Is Drug Company Marketing Evil?
Ronald Bailey | February 22, 2008, 11:56am
There's an active research industry ginning up studies that suggest that doctors are being unduly seduced by the blandishments of pharmaceutical company marketing. For example, one such "conflict of interest" study published in the Journal of the American Medical Association in 2006 worried that "conflicts occur when physicians have motives or are in situations for which reasonable observers could conclude that the moral requirements of the physician's roles are or will be compromised."
It is certainly true that drug companies spend billions marketing their drugs to physicians. Pharmaceutical sales reps take them to lunch, pay for conferences, and provide them with billions of dollars in free samples. Obviously, this marketing must work in the sense that it does persuade doctors to prescribe their medicines more frequently than if there were no such marketing. If it didn't work, the pharmaceutical companies wouldn't do it. Is that a bad thing? Some legislators in thrall to conflicts of interest activists think so and are proposing regulations to limit drug company marketing in various ways. Are such regulations really necessary to protect patients?
Emory University law professor Paul Rubin has an
excellent column on this topic in the current issue of
Forbes. To wit:
Drug company reps offer overworked doctors useful, lifesaving information in an efficient manner. The drug companies are of course motivated by profit, but economists have known since Adam Smith that the profit motive is the best way to induce someone to do something useful.
Marketing and research are both information activities; they work together to get effective drugs to patients. The two activities are not in competition for resources. The denouncers of drug companies don't understand this. One of the senators sponsoring the bill suggests that "the millions of dollars these companies spend on marketing … could be put into research." In fact, drug companies would not switch money from marketing to research. If they cannot market drugs in the best way, they will reduce spending on research. What's the point of inventing a new drug if doctors and patients don't know about it?
Academic physicians think that doctors should obtain information by reading medical journals. Practicing doctors do not have time to comb through the International Journal of Medical Sciences or the Annals of Internal Medicine. A meal with a pharmaceutical salesperson is a time-efficient way for a busy doctor to learn about new drugs, or perhaps a better therapeutic alternative, or a drug with easier dosing or fewer side effects than the old drug. Physicians interact with more than one drug rep, so they have competing sources of information. ...
Finally, by leading consumers to purchase newer drugs, marketing increases investment in innovation and thus makes research more likely.
As Rubin notes on costs, a 2007 study by Columbia University health economist Frank Lichtenberg found:
...a reduction in the age of drugs utilized reduces non-drug expenditure 7.2 times as much as it increases drug expenditure. For example, reducing the mean age of drugs used to treat a condition from 15 years to 5.5 years is estimated to increase prescription drug spending by $18 but reduce other medical spending by $129, yielding a $111 net reduction in total health spending.
Since newer drugs lead to lower overall medical costs, marketing drugs to physicians is good for patients.
Do conflicts of interest studies actually show that patients have harmed by drug company marketing? As Rubin observes:
A widely cited 2000 article in the Journal of the American Medical Association summarized 29 published studies critiquing the interaction between doctors and drug reps. Notable feature of these articles, as quoted in the summary paper: "No study used patient outcome measures." (emphasis added) That is, in all of the medical literature on drug sales, there was no evidence of harm to patients caused by doctors and drug reps breaking bread. These articles were written by physicians who by their oaths put patient welfare at the top of the list, but they were critical of the industry based on analyses that totally ignore this measure.
Rubin concludes:
It is truly amazing that this society keeps coming up with ways to demonize and penalize an industry that has provided us with so many benefits.
Amen.
If you're interested in this topic, please see my articles "Is Industry-Funded Science Killing You?" and "Goddamn the Pusher Man."
Absurd Conflicts of Interest Disclosure: I have just completed a long peer-reviewed study of the conflicts of interest literature for the American Council on Science and Health which will be published later this year. And yes, ACSH paid me to do the research and the writing.
I am also an adjunct scholar at two Washington, DC-based libertarian public policy think tanks, the Cato Institute and the Competitive Enterprise Institute. It was explained to me that being an adjunct scholar means that I don't get paid anything, but that the institutes can use my name for media and fundraising purposes. I have worked on a contractual basis as an editor of three books on environmental policy for the Competitive Enterprise Institute, all of which were published by commercial publishers.
I regularly drum up grants from non-profits to pay for my reporting habits. This is not an exhaustive list, but I have received travel grants to cover United Nations Climate Change conferences and World Trade Organization conferences from the Altas Economic Research Foundation, the International Policy Network, and TCSDaily. In addition, I once went on a junket paid for the government of the Northern Marianas Islands. I generally disclose these grants because I'm grateful for their help. No grantor has ever exercised any editorial control over my reporting.
