Healthy Skepticism Library item: 1753

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Metherall M.
Drug deals
Sydney Morning Herald 2002 Apr 13

Full text:

Peter Stefopoulos, 65, is like many Australians of his age. He can thank the Pharmaceutical Benefits Scheme for paying to keep him alive. But the self-made man who arrived alone from Greece at age 15 looks a little unsure when you ask what the PBS means to him.

He’s on six drugs to manage his diabetes, hypertension and cream for his skin complaint. His GP says he would be “bloody lucky” to be alive without the medicine, costing the taxpayer at least $100 a month.

These days, Stefopoulos, a retired Canberra shopkeeper, pays about $25 a month towards his drugs. He’s not overly worried about the prospect of a Budget-time slug on his prescriptions. As he says, “it’s not how you look, it’s how you feel … we live in a lucky country”.

But the gathering speculation about controls on future drug costs is threatening a central feature of the lucky country, the PBS. Stefopoulos, as an aging chronic disease sufferer, belongs to the group which accounts for 80 per cent of the PBS’s cost.

Next month’s Budget is heading for measures to increase significantly the out-of-pocket cost to patients as well as moving to tighten doctors’ prescribing.

PBS costs are expected to swell by 20 per cent this financial year to more than $4 billion, a boom the Government wants to stop. How it will achieve this without hurting millions like Stefopoulos is a question that has had no clear answer from the Health Minister, Kay Patterson.

Increasingly, consumer groups and doctors like the one who treats Stefopoulos believe more has to be done to restore balance to the prescription of drugs and to examine their benefits as well as costs.

The pharmaceutical industry pressure on doctors begins when they turn on their practice software, the standard version of which flashes fresh drug blurbs but allows no space for non-pharmaceutical preventive measures like diet and fitness. The schmoozing from freebie-bearing drug company representatives is constant to back up the drug-clogged marketing in medical journals.

The Consumer Health Forum’s chairman, Lou McCallum, says there is too much pressure to conclude consultations with a script, when diet, exercise and therapeutic group activity could also fight the constellation of Western ills: heart disease, high blood pressure, diabetes, depression and arthritis.

All this is known and accepted but Australian medicine is dominated by the paradigm “see your doctor … And we know there is a reasonable chance it will lead to a script”, says McCallum.

The pharmaceutical industry estimates that the “natural” increase in existing drug costs is about 6 per cent. If Australia wants to continue getting world-best medicine, costs could go into a double-figure percentage increase, according to the chief executive of the Australian Pharmaceutical Manufacturers Association, Alan Evans. At that rate, and it’s a modest assumption given recent history, the PBS cost would double in eight years.

Is this the best medicine for Australia? There is scant evidence of a Government strategy to investigate the real costs and benefits of galloping drug use and cost.

Health leaders like McCallum, Evans and the chairman of the Pharmaceutical Benefits Advisory Committee, Professor Lloyd Sansom, ask why there is so little comprehensive knowledge about the longer-term impacts of drugs in terms of future hospital and doctor treatment.

Professor Sansom’s committee recommends to the Government which new drugs should get subsidies. Recently he expressed his frustration to the Herald over the lack of data available about the long-term economic effects of the drugs it approves. This contrasts with the exhaustive forecasts of likely benefits the committee requires from drug firms – information the committee can’t test after the drug’s introduction.

That information vacuum about the real-life impact of drugs was underlined this week by a divergence between two national doctor groups on how to grapple with the issue.

Reports that the Government-financed Australian Division of GPs was developing a scheme to provide incentives to doctors’ groups which reduced their costly drug use were attacked by their more powerful rival, the Australian Medical Association.

It turns out the division’s pilot scheme, which is designed to improve prescribing, will mean that some of the savings will be returned to division branches, not to individuals to fund other practice improvement measures.

The scheme may indeed mean higher drug costs in some areas if the treatments require it, says the division’s president, Dr Julie Thompson.

Dr Thompson also rejected an attack by Evans on the division’s “quality use of medicines” scheme. The drug companies’ share of PBS spending had gone from less than 50 per cent to more than 70 per cent in the past two decades.

“Clearly drug manufacturers have the most to lose if quality use of medicine programs result in a reduction in the use of drugs such as antibiotics in line with best-practice prescribing,” Dr Thompson said.

