The Pharmaceutical Journal Vol 267 No 7165 p346
15 September 2001

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The inevitable needn’t happen!

By John Ferguson

For the past several years I have spent two August weeks in Florida. The local Florida newspapers always fascinate. Their obsession with health and medicines ensures a rich vein of information for interested observers. The pieces also remind me forcefully of the developments that would “inevitably” transfer to Europe but in practice never materialise.

Managed care

Several years ago, “managed care” was the inevitable development, and many speakers from the United States lauded the health maintenance organisation (HMO) concept at conferences in Europe. The then National Health Service Executive even drafted guidance for health authorities in England on what was not acceptable in “medication management” packages that they might be approached to negotiate by manufacturers.

This year the headline on the front page of the St Petersburg Times of 5 August was “Could HMOs have healed themselves?”. This introduced a long piece about the six years that the US Congress has spent debating a proposed patients’ bill of rights, a development that had resulted from complaints from thousands of constituents, newly enrolled in HMOs, who were upset that they were being denied some medical procedures because of cost cutting. Apparently, the media in the mid-1990s were filled with horror stories about sick people being turned away from hospital emergency departments that refused to accept their insurance and some who died after being denied appropriate care.

The article made it clear that the situation had improved in recent years mainly as a result of legislation enacted by state legislatures, tighter state regulations on licensed health plans and voluntary improvements by fund managers. Nevertheless, the debate on whether federal legislation in the form of the patients’ bill of rights was still needed rumbled on. The lobbyist for the American Association of Health Plans considered the Congress to be “beating a dead horse”, while the Consumers Union was of the opinion that voluntary improvements had not been sufficient to give patients complete confidence in their health plans and “The horror stories are still happening”.

All this, together with reports on the same front page about changes by the Bush administration to Medicaid (the programme providing health care benefits to welfare families and others on low incomes), was a stark reminder of the great differences between the health care system in the US and those, for example, in the member states of the European Union. The name of the new US Health and Human Services Secretary, Tommy Thompson, is prominent in media reports. In the item about Medicaid, he was quoted as saying that the number of Americans without health insurance has fallen from 42.8 to 39.3 million, a figure which is still staggeringly high in European terms.

Virtual pharmacy

The second development that would “inevitably” transfer from the US to Europe was the virtual or e-pharmacy, which was to sound the death knell of the bricks and mortar pharmacy. Yet, an online survey in the US has shown that virtual pharmacies have proved to be no match for real ones.

Charles Hamlin, president of Insight Express, the market research organisation that carried out the survey, has stated: “The online drug store business model makes sense in theory but not in practice ... mainly because people desire the personal interaction they receive with the local pharmacist.” This is not to say, of course, that a “real” pharmacy should not take advantage of the potential of providing an online service for those customers who want that facility. It demonstrates that this combination, efficiently provided, has little to fear from a “virtual” pharmacy.

DTC advertising

The next “inevitable” import to the EU from the US is said to be direct-to-consumer (DTC) advertising of prescription-only medicines. The St Petersburg Times reported that the pharmaceutical manufacturers spent $1.8bn on DTC advertising in 1999, up from $55m in 1991.

The newspaper then referred with tongue in cheek to a report published by the Institute for Policy Innovation, which suggests that such advertising is good for the public and that the people to fear are “those who want to control it”. The report states that advertising stimulates competition, but, as the newspaper says, this ignores the fact that there is no competition for medicines that are still under patent, and those, understandably, are the most widely advertised. An IPI spokesperson confirmed that the institute, which raises funds primarily from organisations and individuals, received some support for this particular report from the pharmaceutical industry. The report concluded by stating that the organisation Families USA (“the voice for health care consumers”) had found that the nine leading pharmaceutical companies spent more money in 2000 on marketing, advertising and administration than on research and development.

The EC Commission has already amended its original proposals on “information” to consumers about prescription-only medicines for three categories of medical conditions. One would suspect that the climate will change even more when the politicians — the Council of Ministers and the European Parliament — become involved. They, and particularly health ministers, are likely to be concerned about the inevitable large cost increases that would have to be faced if the figures for the US were reflected in Europe.

Bad time

The pharmaceutical industry had a bad time in the US media in the first two weeks of August. There were the reports that the editors of more than a dozen major learned journals, published internationally, had agreed not to accept for publication any paper on research that a pharmaceutical manufacturer had funded on condition that the results would not be submitted for publication if they were detrimental to the medicinal product of the funding company. Radio reports made clear that this practice was not widespread and the editors had acted to ensure that it did not become so.

Another blow for the industry was the withdrawal from the market by Bayer of its statin Baycol (cerivastatin), following the reported deaths of 31 patients who had been taking the product. Sales in 2000 totalled $554m and the estimate for the current year had been over $800m.

Baby aspirin

For light relief, by far the most amusing press report concerning medicines was headlined “Baby aspirin for the baby boomers”. This related to a decision by a division of Johnson & Johnson to remarket aspirin 81mg (ie, 1.25 grains) under the St Joseph brand, first marketed as aspirin for children in 1891.

The decision was apparently taken as a result of focus groups of 60-year-old men becoming “teary eyed at the memory of the little orange chewable pill” they had been given in childhood to relieve pain. With 26 million Americans reported to be taking aspirin on a regular basis “to avoid heart attacks and strokes”, the company had identified a new niche market for junior aspirin packaged and promoted for adult use, in both chewable and enteric-coated forms.

Incidentally, aspirin products for children are still on open display in pharmacies in the US, with warnings on the labels not to use the products for the treatment of certain symptoms. In many countries these products were withdrawn from the market in the mid-1980s when the link with Reye’s syndrome was established.

John Ferguson, FRPharmS, is a former Secretary and Registrar of the Royal Pharmaceutical Society and is currently interim secretary general of the Pharmaceutical Group of the European Union