Wovon man nicht sprechen kann, darüber muß man schweigen.

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?"

I.

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.

II.

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.

III.

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.

IV.

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.

Comments

Thanks for addressing this logical inconsistency. It has seemed odd to me that the DTC ads usually say "ask your doctor if so and so might be right for you," because it would seem that my doctor, being a doctor should already know what drugs I might need or should earn his fee by performing some sort of exam and/or ordering some test to find out. As someone pointed out, when it says tell your doctor if you have liver disease, your doctor should tell you this, not the other way around. I love the new DTC ad that has the woman walking the basset hounds in it which says tell your doctor if you've ever had an infection or expect to get an infection. Can't remember the drug it's advertising and can only hope the basset hounds in the ad didn't have infections or expect to get them because basset hounds, remarkable creature though they are, are not know for there verbal skills.

As a poor person and someone who has worked in a low income clinic (hence becoming poor) I think some very good doctors often base their treatment on which drugs they can get as free samples to provide to patients who can't afford any drug treatment. I've experienced this with allergy meds, having a doctor say, so and so would be better for you but you can't possibly afford it and I've got these free samples of such and such and after that there will probably be some other free sample I can give. Hence financially poor patients become guinea pigs, but as they say, it's better to be a live guinea pig than a medical research corpse. Not that I'm defending doctors, well not all doctors anyway.

As for psych drugs it's a little different because the ads ask the patient to "ask your doctor if you have a genetic mental defect that makes you incapable of making decisions about your health care, if you are unhappy but have nothing to be upset about; but at the same time understand that your doctor can't diagnose or recognize any illness without your subjective report of symptoms so he needs your subjective report of symptoms even though you are genetically incapable of providing a clinically significant subjective report of symptoms because you biological defect makes your accurate experience of your life impossible.

And, I'd like to ask you, oh wise one, what the hell that drug for restless leg syndrome does as it has this caution, "tell your doctor if you experienc uncontrollable urges to gamble." Does this mean having restless legs keeps people from wanting to gamble? What is the neurological relationship between restless legs and gambling? Can your legs have a valid reason for being restless or is all leg restlessness pathological? Is "restless" a clinically meaningful diagnosis? ...

Thought your readers may be interested in a mental health campaign I'm helping to start called everyminute.org that is fighting stigma in trying to organize a grassroots lobbying force to secure more research funding. We just launched our website last week at http://www.everyminute.org Please check it out if it sounds interesting to you. Thanks!
Jace

Great. I'm on board. How exactly to we hand the wallet to the doctor? And how do I convince my doctor, who is already working himself to a thin thread, that he should be in charge of yet another aspect of health care?

I generally think of "ask your doctor if Euphorinol is right for you" as code for "You're depressed. I know it, you know it. You got passed over for that promotion. Your husband's put on a few since the wedding, and for that matter so have you. Having kids and a mortgage and a president with cottage cheese for brains isn't everything you thought it would be. Go see your doctor and badger her into giving you a script for Euphorinol. Because what was once called 'life' is now a treatable medical condition(TM)."

The physicians I work with take patient choice into account when prescribing medication, as should any doc; If Mr. Jones really prefers one statin to another, whatever. Go nuts (I work with cardiologists--bazillions of drugs, but only a handful of drug classes). I can see psychiatry being a bit trickier...one, I don't know how I feel about general practitioners getting hit up for the latest SSRI or atypical antidepressant without any more specialized follow-up (maybe having GPs handle 'uncomplicated' depression is OK, but how do you know it's uncomplicated until you've had a specialist take a peek? Dr. Family Practice thinks everything's cool, bumps up a dosage because the patient is experiencing more symptoms...and ding! kindles a manic episode because there was undiagnosed bipolar I there the whole time), and I think these are "go ask your family doc" type ads. Two, it's much easier to convince people they have, say, a problem with depression than it is to make them believe they have diabetes or whatever. (Pt. looking at the Zung Scale: "Loss of interest in previously enjoyed activities? Well, I guess I don't like to shop as much as I used to..." ) Three, sometimes (especially in psychiatry) patient drug choice doesn't matter. You have a cirrhotic liver and you need mood stabilization? Kiss that Depakote goodbye. Your kidneys are shot? No lithium for you.

Love the blog, by the way. Sorry this was so long--this is kind of a pet peeve of mine.

The BJP has quite a few articles on cost effectiveness of various drugs and therapies. Different economic systems the NHS is. If you want the same info in the US, you need to read the Journal of Managed Care and the like. Random paper example (I only read the abstract):http://www.ajmc.com/Article.cfm?Menu=1&ID=7019

- It must be very tempting for doctors to prescribe "something" just to make the patient go away - even if they don't actually have the condition the drug is indicated for.

- In the UK, psychiatrists are often in private practise. So the psychiatrist gets paid by the patient for seeing them, and if the patient doesn't like the service they are getting they can - and will - go elsewhere. So if the patient thinks they need some particular drug, the psychiatrist has a very direct financial incentive to prescribe it to them. If he doesn't write a prescription, he's not going to get paid next time.

- Added to this, there is sometimes a black market in prescription drugs, so the patient will buy it anyway without a prescription. (see, for example, all the junk email for erectile dysfunction products). In the interests of patient safety, it may be adviable to prescribe them the genuine article rather than whatever they're going to buy on the black market.