Take the costly statins for cholesterol lowering. Despite a controversial move by the Government last year to rein in the $500 million cost of statins, their cost keeps rising, to $600 million last calendar year. Officials say measures are still to take full effect but the rise has been slowed. But growing evidence from around the world is suggesting more, not less, use of statins is justified in reducing the risk of life-threatening, not to mention costly, heart attacks.

The division’s goal is to start a process which amazingly has never been seriously tried in Australia – to measure the physical and financial outcomes of drugs through surveys of doctor groups. One hoped-for result is more information on whether common drugs add to or lower hospital and doctor costs.

But the response from the AMA’s Kerryn Phelps to the division’s scheme was to suggest the doctors were there to serve their patients “and not to serve bureaucratic bottom lines”.

Dr Phelps, whose famous clash with former health minister Michael Wooldridge last year was fuelled by the issue, betrays the AMA’s nervousness about outside scrutiny of doctors’ prescribing. The AMA, she says, believes direct consumer marketing of pharmaceuticals should be limited and “scapegoating of doctors” should not be the way Governments control prescribing.

But the evidence available on family doctors serving their patients’ interests in prescribing practices indicates there’s a lot of room for improvement. A National Prescribing Service survey of GPs 18 months ago found significant numbers of doctors were astray in the treatments they ordered for their patients.

In hypertension cases, only 12 per cent of doctors chose what the National Heart Foundation believed was the correct answer in options to reduce mortality in patients with uncomplicated levels of the disease. Nearly three-quarters selected two other drug types, neither of which had been shown to reduce mortality in patients with uncomplicated hypertension.

With chronic obstructive pulmonary disease (illness of the lung), fewer than 2 per cent of doctors correctly identified all five of the proven management options.

With acute sinusitis cases, 44 per cent chose an antibiotic, amoxycillin, as first-line therapy, when Government therapeutic guidelines suggest most cases are viral and often require no antibiotic.

While incorrect prescription of antibiotics has declined in recent years, continued misuse of these drugs will intrigue many patients who have known for a generation that antibiotics are impotent against viruses.

The National Prescribing Service’s pre-winter series of ads is aimed at driving the message home to delinquent prescribers with a “common colds need commonsense” campaign. The service says “as GPs will be aware, antibiotics have no effect on treating viruses such as the common cold, influenza, most coughs and most sore throats – yet the problem of antibiotic use is increasing.” It adds that 10 per cent of all Australian patients used an antibiotic the last time they suffered such symptoms.

When the NPS sought to prepare doctors before the listing of the arthritis “wonder” drug Celebrex in 2000 it found its educational satellite broadcast was poorly attended and in the same period drowned out by the intensive marketing to doctors and consumers of the new drug.

Official statistics showed that 800,000 prescriptions were written for Celebrex in the first month after listing. Later research indicated that scripts were made out to patients “not predominantly in at-risk groups who would benefit most”.

Big critics of the pharmaceutical industry such as the Doctors Reform Society estimate the industry spends a whopping $750 million a year on spruiking its products to doctors and patients in Australia. The calculation is based on a minimum 10 to15 per cent slice of the local industry’s $6 billion-a-year income.

The figure is dismissed by Alan Evans, who says $100 million would be closer.

The drug-makers’ burgeoning profits have made them the number one profit-earners worldwide. Evans earnestly argues that nobody hears about the downsides in what he says is a high-risk industry – like Bristol-Myers Squibb’s share price plummeting 30 per cent after indifferent product research results recently.

By contrast, Pfizer, the world’s biggest pharmaceutical company, last year collected an income of $US32 billion ($59.8 billion), an increase of nearly $US3 billion. That rise alone is more than the total cost of drugs to taxpayers in Australia.

“Everybody is wanting to kick us, but they have lost the plot. The reality is you won’t get prices in Australia lower,” insists Evans.

Australia’s own Productivity Commission has confirmed that Australia, because of the monopoly-buyer position of the PBS, pays among the lowest prices for its pharmaceuticals of any Western country.

Evans this week urged a lift in subsidies for the PBS rather than bumping up what patients have to pay out of their own pocket.

His plea for a more “equitable” outcome where the sick and the poor were protected from rising drug prices seemed at odds with the free enterprise philosophy of global business.

Evans says his association’s board recently decided to back subsidies against increased co-payments, not to secure profits but in deference to the success of PBS equity. “If you were looking for greater profits, you would have a free market.”

But the Doctors Reform Society’s Dr Con Costa says the free market in the US means many patients with common conditions are paying $1000 a month in drug bills out of their own wallets. “That’s why the revolution, if it comes to the US, will be over drug costs.”