people who sold stuff like packaged goods were completely different from the kind of people who sold stuff like prescription drugs. In those days, drugs ads were for doctors, not the public. They were designed by people who worked at these small, technically minded medical advertising companies and targeted this small, technically minded audience.
"Nobody had ever thought that these drugs should be or could be advertised to the patients. It was just outside of people's brains," Davis says. "They thought that only doctors could understand the products. They're technical products. They're scientific products."
But it was more than that. There was a fear — shared by doctors and drug companies alike — that advertising drugs directly to consumers could be harmful. Both the drug companies and the doctors worried that even though consumers couldn't really evaluate whether or not a drug was appropriate, they might become convinced by an ad, and pressure their doctor to prescribe it.
Not only might doctors end up passing out inappropriate medications, but also, drug ads could disrupt the doctor-patient relationship — a relationship that, at the time, was mostly a one-way street. Davis tells this story about his own mother, a sophisticated woman whom he found fumbling with a bottle of pills one day. When he asked what she was taking:
" 'Well,' she said, 'I take a yellow pill, a green pill and a white pill.' I said, 'That's great. What are they for?' "
His mother had no idea what they were for, Davis says. All she knew was that her doctor had told her to take them.
"It was very passive from the patient standpoint," Davis says. "The patient just took whatever orders were given by the doctor."
An Advertising Revolution
It used to work like this: Doctors decided what to prescribe. Drug companies — through medical advertisers — tried to influence doctors. Patients did what they were told.
The only problem, says Davis, was that the system wasn't working out for the drug companies. For them, the system was much too slow.
Because doctors exclusively held the keys to the kingdom, drug companies spent enormous amounts of time and money trying to get their attention. To give you a sense, the average doctor got around 3,000 pieces of mail a year from the drug industry, and to break through this noise often took years.
And so Davis, who had previously only sold packaged goods, approached William Castagnoli, the then-president of a large medical advertising company. The two came up with a solution: They would advertise directly to the patient. They'd get the patient to go in and ask the doctor for the drug. "Pull the drug through the system," Davis says with a certain amount of glee.
There was only one small problem with this solution: It was almost impossible to do.
In the early 1980s, FDA regulations required that drug ads include both the name of a drug and its purpose, as well as information about all the side effects. But side-effect information often took two or three magazine pages of mouse print to catalog, and this wouldn't do for a major television campaign. As Castagnoli says, "We couldn't scroll the whole disclosure information over the television screen — OK?"
But then, in 1986, while designing an ad for a new allergy medication called Seldane, Davis hit on a way around the fine print. He checked with the Food and Drug Administration to see if it would be OK.
"We didn't give the drug's name, Seldane," he says. "All we said was: 'Your doctor now has treatment which won't make you drowsy. See your doctor.' "
This was one of the very first national direct-to-consumer television ad campaigns. The results were nothing short of astounding. Before the ads, Davis says, Seldane made about $34 million in sales a year, which at the time was considered pretty good.
"Our goal was maybe to get this drug up to $100 million in sales. But we went through $100 million," Davis says. "And we said, 'Holy smokes.' And then it went through $300 million. Then $400 million. Then $500 million. $600 [million]! It was unbelievable. We were flabbergasted. And eventually it went to $800 million."
Pharmaceutical companies took note.
Today, drug companies spend $4 billion a year on ads to consumers. In 1997, the FDA rules governing pharmaceutical advertising changed, and now companies can name both the drug and what it's for, while only naming the most significant potential side effects. Then, the number of ads really exploded. The Nielsen Co. estimates that there's an average of 80 drug ads every hour of every day on American television. And those ads clearly produce results:
"Something like a third of consumers who've seen a drug ad have talked to their doctor about it," says Julie Donohue, a professor of public health at the University of Pittsburgh who is considered a leading expert on this subject.
"About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored."
Whether the increase in the number of prescription drugs taken is good or bad for patient health is an open question. There's evidence on both sides. What's not up for debate is this: By taking their case to patients instead of doctors, drug companies increased the amount of money we spend on medicine in America.

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So yeah, totally buy that brand-name pills are a huge source of unnecessary cost. There's certainly value in making drug research profitable so people have an incentive to do it, but it's well beyond that.

The two things I thought were most interesting from this bit: First, the average American has twelve prescriptions per year? Holy hell. I can't even fathom that. I assume that's probably inflated by short-duration prescriptions (docs don't like giving you a prescription for more than a couple weeks of Vicodin at a time), but still. Twelve is the *average*?

