Monday, December 8, 2014

A $50 Drug or a $2,000 Drug - Which Would You Prescribe?

Imagine this situation: You are an eye doctor, treating older patients with an all-too-common problem, wet macular degeneration, which, untreated, can lead to severe vision loss. A cancer drug has been used to treat the condition successfully, at a cost of about $50 a pop.

Now, the same pharmaceutical company that makes the cancer drug you've been using introduces a new drug specifically designed to treat macular degeneration. Great! Except it's going to cost $2,000 per dose.

Oh, and remember that the condition arises most often in patients 60-plus, so Medicare is going to have to pay for much of the cost.

Are you going to switch your patients from Drug A to Drug B?

According to an article by Katie Thomas and Rachel Abrams in today's New York Times, you're significantly more likely to do so if you're being paid "consultant" fees by the pharmaceutical manufacturer.

Raise your hand if you're surprised.

I'm not seeing many raised hands, and I'm not surprised.

Since I started this blog back in 2009, I've argued against "gimme caps" and their like (see here or here) because there's abundant research that we are all way more influenced by even small gifts than we want to admit we are. Thomas and Abrams note that

Specialists who study conflicts of interest between physicians and the drug industry say even modest payments have been shown to influence behavior.

"That’s why a sandwich is so effective — no one wants to feel like they were being bought off for $5," said Dr. Adriane Fugh-Berman, an associate professor at Georgetown University Medical Center in Washington and director of PharmedOut, a project that educates doctors about drug marketing claims. "That’s why they convince themselves that the drug is better."
And of course, the ophthalmologists who are prescribing Genentech's Lucentis (the $2,000 drug) instead of Genentech's Avastin (the $50 drug) do insist that it's because Lucentis is a better drug. 

But here's the kicker. While not every doctor who prescribed Lucentis frequently received consulting fees from Genentech, a suspiciously high percentage of them did:
Half of the 20 doctors who received the most money from Genentech to promote Lucentis in 2013 were among the highest users of the drug in 2012, billing for higher amounts of Lucentis than 75 percent of their peers. The figures were compiled from two federal databases that covered different periods, and it is not known whether or how much Genentech paid the doctors in 2012.

The 20 doctors earned $8,500 to $37,000 over five months in 2013, payments that included consulting and speaking fees as well as travel expenses and meals. Genentech says it has an annual cap of $50,000 a doctor for speaking fees.
That's not a smoking gun, but it does raise eyebrows, and questions. 
Eric Campbell, a professor of health care policy at Harvard Medical School, said doctors frequently denied that relationships with drug companies could change their behavior, despite many studies to the contrary. "They are suggesting that the drug companies that are spending this money, that these companies are dumb enough to be wasting their money," he said.
I don't think the companies are that dumb. Do you?