| EDWARD HARRIS President of the medical staff Drug Cost Side Effect |
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 Harvard Pilgrim Health Plan lost $94 million
last year from operations. Oxford Health Plan had similar problems. So did Kaiser. Why?
One of the most obvious reasons, and one that has affected UCSF Stanford Health Care in a
big way, is the cost of prescription drugs. Nationally, these costs have risen 18 percent
in the past year, far more than even hospital costs, and obviously more than the flat
reimbursements physicians have received from HMOs. Why do drugs cost so much? One important and justifiable reason for the high prices is the enormous cost of developing new drugs and then pushing them through the phase I and II studies that are appropriately demanded by the Food and Drug Administration. After development dollars are spent, the drug companies' marketing and sales divisions are pressured to generate pay-back for all the money spent over many years to bring the drug to the marketable stage. Initial costs for prescriptions are set at what the market will bear, which is
determined by how effectively advertising can make doctors and patients believe that it is
essentially malpractice not to use the new drug rather than the old ones. And the gloves
are now off in the fighting ring of marketing. For years we've known that there are two cyclooxygenase enzymes, that produce prostaglandins, contributing to pain and swelling in arthritis. COX-1 is a constituitive enzyme, producing prostaglandins that coat the stomach and help with blood flow in the kidney. COX-2 is induced within inflamed tissues, such as the joints in arthritis. The non-steroidal anti-inflammatory drugs (NSAIDs) available up until now (e.g., aspirin, indomethacin, ibuprofen) inhibit both enzymes. That's one of the reasons that in some patients they can mess up platelet aggregation, cause G.I. bleeding and, in patients with congestive heart failure or certain kidney problems, cause renal insufficiency. Celebrex and its close competitor, Vioxx (rofecoxib, produced by Merck), selectively inhibit COX-2. Thus, they can be very useful. For example, changing over to a COX-2 inhibitor from the older variety in a patient scheduled for surgery a few weeks later would provide pain relief without an increased risk of bleeding at the operative site. The same goes for the arthritis patient who is susceptible to NSAID-associated endoscopic ulcers," or who is on anticoagulants or relatively high doses of glucocorticoids. But you knew all that, right? You read journals and appreciate the "bench to bedside" approach of the modern pharmaceutical industry. But do you need the notepads, pens, tote bags, gourmet dinners, fine wines and other marketing material we are often inundated with in order to understand the rationale and data for new drugs? What you need most is time - time to read your journals as opposed to filling out forms justifying prescriptions to an HMO medical director. To recoup their considerable costs, drug companies are encouraging physicians to use the COX-2 inhibitors in every patient - even in the many arthritis patients who have tolerated much less expensive drugs such as aspirin, nonacetylated salicylates, naproxen or ibuprofen that have been around for 20 years and more. Now, as if earlier marketing to physicians with exorbitant expenditures wasn't sufficient to drive up the cost of drugs and cause untold chaos and confusion about what is indicated and when, the following message arrived last week from the medical directors of both Searle and Pfizer, Inc.: [FROM SEARLE/PFIZER TO YOU:] Dear Health Care Professional: We would like you to know that A TV advertisement will
announce the availability of CELEBREX and encourage consumers to contact their health care
providers to discuss this new medication. This by-passing of the physician and his or her judgement is being balanced by the HMO, another force outside the physician's control. Case in point: My daughter-in-law has some stress-induced knee pain; the standard NSAIDs tear up her stomach. Her physician prescribed Celebrex. But her HMO refused to pay for it until her doctor filled out a two-page, detailed justification. What is more, the HMO medical director urged the physician to prescribe the older stomach-pain-generating NSAID along with omeprazole - apparently not cognizant of the fact that the average wholesale cost of Celebrex is only $2.00, whereas that of omeprazole is $3.60. What is happening? The patients will be bombarded with encouragement from Searle/Pfizer urging them to persuade their doctors to prescribe Celebrex. And they'll come armed with data and be very disappointed (and maybe go to another doctor) if they don't get the medication. On the other side of the battlefield will be the HMOs, trying desperately to keep their prescription drug costs down by spending money to send writs of justification to the physicians and hoping that the docs will be so frustrated that they'll tear up the Celebrex prescription and prescribe good old inexpensive naproxen, etc. Our capacity to prescribe cost-effective medicine for our patients has been hobbled. Yes, for some patients, morbidity from side-effect X can be minimized by prescribing the more expensive new drug Y. That strategy saves money, but the converse is true for the patient who doesn't understand the nuances of biopathology and pharmacology that make Y unnecessary for him or her but who demands and gets the more expensive drug anyway. It also doesn't save money if an HMO medical director puts blanket prohibition on prescriptions of Y, perhaps leading to expensive complications from using the old ones. We could slough this off and brush it aside, if it were not costing industry an arm and a leg to advertise. Our first step as physicians should be, through county, state and national societies, to pressure regulatory agencies to prohibit direct advertising of prescription drugs and, in turn, pressure industry to pass on the immense savings to those for whom these drugs are prescribed. |
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