The second was the comment about drug ads "disrupting the doctor-patient relationship". The relationship they describe, where the woman takes the pills with nfi what they're for, sounds pretty dysfunctional. For really common, obvious medical cases maybe that's fine, but if your medical situation is even slightly complicated, the only way you're going to get good care is by talking with the doctor and understanding your situation.

Ultimately it seems like you need to get the doctors properly incentivized so when someone comes in asking for a drug, the doc can explain why it is/n't appropriate, what the options are, and all that. We're obviously not going to get that in a broad systematic way from this administration, but at least encouraging people to ask their doctors questions is a step in the right direction.

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Yeah the numbers are pretty scary. As you said, 12 Rx/year on average? Damn. So for all the reasonably healthy people out there with 1-3 Rx per year, they're cancelled out by the hypochondriacs with 20 Rx/year. Probably many of the culprits are the obese, the depressed, and seniors. They take pill A for some disease, but they need pill B for pill A's side effect, and then pill C for pill B's side effect, and pill D enhances the efficacy of pill C, and so on. I guess that's why in Holland and probably other universal health care nations, doctors are actually given cash bonuses for prescribing cheaper generics when available. If a generic is 10 Euros and brand-name is 15, the doctor can pocket like half of the difference. People need to remember that pain is part of life. Your body can't feel perfect all the time. Don't they say "just tough it out" and "whatever doesn't kill you makes you stronger"?

Especially for seniors who complain about every little discomfort - it's irresponsible and maybe even harmful to them (drugs may help but cause side effects, long-term addiction, reduced efficacy over time, etc.). Some seniors have a huge pill case like a tackle box full of daily meds, and some have doctor's appointments like 3x/week! The psychiatric drugs really concern me. Sometimes you're sad, and sometimes your kid is hyper at school. That doesn't mean you have clinical depression and your kid is ADHD. Yet they get medicated all the same, every day, at huge cost. I know some people have legitimate mental conditions where drugs really improve their quality of life, but most of us would believe without data that such drugs are over-prescribed in America.

Apart from the short-term drugs, I think some of the big money-sinks are the "daily until you die" drugs like Lipitor. These "lifestyle" drugs are shortcuts for healthy living. I know some people have legitimate cholesterol issues and need statins to be healthier. But for the elderly or lazy folks who don't want to exercise and eat right, popping a statin will make up in part for your bad habits. Lipitor cleared nearly $7B in the US in 2004, which is more than the GDPs of many nations. And 66% of Lipitor's worldwide sales are to Americans, even though we're only 5% of the world's population. I know Americans are more obese on average, but come on.

The other top-selling drugs are here: http://www.forbes.com/technology/2004/03/16/cx_mh_0316bestselling.html

As you can see, they are mostly "dailies" for chronic diseases like depression, asthma, ulcers, circulatory issues. I think the penis drugs make a lot of money too, though not sure if they are covered by insurance. Viagra topped $1.6B in 2005.

http://money.cnn.com/2006/01/05/news/companies/sexdysfunction/index.htm

Obviously DTC ads play right into this problem. You have a discomfort or are not feeling right about some aspect of your body. Then the TV says a magic pill just makes it all better and you will be like the happy, pretty people in the commercials. But people haven't done the research about side effects, which patient sub-population would benefit most, cheaper alternatives, etc. And doctors may not have time to discuss in detail (15 min per patient at Kaiser, or so the rumor goes), or don't want to say no because they worry about angering customers and losing them to competitors who will prescribe anything they want. Jeez - 2/3 of patient-requested Rx's get honored? I guess 2/3 of people deserve honorary MD or PharmD degrees. As you said, marketeers get in the way of the doctor-patient relationship. People become consumers instead of patients, and we all know Americans don't consume very responsibly. As you said, the doctor is ultimately responsible because he or she signs the Rx. So if we can incent or threaten them to be more austere with Rx's, maybe it will get better. Like if we chart doc Rx habits and see that some are several standard deviations above the mean, then they get a fine or whatnot. And we can combine that data with patient outcome metrics to see which drugs deliver the most bang for the buck, and which docs are managing resources most efficiently. Some of this is already going on behind the scenes, and now our data collection, stats, and computing power align for more thorough analyses. So if we can build on that, and reward the docs who use drugs most effectively for their patients, then maybe some behavioral changes can happen. Because obviously we can't count on the patient to make the right choices, just as we can't trust children to own a gun or drive a vehicle.