In addition, I have spoken at scores of universities, conferences and non-profit organizations around the world--mostly for just travel expenses (although on a few happy occasions I have received a small speaker's fee).
I am very happy to acknowledge (as I did in the book) that I received grants from the Richard Lounsbery Foundation, the Bruce and Giovanna Ames Foundation, and the Alliance for Aging Research to support my work on my latest book, Liberation Biology: The Scientific and Moral Case for the Biotech Revolution (Prometheus, 2005).
I also own shares in various biotech and pharmaceutical companies (no more than 1000 in any one company, alas). I purchased all of the shares with my own money and all are held in my retirement accounts. May your deity of choice have mercy on you if you even think about taking any investment advice from me.
Past and Current Charitable contributions and memberships (that I can remember):
American Civil Liberties Union
Society of Environmental Journalists
American Society of Bioethics and Humanities
Drug Policy Alliance
Center for Reproductive Rights
Committee to Protect Journalists
Equality Virginia
National Rifle Association
Marijuana Policy Project
Second Street Gallery
Whitman-Walker Clinic
Nature Conservancy
USO
CARE
In the past I have generally, but not always, voted Republican or Libertarian. In fact, I voted for Barack Obama in Virginia's Democratic primary earlier this month.
Finally, I strongly dislike fish and lamb.
Bill Mill | February 22, 2008, 2:25pm | #
The real evil is how flimsy the research required to get an evolutionary patent on a drug is, and it ties into the marketing of drugs. Here's how the scam works, it's really quite simple:
Pfizer has a drug A that is effective for migraine headaches. When the patent is near expiration, they change the ratio of ingredients in the drug slightly and run trials on several mixes.
At this point they will run and rerun studies on mixes until they find one that happens to show a small improvement in outcomes; they then register a patent for this drug B just as drug A's patent is about to expire.
And now the game is on, and this is where the drug companies excel: they need to convince doctors that drug B is worth convincing their patients (who are generally insured) that they need drug B for that nominal improvement in outcomes, and that drug A (which is now generic and wicked cheap; it's probably cheaper by several orders of magnitude) is hopelessly outmoded. Doctors get free lunch from the drug companies *every* *day*, and get pressed on drug B very frequently.
They, of course, claim that they are unaffected by the marketing, and that they will do whatever is best for the patient. But likely, they will overvalue drug B relative to the improvement it brings because of their exposure to the marketing.
But, drug B is likely to be no better *at all* than drug A; the improvement shown in the study is likely to be merely a statistical outlier. But the drug company will perform studies over and over again, until they find such an outlier, and then they will hammer that home with their marketing so that they make exorbitant profits on a drug that's neither better nor different by scamming the patent system.
(There's a great article on this in NEJM, I'll try and find it again later, I should really bookmark it)
In this story we see that everyone (everyone!) has misplaced incentives. The drug company is incentivized to hold off on improvements to A until the patent is just about to expire, and they're incentivized to cheat the patent system, and they're incentivized to spend outrageous amounts of money convincing doctors not to question the economic value of spending 1000% more on a drug that's 2% more effective.
The doctors are incentivized to listen to the pharmaceutical companies' pitch because they
a) get free lunches and steak dinners and pens and pads and coffee mugs and espresso makers and free samples and so on
b) have their prescription habits monitored. Outrageously, Pfizer knows if doctor A has been prescribing drug B or drug A because they pay a company a lot of money to get this information (which should not be available). The doctor knows that if he doesn't prescribe B, the favors will stop, or they'll get bugged more by a sales rep particularly interested in them. I cannot convey how disgusting I find this practice.
The patients who are insured are incentivized to take drug B, because their insurance company is paying for it, so what do they care? They never see the cost of it.
The only patients who should act in their own interest are the uninsured ones, but they're also the least likely to. They tend to be poorer, less educated, and more swayed by than insured patients are. Therefore, they're very likely to be stuck paying the extra 1000% for the 2% (*cough*) improvement that drug B gives them. Remember that their doctor probably prescribed it to them, because his prescription habits are being monitored, and because the patient probably either didn't know about the alternative or demanded to not take the generic (a surprisingly common phenomenon).
So! Dealing with the marketing of drugs is treating a symptom of the system, but not its cause. We either need to reevaluate how we judge medical research, reevaluate how and whether to grant patents, or both.
(I worked in the pharmaceutical research industry, my fiancee is a resident, and my mom manages a blood lab. That's my own disclosure. I should really write this up with references (I have lots), sorry for the extremely long comment.)
Dave W. | February 22, 2008, 2:40pm | #
Just exactly why do you think I linked to my two feature articles on the topic immediately after my "Amen," huh?
