Medical care in the United States of America costs “too much.” That’s a generally accepted wisdom, I think. Not too many physicians believe we get paid too much, although I think one could make a good case that physician salaries or profits are somewhat out of proportion. Many physicians believe insurance companies are the cause of excessive health care costs.

Do we do too much medicine? I think so. In the mid 1990’s, I was stationed at an Air Force base in Mississppi and I suffered a broken jaw when another softball player ran into me at full speed. My jaw had to be wired for a month and I lived on Ensure and similar food. When I went to the ER for the immediate care, I had to refuse a CAT scan. I did not have a concussion; I did not lose consciousness. But it had become “standard of care” to perform a CAT scan after any injury to the head.

It is now standard of care to perform laboratory tests to monitor patients taking many medicines. Not all of the tests are unreasonable, but some of them get fairly expensive and the yield is pretty low. All of these tests drive up costs.

Doryx is a new doxycycline antibiotic. Generic doxycycline can be purchased for about $30 for a month’s supply. Doryx costs over $600 for a month supply. Olux is a sophisticated foam vehicle for clobetasol, a topical steroid we use frequently. A 100 gm can of Olux runs around $250, whereas generic clobetasol solution can be purchased for less than $50 for 100 cc. Aldara is a medicine brought out 3M ten years ago for the treatment of warts. It was too expensive in 1997 at $125 for 12 little packets of the drug (one month supply at 3 packets a week). Subsequently, it was shown to be useful for the treatment of actinic keratoses (pre-skin cancers) and for early, superficial skin cancers. 3M has sold off its pharmaceutical arm and the new manufacturer, Graceway Pharmaceuticals, sells the medicine for about $250 for twelve little packets. I refer the reader to The Truth About the Drug Companies: How They Deceive Us and What to Do About It. by Marcia Angell. The author is the former Editor-in-Chief of the New England Journal of Medicine. She documents only too well how pharmaceutical company profits have risen over the years, at all of our expense. She documents how research has been driven by pharmaceutical companies and not by NIH, the FDA, or universities.

Our prescription writing is also affected by biased publication. Please see Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy, by Turner, et al, in the New England Journal of Medicine, 2008; volume 258, page 252. From the abstract: “Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published. Whether and how the studies were published were associated with the study outcome. A total of 37 studies viewed by the FDA as having positive results were published; 1 study viewed as positive was not published. Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive. Separate meta-analyses of the FDA and journal data sets showed that the increase in effect size ranged from 11 to 69% for individual drugs and was 32% overall.” To put that more simply, the published literature misrepresents the real effectiveness of antidepressant medicines. They are not as good as we think. If a careful, responsible physician were to carefully read the literature, he or she would get an overly positive view of the use of these medicines. So, we are paying for medicines that are not as good as we think they are. We are being misled. With intent? I am unable to answer that question.

What about marketing? Does it influence us? See Dr. Angell’s book for comments about marketing. The Association of American Medical Colleges (AAMC) published a symposium, The Scientific Basis of Influence and Reciprocity , which is available for free download. It is a large file in PDF format. Basically, we ae severely influenced by pharmaceutical companies. Worse, we have built-in incentives to over use and over-charge. We are also not as honest as we think we are. You should also read,“Following the Script: How Drug Reps Make Friends and Influence Doctors” from PLoS Medicine.

I will have lots of comments in this blog about this subject. For the record, I own stock in Abbott Laboratories. I don’t take drug lunches or dinners. I subscribe to the philosophy outlined in No Free Lunch. More succinctly, from Robert Heinlein’s novel, The Moon is a Harsh Mistress, he coined a phrase, TANSTAAFL (There Ain’t No Such Thing As A Free Lunch).

Finally, I remember Pogo, a cartoon character from when I was a child and young adult. He has disappeared from the newspaper comic sections, but certain of his comments live on: “We Have Met the Enemy, and He is Us”.

We all own this problem.

Yours for Cthia,

Michael