Overcharging for drugs

As you may have seen on 60 Minutes (October 2014), the drug company, Regeneron, introduced a new anti-cancer drug, called Zaltrap, which costs a patient $11,000 a month. (It performs the same as an older drug, which costs $5000 a month; both extend the median survival rate by 42 days.) A Medicare patient taking this drug would face an out-of-pocket co-pay of $2,000 a month —the typical monthly income of a person on Medicare.

Dr. Peter Bach, Sloan-Kettering’s expert on cancer drug prices commented, “We have a pricing system for drugs which is completely dictated by the people who are making the drugs.” In other words, the cost is what the traffic will bear, not the often-touted “cost of R and D.” Because oncologists buy the drugs wholesale from the pharmaceutical companies and sell them retail to their patients, the conflict of interest is obvious. The docs make more on the new drug than the old one (and the insurers are billed for the retail price).

Interestingly, Dr. Bach and two colleagues wrote an op-ed piece in the New York Times castigating the company’s price-setting practices. Right after the editorial was published, the drug's manufacturer, Sanofi, cut the price of Zaltrap by more than half--irrefutable evidence that the price was a fiction. "Oh, okay, we'll charge a different price." As doctor Bach commented, “It was like we were in a Turkish bazaar.” Even though the company cut the price, they still made the same amount of money on the drug, thanks to shenanigans having to do with insurance. (To get the whole story click here. To see the op-ed piece, click here.)

Similarly, a new pill for hepatitis C, called Sovaldi, was introduced by Gilead Sciences. Each pill costs the patient $1,000 or $84,000 to $150,000 for a course of treatment. Again, Gilead Sciences, which bought the company that created the drug, charges what it thinks the market will bear. This drug will earn Gilead $10 billion this year alone.

In Switzerland, the cost of an anti-cancer drug called Gleevac is $3,633 per dose; in the US, the cost is $6,214.

Even the costs of generic drugs are rising precipitously. For example, the price of the drug digoxin, which is used to treat rhythm disturbances of the heart, tripled from October 2013 to June 2014. Instead of paying pennies per pill, as in the past, patients are now making copayments of up to $200 a month for the drug. Why? There was no drug shortage, no new patent or new formulation. Digoxin is not hard to make. What had changed most were the financial rewards of selling an ancient, lifesaving drug.  Many more manufacturers are following suit and the prices of generic drugs are rising across the board—again, for no good reason except for corporate profits.  In the case of digoxin, Lannet, the major supplier in the US, the company’s reported sales for cardiovascular products (mainly digoxin) rose to $16.9 million from $4.5 million in just a few months.

I could go on…..in fact, here is some more damning information aired on two NPR programs, one about the high cost of MS drugs and the other about insulin. 

Next week, rewarding doctors to promote drugs.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

My beef with prescription medicines

Where to start? The wrongdoing of big pharma is so vast that many books have been written about the ways in which drug companies deceive us. One good one is The Truth About the Drug Companies: How They Deceive Us and What To Do About It. The author is Marcia Angell, M.D., who is the former editor in chief of The New England Journal of Medicine. She describes the pharmaceutical industry as having “moved very far from its original high purpose of discovering and producing useful new drugs” to becoming “a marketing machine to sell drugs of dubious benefit.” The companies now “use their wealth and power to co-opt every institution that might stand in its way, including the U.S. Congress, the Food and Drug Administration, academic medical centers and the medical profession itself.” Since the early 1980s and with few exceptions, pharmaceutical companies have consistently ranked as the most profitable in the United States (more than $200 billion a year).

Here are some of the ways big pharma deceives:

·         Over charging. The cost of the drug is unrelated to the costs of research and development, as they would have you believe. Instead, the costs, which are continually rising, are based on what the traffic will bear.

·         Manipulating research findings to make drugs look good. As much as 90 percent of published medical information—the kind of information that doctors rely on—is flawed, according to the world’s foremost expert on the credibility of medical research.

·         Rewarding doctors to promote their drugs. Companies spend more than four billion dollars nationwide in payments to doctors for attending and promoting drugs at industry-sponsored conferences.

·         Rewarding doctors to prescribe their drugs. The rewards range from meals to generous honoraria for speaking at conferences. As a rule, the doctors who prescribe the most are rewarded the most.

·         Promoting old drugs as new. Most of the new drugs approved by the FDA are “me too” drugs—old drugs whose molecules have been only slightly altered so they can appear as new. They are more expensive but no more effective than the old models.

·         Passing off their professionally-written articles as the work of academics. Drug companies pay professional writers to produce academic papers according to the companies’ specifications then get the academics to put their names to them.

·         Passing off marketing as “education.” The drug companies’ so called “education” programs come out of their marketing budgets, which, collectively in 2001 amount to $19 billion. By masquerading marketing as education, big pharma can evade legal constraints on marketing activities.

