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Take Your Pills, All Your Pills

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The New York Times
March 11, 2006

Joseph A. Brocato's weekly self-injections of a drug to treat hepatitis C left him so feverish and fatigued, he said, he often thought of quitting. He didn't, thanks to a nurse who urged him by phone to stay the course.

The nurse, Colleen Dinsdale, did not work for Mr. Brocato's doctor. Rather, Ms. Dinsdale was paid by the drug's maker, Roche, and its distributor, McKesson. Each month that Mr. Brocato took the drug, Pegasys, and its companion pill, ribavirin, meant $3,000 in sales - most of it paid by his insurance company. His share was a $50 co-payment.

The take-your-medicine program is part of a sales and marketing strategy that is gaining urgency for drug makers experiencing slowing sales. As it turns out, the industry leaves billions of dollars on the table - or the pharmacy shelves - annually because people do not take their drugs as often or as long as prescribed.

And so the hand-holding with patients like Mr. Brocato, who recently completed his yearlong course of therapy. "They don't ever let a week go by that they don't contact you, not just to say you are coming up on a refill of your drug but just to say, 'How are you feeling?' " said Mr. Brocato, a 57-year-old auto parts deliverer who lives in Dundalk, Md. He said he called Ms. Dinsdale so much that he programmed her number into his cellphone.

Stimulating sales this way is the focus of other industry initiatives, including television advertisements like one by AstraZeneca in which a doctor asks a series of patients if they are taking their Toprol-XL hypertension pills daily. "You can't forget," the doctor gently scolds. "High blood pressure can make your heart work harder than it should, every day."

Lending credence to such efforts are many studies showing that failure to take medicines as prescribed can cause patients to develop more serious and costly complications later. So as industry tactics like wining and dining doctors draw scrutiny, spurring people to take their pills is a less controversial way to increase sales, one that the industry says is in the best interests of patients and insurers.

Still, the efforts are not without detractors. Some medical experts worry about consumers' privacy or the possibility of undermining doctor-patient relations. There are also questions about the industry's motives.

"They're about brand loyalty and not about public health," said Dr. Jerry Avorn, a professor at Harvard Medical School and the author of "Powerful Medicines," a book critical of pharmaceutical marketing and regulation.

Dr. Avorn nevertheless said that low patient compliance with prescriptions was a big problem for the industry and public health. "I'm often surprised to hear drug companies worry about increasing their market share from 7 percent to 9 percent for a particular disease, when the 500-pound gorilla issue is that half the people who were prescribed those drugs aren't taking anything," he said. "A ton of money is wasted on paying for drugs which people use so irregularly that they get no clinical benefit."

The World Health Organization, in a report in 2003, called noncompliance a "worldwide problem of striking magnitude." It estimated that in developed nations, half of patients did not take medicines for chronic diseases in the prescribed manner.

Insurance companies have their own programs to get customers to take their medicine. But it is the drug companies that feel the most direct impact when patients fail to finish or renew prescriptions.

"We talk about this in terms of the leaky bucket," Anne M. Faul, director of pharmacy strategy and analysis at GlaxoSmithKline, said on a recent Webcast organized by Frost & Sullivan, a consulting firm, and sponsored by McKesson.

GlaxoSmithKline, which makes the diabetes drug Avandia, is offering to pay for employer groups in 10 cities to replicate an experiment that started in 1997 in Asheville, N.C.

In that test, Asheville municipal employees with diabetes were encouraged to take treatments for their disease, through efforts by pharmacists and diabetes educators and by the waiver of co-payments. As a result, the patients' control of their blood sugar improved and the city's overall medical costs fell. Spending on drugs alone, however, increased.

Research finds various reasons that people do not take their medicines. Forgetfulness accounts for about one in four cases, according to a survey of 10,000 people in 2002 by Harris Interactive and the Boston Consulting Group. Another reason is that patients may feel no urgency about taking daily pills for conditions like osteoporosis and high cholesterol, in which drugs do not relieve any immediate symptoms but reduce the risk of future problems.

Other reasons, cited by the survey and other specialists, are ones the drug industry's inducements cannot necessarily resolve - like complaints that the drugs cost too much or do not work or cause unpleasant side effects.

Kay Wissmann of Chicago said she stopped taking tamoxifen, intended to prevent a recurrence of breast cancer, because it made her feel terrible and exhausted. "That's one of the things oncologists don't realize, because they've never taken the medications themselves," she said.

Even though she had a relapse of cancer, she said that not taking the drug was the right decision.

AstraZeneca, which sells tamoxifen under the brand name Nolvadex and another breast cancer drug, Arimidex, helped pay for a meeting of a group of cancer patient organizations in Washington in November to plan a compliance initiative. A paper is now being prepared and discussions are continuing on possible remedies, said Terri Ades, director of cancer information at the American Cancer Society.

Some companies let patients enroll in a program that provides information about their disease as well as reminders to take their drugs. Novartis, for example, recently started BP Success Zone for users of its blood pressure drugs, including Diovan, its biggest product.

Customers can interact on a Web site, through e-mail or regular mail or at the pharmacy. Patients are offered advice on diet and exercise. They can also get a free monitor to test their blood pressure.

"You've got to give them some success metric," said Kurt Graves, global head of the general medicines unit of Novartis.

Participants receive a card that entitles them to discounts on refills. When the card is used, it provides information to the company on how often patients renew prescriptions.

In Florida, Eli Lilly is offering the state's Medicaid program a bigger discount on Zyprexa, the schizophrenia drug, the longer patients stay on it. It is up to the state to figure out how to keep patients on the drug.

It is the brand-specific nature of some programs that concerns some specialists. Dr. David S. Sobel, medical director for patient education and health promotion in Northern California for Kaiser Permanente, a big health maintenance organization, said drug company compliance programs were not necessarily bad but that Kaiser preferred to run its own.

"If somebody's in a program for a certain statin and we change that statin, are they out of the program?" Dr. Sobel said, referring to cholesterol-lowering medication. "If it goes generic, do they shut down the program?"

Dr. John Abramson, a physician and author of "Overdosed America," said another potential problem was that medicines were overprescribed. In such cases, compliance programs would be inducing people to keep taking pills they did not need.

Some specialists say there is a potential for abuse in the closer links being forged between pharmaceutical companies and their patients. In the past, drug companies generally dealt only with doctors and insurers.

But organizers of the industry programs say that instead of bypassing the doctor, they are providing services like 24-hour-a-day call centers that many doctors cannot. "We are an extension of the physician's office," said Kerr Holbrook, vice president for marketing at McKesson's specialty pharmaceuticals division, which runs the program that worked with Joseph Brocato.

Patients generally join such programs voluntarily, so privacy is not an issue, they say. In some cases the doctors recommend the programs to patients, saying the company efforts are useful and unobjectionable. "They have really been hands off with corporate influence," said Dr. Robert G. Gish, a hepatitis specialist in San Francisco who is a consultant to various drug companies.

The National Multiple Sclerosis Society, a patient advocacy group, said it stopped its own compliance programs because the drug companies were doing such a thorough job.

Still, the programs tend to be for more expensive drugs. "Candidly, the higher the price of the drug the more likely that somebody is going to do this," said Ted Dacko, president of HealthMedia, a company in Ann Arbor, Mich., that runs compliance programs for drug companies and insurers. "You're not going to be doing this for Tums."

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