Okay, I'll play. I went to the links to find a discussion of whether pharma could really be fairly considered "penalized" (as opposed to say, scrutinized or criticized or taxed). The search string "pena" came up negative in both articles. Conclusion: "penalized is not discussed and the "amen" unsupported in this sense.
That left the term "demonized" (which really smacks of hyperbole on its face to one without benefit of grants and sinecures like myself).
At one of the linked articles, the search string merely turned up "demonstrated." So nothing in that artie.
In the other article, "demonized" was mentioned because some other pharma advocate had concluded that pharma (more specifically academic-idustrial research relationships) said taht others were "demonizing." So I read the article (actually I think I read it when you first published it). It sounded like people were criticizing pharma:
(i) because they thought that biased scientists had been to quick to clear COX2 drugs; and
(ii) because research was manipulated to exaggerate improvements in drugs with small improvements; and
(iii) because unfavorable studies on new drugs were quietly buried.
And I was reading about these things, and I thought. Maybe they are true criticisms and maybe they are not. Maybe they are real problems and maybe they are not (pharma itself seems to have admitted thru its actions that the COX2 thingee was a substantial problem at this point in time).
And I thought further, I thought: assuming these things are problems, what kind of people would cause these problems? And I thought: regular, fallible, sinful people. People like me and you. Peaople like clients and co-workers I have had in the past and will probably have in the future. regular folks. Imperfect folks. Folks who want to do good, but still make a buck and become conflicted when these imperatives conflict. People like the fizics phds and engineers you meet on the internet at libertarian boards. If these problems exist at all, these are the kind of people that would be causing the problems, alleged in these criticisms.
Then I thought further.
I thought about who would
not be causing these problems. Of course, I thought about Jesus The Christ. He would not be causing these problems. He was too good. He was content to live in poverty and stuf. Good for Him. He is a good example.
And then I thought of someone else who would not cause these problems. And I thought of . . . Satan. The red guy with the horns and the pitchfork whom I fervently believe exists. I thought, "Satan would not cause these problems because he is too bad." I thought that a scheme of the devil would be more diabolical even that the problems alleged to exist by CPSI. The AIDS might be Satan. Or cancer. Even the diabetes spike. But COX2 and overhyped new drugs. That is just not, just not . . . evil enough. It is not something a demon would do. The criticisms you discuss in that article do not, therefore, seem to be fairly considered as a form of "demonizing."
But Stossel sed it was "demonizing." and now Rubin says it is "demonizing." Which is why, in this blog entry, I wish you would have written:
Rubin concludes:
"It is truly amazing that this society keeps coming up with ways to demonize and penalize an industry that has provided us with so many benefits."
Of course, I agree, but still I realize that some skeptics understandably have a hard time grasping the concept that a sector as profitable as pharma could possibly be demonized or penalized. The reason is [explain away apparent contradiction on its own terms, if possible].
Cause as of the right now, I don't think that pharma is "demonized" or "penalized." I think that Stossel and Rubin say it, and you repeat it, as a form of crocodile tears. I am open to persuasion otherwise. But I need a better convincer. I am not sure you can be that convincer, but you seem to be reaching out, and, of course, I want to encourage and facilitate that.
Bill Mill | February 22, 2008, 4:37pm | #
J sub D, it's real:
> “We got the numbers of what the physicians were prescribing. If I brought in lunch one week, I could see the following week if that lunch had an impact,” Ms. Slattery-Moschkau said.
from http://www.nytimes.com/2006/07/28/business/28lunch.html
> The rep was so friendly, in fact, that she thanked Drexler for all the prescriptions he had been writing for Berlex's pharmaceuticals.
> Drexler found the statement odd. He wasn't in the habit of divulging to salespeople how often he prescribed their company's drugs, so he wondered just how the rep knew. Drexler called local pharmacies and asked the pharmacists if they had any knowledge of drug reps gaining access to prescription records. But they were as befuddled as he was.
> Then one day, a rep with whom Drexler was particularly friendly spilled the beans. He told Drexler that he and his fellow reps were provided with detailed prescription information, which was stored in their laptops, on every physician in their sales territory.
http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2006/08/06/CMGTSJU4NT1.DTL&type=politics
> About halfway through the lunch, one of the representatives turned to a family practitioner-friend of Mitchell's who had accompanied him, and asked her why she wasn't prescribing much of their drug. The doctor reassured her hosts by telling them they had nothing to worry about, that she was indeed prescribing Cardizem. The inquiring Aventis representative then pulled out a "palmtop computer" and confronted the physician with exactly how little Cardizem CD she had prescribed the previous month compared with competing high blood pressure medications. The data on the computer screen, Mitchell noted, included the names and quantities of every drug Mitchell's physician friend had prescribed in the previous three months.
http://www.guernicamag.com/features/159/inside_information/
That's all just from a quick search.