Next week: Drug companies over charge

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Tests as a revenue source

Tests are a significant source of revenue for medical establishments. As Elisabeth Rosenthal writes in The New York Times, “Testing has become to the United States’ medical system what liquor is to the hospitality industry: a profit center with large and often arbitrary markups.” As you might imagine, tests are often performed without a legitimate need for them. “It’s one of the most lucrative revenue streams they have,” according to Dr. Eric J. Topol, a cardiologist at Scripps Health in San Diego. In this case, he’s talking about echocardiograms—ultrasound pictures of the heart. He continues, “At many hospitals, the threshold for ordering an echocardiogram is the presence of a heart.” For example, one internist required that his patient have an echocardiogram before having elective cataract surgery. (The echocardiography professional society specifically advises against ordering the test for preoperative assessment of patients with no history or symptoms of heart disease.)

The cost of medical technology equipment is often the excuse for the high prices for some of the tests. But echocardiography equipment, as well as many other technologies, have become cheaper, just as high definition TVs have. Electrocardiography devices can now be purchased for as little as $5,000. Yet the charge for these tests remain high. Plus they vary from place to place. One patient was billed $1,400 at one location and $5,500 at another.

Angiograms are also performed unnecessarily. (Angiograms look for blocked arteries, using a thin tube injected with dye that can be shown on X-rays.) Every year in the United States, more than a million people get an angiogram, frequently without a sound basis for doing so—such as people who have no symptoms of heart problems but perhaps high cholesterol. The American College of Cardiology sponsored a study of such cases, which consisted of nearly two million angiograms. The researchers found no significant artery blockages in 62 percent of the angiograms.

Finally, an article in The Annals of Internal Medicine concludes that, for people showing no symptoms of cardiac problems, stress tests, electrocardiograms and myocardial perfusion imaging have not been shown to improve patient outcomes and can lead to potential harm. The tests commonly produce false positives that lead to further unnecessary testing, and all involve extra expense.

You get the idea. I’m sure you could find many more examples.

Next week: My beef with prescription medicines.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Over-diagnosing thyroid cancer

In last week’s post, I mentioned that in the US, thyroid cancer rates have more than doubled since 1994. But cancer experts agree that cases of thyroid cancer have not actually increased; they have simply been over-diagnosed. In South Korea, the reason they’re over-diagnosed is that doctors are actively looking for cancer through screening. In the US and Europe, where screening for thyroid cancer is not a common practice, small tumors may be discovered when patients are scanned for other conditions, such as when performing ultrasound exams of the carotid artery. The result of all this screening for this and that is that the doctors are in fact finding very tiny tumors—tumors that are non-aggressive and unlikely to amount to anything. (In fact, on autopsy, as many as a third of all people were found to have thyroid cancers that were never a problem.)

But here’s the thing: even though more tumors are being detected, the death rate from thyroid cancer has remained both low and steady. If early detection were saving lives, death rates should have come down. They have not.

What’s more, unnecessary screening for thyroid cancer has led to some aggressive and unnecessary surgical procedures—some of which have been disastrous (“Oops. Cut a vocal cord.” This happened in two percent of the surgeries in South Korea.)

Many in the medical profession counsel a “wait and see” approach—just leaving a newly-detected tumor alone. However, they’re finding it a tough sell. For one thing, fearful patients are reluctant to take the “do nothing” advice. What’s more, as one doctor said, “In the US, we have a fear that if we miss a cancer, the patient will sue.”

Doing nothing would definitely be my choice.

Next week: Tests as a revenue source for doctors.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

An example of testing run amok

In his book, Overdiagnosed, Dr. Welch tells the following story:

As part of her annual checkup, a sixty-five-year-old woman was screened for osteoporosis. She was told that her bone density was a little below average for her age and that she was at risk for bone fractures (she did not actually have osteoporosis.) Her doctor started her on hormone replacement therapy until it was learned that such therapy increased the risk of heart attack and stroke as well as breast cancer. So she was put on a different medication and developed a terrible pain when swallowing. As a result, she was sent to a gastroenterologist, who performed an endoscopy and found that she had severe inflammation and ulcers in her esophagus—a known side effect of the drug she had been taking. She was switched to another medicine and the problem with her esophagus went away, but she developed a painful rash and was referred to a dermatologist who suggested she stop the medication. The rash went away, but treatment continued.

Next she was referred to an endocrinologist who did a thorough evaluation of all her glands and hormones, including a careful physical exam of her thyroid gland, on which the doc thought he felt a lump. So she was sent to a radiologist, who did an ultrasound exam of her thyroid and found three lumps. To check for cancer of her thyroid, she had needles stuck in all the lumps to remove some fluid (containing cells) from each. Under the microscope, the pathologist thought some of the cells looked suspicious. He thought that perhaps her thyroid should be removed, so she was referred to a surgeon. Luckily for her, the surgeon put a stop to the whole business, knowing that nearly all adults have some evidence of thyroid cancer. The woman, who was fine before the disastrous bone density screening, is again fine.

No sooner had I written this example, than I came across a study reported in the November 6, 2014 issue of The New York Times with the headline: “Study Points to Overdiagnosis of Thyroid Cancer.” The story refers primarily to South Korea, where they began screening for thyroid cancer 15 years ago. (In the US, thyroid cancer rates have more than doubled since 1994, again, because of overdiagnosis.)

Next week: Over-diagnosing thyroid cancer.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.