Requiring TV drug ads to post list prices: a good step from HHS -- but not enough!

"What I say to the companies is if you think the cost of your drug will scare people from buying your drugs, then lower your prices."

Terrific quote from the not-always-terrific Health and Human Services Secretary, Alex Azar. The Department of HHS will require TV ads for drugs to disclose the list price for the drugs they advertise. Sure, they will be at the end in the small print along with the side effects (‘nausea, vomiting, headache, baldness, serious infections, death, etc.’), and thus far there are no plans to require it in print ads, but it is a big step forward. There is so much evil being done by the Trump Administration that it is nice, every once in a (long) while to be able to point out something that is good. The #Trumpenik himself tweeted something very similar to Azar’s quote.

This has been one effort by the Administration to try and control drug prices by a very indirect route that, tellingly, does not include actually controlling drug prices. It does not even include allowing Medicare (the nation’s biggest drug purchaser) to negotiate drug prices with pharmaceutical manufacturers (that ban was built into the GW Bush era legislation that created the Medicare drug requirement, Medicare “Part D”). Still, it is something and something that is not insignificant. You can tell this from the reaction of the drug manufacturers, represented by PhRMA (the Pharmaceutical Research and Manufacturers of America), which said “We are concerned that the administration's rule requiring list prices in direct-to-consumer television advertising could be confusing for patients and may discourage them from seeking needed medical care." It takes some chutzpah to say such a thing; what PhRMA wants is for patients to demand these drugs (some of which cost upwards of $30,000 a year. Or, for some, a month!) from their doctors, and then the doctors to put pressure on insurers to cover them.

Yes, often the price paid by the insurance company will be much less than the list price that the new regulations will require them to put on their TV ads. But there will still be those, the poorly insured and uninsured, the most needy, who will have to go without, who, even if they are not discouraged from seeking needed medical care will find out that it is not really available to them. While PhRMA is the trade group for the most profitable industry in the US, their objection to posting list prices is mirrored by health providers, especially health systems, who argue that posting their prices from their “chargemaster” is deceptive because insurance companies often (usually) pay less. Yeah, so? Why not charge less and let them pay the charge? This is how it is in most other industries, and in healthcare in most other countries.

The pharmaceutical industry has a well-deserved reputation as an evil cabal, and it is not only the “outliers”. Yes, we have the fantastic extremes of Heather Bresch’s Mylan and its Epi-Pen®, and Martin Shkreli and colchicine, but we also have the “mainstream” pharmaceutical companies who have unconscionably raised their predatory pricing on key life-saving drugs, like insulin. NBC reports a doubling of the price of insulin from 2012-2016, and stories on people who are affected abound. In 2017, the pharmaceutical companies were accused of fixing the price of insulin. They deny it, but their actions belie that denial; in March, Eli Lilly agreed to sell a “generic” version of its Humalog® for half price and ExpressScripts, a pharmacy benefit manager (PBM, read either facilitator or middleman, but however you read it, it is “moneymaker”) said it would offer to cap insulin costs at $25/month. Interesting for a drug whose discoverers refused to patent it because they wanted it freely available to the public. (And, interestingly, insulin still does not require a prescription, although the needles and syringes do…) The NY Times recently reported that “Lawmakers in Both Parties Vow to Rein In Insulin Costs”, but we shall see.

Of course, while its reputation as evil is well-deserved, the pharmaceutical industry is not alone in making rapacious profits from our health needs. The entire “industry” is not about making people healthier, or even curing the sick, but on making money. This includes, of course, insurers, but also health providers, hospitals, health systems, nursing homes, doctors, etc. Ever try to get a price on any health care you need, besides drugs? Ever try to figure out a bill? Two stories from my own life I have written about before but will re-tell here:

Some years ago I had outpatient hernia surgery. I arrived about 6:30am and was back home in my bed by noon. Later I got the bill from the hospital for its charges (not including the doctors’): $10,000. Then my insurance company told me that I would pay $400, they would pay $1,600, and the hospital would write off the other $8,000 as a contractual adjustment.

Of course, if I had been uninsured, I would have not been billed for the $2,000 the hospital actually received, but for the whole $10,000! This is why they don’t want to list their charges. This obfuscation is motivated by insurance companies looking to show what a good deal they provide their customers (look! We saved you $8,000!). Of course, this is baloney; since the hospital was willing to settle for $2,000, that is what they should have charged, everyone.

And price lists? Time for the other story.

I live an hour from the border, and, with Medicare but no dental coverage, I go to Mexico to get my teeth cleaned. It costs $35; a lot less that in the US and is done quickly and thoroughly by a dentist. It costs everyone $35. If you have dental insurance (they take it), it costs $35. But say you need more – a filling, a crown, implants. Not only is it a lot cheaper than in the US but they can tell you exactly how much it is going to cost! A friend had several implants, and this cost thousands (but a fraction of the US cost); the point is they told her exactly what the cost would be up front. This, it turns out, is actually possible!

The article I cited at the beginning, from the Associated Press (and read by me in the Arizona Star, shout-out), quotes

‘Leigh Purvis, a pharma expert with AARP's research division, [who] said disclosure will help dispel a "cloak of darkness" around prices and encourage more informed discussions between patients and their doctors. But she cautioned against expecting too much.

‘"The overall idea of reducing drug prices is something for which there is no silver bullet," said Purvis. "This is just one step, one tool in what will have to be a very big arsenal."’]

She is right. I said it was a good step, worthy of praise, but it will not alone be enough to bring down drug prices. Or the cost of any of the health care we are regularly ripped off for. While the burden will continue, as always, to fall heaviest on those who can least afford it and have the greatest need, it is impacting everyone. Let’s start with letting Medicare negotiate drug prices. Let’s regulate insurance company profits. Let’s make everyone in the health industry post their prices.

Indeed, let’s have a universal, single-payer health system. #MedicareforAll!

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Breaking News: 

Lawsuit by 44 States Accuses Pharma Giants of 'Multi-Year Conspiracy' to Hike Drug Prices by Over 1,000%

A "little information" can be dangerous to your health

“A little information can be a dangerous thing.”

I don’t know who first said that; no one seems to. But it is used all the time, and as a physician I both see the impact of that little knowledge on people’s health and the difficulty of striking a balance between providing meaningful information in a form that people can use and oversimplifying to the point of danger. I have worked very hard on honing this skill, and think I do it reasonably well, but I am absolutely certain that I have failed abysmally time and time again. Hopefully, it has not hurt too many people, but who knows?

I have written before that one of my roles, as a friend and family member, is to try to interpret for them what their doctor meant by what s/he told them. Or, more correctly, what my friends and family members think s/he told them. Indeed, a key part of this is trying to figure out what the doctor (presuming they are reasonably competent) might have said that led my friend/relative to think that what they are telling me is what s/he said.

And, just as I make the assumption that these doctors are reasonably competent, I make the assumption that those friends and relatives are reasonably intelligent, or at least not particularly less so than the bulk of the population (side note: I honestly think that, on average they are far more intelligent). This is borne out by the fact that it is not just friends and relatives. From time to time, I overhear conversations between other people about their health. One of the most common places is the locker room at the gym; this is because I am there dressing for long enough to be able to overhear a conversation, and also because, as a retired person, I go in the middle of the day when all the other retired – and, therefore, older, and more likely to have health problems – people are there. Usually the conversation is bi-directional but almost always one of the people is acting as a health consultant to the other, advising based on their personal experience of having had, or having a friend or relative who had, the same thing. Or, and here is where a lot of the danger comes from, something that seems very similar.

[This is the time to review, either via YouTube or its transcription on one of my old blogs, "Eggs Benedict" and "Choosing Wisely": often the best thing to do is nothing, the Woody Allen bit “Eggs Benedict”.]

Things that seem similar may not be the same – or even similar. To a health professional, there is a huge difference between an orthopedist (a bone surgeon) and an orthodontist (a dental specialist who straightens crooked teeth), but to a regular person they sound a lot alike. And it is not only confusion of words; lots of conditions that are very different sound very similar (you know, a lot of diseases end in “-itis”, which just means “inflammation of”). And even conditions that are very similar – or even the same – manifest differently in different people depending upon a lot of personal characteristics (just to name a few: age, sex, weight, co-existing conditions [another term that doctors use all the time that people may not understand], and duration and exact character of symptoms and findings). Lots of stuff is treated differently in its early stages than in its later stages, and often many different treatments are available. Maybe the one the doctor chose for you isn’t the best, and maybe the one you see advertised on TV or the home remedy advised by your aunt will work better. Or maybe not. Maybe, even, there was some scientific rationale behind that choice of treatment.

Which, of course, leads inevitably to a short discussion of direct-to-consumer advertising of drugs, particularly on television. I see these a lot more than I used to, not because I sit around in retirement watching daytime TV but because of the same gym; while I’m on the elliptical I am often unable to choose shows (ones with plots) because someone else has already chosen the program on the group TV, and there are a lot of ads. Many of them for treatments for pretty uncommon diseases. Which is, by the way, a guarantee that they cost a fortune. After all, why advertise on TV, a very expensive proposition, unless you stand to make a lot of money either because a lot of people have the problem your drug treats (e.g., arthritis) or the drug you are selling (clue: anything whose generic name ends in “-ib”, made from recombinant DNA) is so expensive that even a small market will make you a fortune? There is absolutely nothing at all good (and I’ll say that again!) about direct to consumer advertising of drugs on TV (“ask your doctor about whether [incredibly expensive] ‘Blorkamib’ is right for you!”). Except, of course, for the drug company that makes it and advertises it. These ads create unrealistic hope and expectation, create doubt as to whether your doctor is up-to-date on the latest treatments (you know, s/he is busy seeing patients all day so may not see the ads on daytime TV!), and sets you up to expect miracles. (By the way, there are very few of these.) If you must watch such commericials, I suggest you only focus on the fine print possible – often common and very bad – side effects in the small print at the end.

The late, great Hawai’ian singer Israel Kamakawiwo’ole makes a valiant effort on the last cut of his album “IZ” to explain the cause and treatment of the congestive heart failure (along with, and in part caused by, his tremendous obesity) that eventually killed him at the age of 38. It’s a pretty good discussion of the role of oxygen, although it doesn’t quite get it right, but it may have helped some of those who heard it. He had great influence; his recording of “Somewhere over the rainbow” mixes up the lyrics from different verses, but I suspect that for many people, hIZ lyrics are now the ones they know (so if they seem disconnected to you, don’t blame original lyricist Yip Harburg!).

But it is not just singers who have trouble with it; being educated and smart doesn’t make one medically knowledgeable. I know this from treating lawyers, accountants, engineers, English professors, and even medical school faculty in the basic sciences (although the physiologists, unsurprisingly, understand heart failure better than IZ…). It makes it hard to try to convey accurate information, as completely as possible, without losing people’s ability to grok it and without using metaphors that, while intended to help, may unintentionally send folks off to the wrong conclusions. It is important to try, though, and to ask not if people understand (usually they’ll say yes) but what they understood, so you can correct any misinterpretations.

People will probably do what their mother tells them to anyway.