Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Interesting
- Graeme M Mackenzie (31 May 2005)
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Let's be serious...
- James Penston (3 June 2005)
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Re: Let's be serious... = facts rather than feelings.
- Claus Moldrup (8 June 2005)
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Drugs: Product or Service?
- Markus Lungen, Andreas Gerber (10 June 2005)
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Graeme M Mackenzie, GP Whitehaven CA28 7RG
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But probably unworkable in the NHS. No doubt another vast bureaucratic industry would grow up around assessing efficacy, somewhat negating the cost benefits. It would be better if we just had cheaper drugs. Competing interests: None declared |
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James Penston, Consultant Physician/Gastroenterologist Scunthorpe General Hospital, Cliff Gardens, Scunthorpe, North Lincolnshire DN15 7BH
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Sir, Reading Claus Moldrup’s proposal for a “No cure, no pay” policy [1], one is tempted to utter the memorable words of John McEnroe: “You can not be serious!” As Moldrup himself recognises, such a policy would be suitable only in the case of a drug that is effective in a large proportion of the patients being treated. Yet, few medicines satisfy this condition. In 2003, Allen Roses of GlaxoSmithKline let the cat out of the bag when he commented that “The vast majority of drugs – more than 90% – only work in 30 to 50 percent of the people.” [2] Is it seriously being suggested that pharmaceutical companies would accept a reduction of 50-70% in their profits? Estimates of efficacy in the range of 30-50% are, of course, greatly in excess of those expected from many of the drugs used for the long-term management of chronic disease. In the case of statins, for example, less than 5% of patients prescribed these drugs over prolonged periods obtain any benefit whatsoever. [3,4] How, then, is the “No cure, no pay” policy to be applied in these cases? Moldrup’s answer appears to consist of the use of surrogate end-points – for instance, a lowering of cholesterol with statins or a reduction in blood pressure with angiotensin-receptor blockers – together with the abandonment of clinical outcomes. But the unsatisfactory situation in which the vast majority of patients receive drugs unnecessarily will persist. Moreover, the prescription of expensive, long-term medication to large sections of the population, most of whom would remain well regardless of treatment, will continue to waste scarce health-care resources. Does anyone seriously believe that this is rational prescribing? Fiona Godlee hit the nail on the head: the policy of “No cure, no pay” is simply “off the wall.” [1] Moldrup C . No cure, no pay. BMJ 2005;330;1262-4. [2] Roses A. Quoted in the Independent, 8th December 2003. [3] Freemantle N, Hill S. Medicalisation, limits to medicine, or never enough money to go around? BMJ 2002;324;864-5. [4] Penston J. Fiction and fantasy in medical research: the large- scale randomised trial. The London Press, London, 2003. [5] Godlee F. Editor’s choice: Winning hearts and minds. BMJ 2005;330; 28th May. Competing interests: None declared |
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Claus Moldrup, Associate Professor Danish University of Pharmaceutical Sciences
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James Penston argues that the “no cure no pay” proposal that I present [1] is “off the wall” for two reasons. 1. The pharmaceutical companies are not willing to accept a reduction of 50-70% in their profits. Penston’s argument is based on an Allen Roses statement: “The vast majority of drugs – more than 90% – only work in 30 to 50 percent of the people.” [2] First, “no cure no pay” strategies have been practised in real life, as my paper documents. Even in cases with market leaders, even in cases with products in areas that are difficult to treat to target. In other words, fact is that pharmaceutical companies “walk the talk” in these cases. The pharmaceutical world is unfortunately not that simple, as Penston argues. In reality, a pharmaceutical company with a product that apparently has a great potential but a low market share (for a lot of reasons), indeed, would accept to pay a large percentage back if the market share at the same time increased significantly. From an academic point of view, if only 30–50% of the prescribed drugs work as intended in the particular patient, this is a good case for a “no cure no pay” strategy. Fact is that this will force the health care system to monitor and evaluate the treatment and enforce the right pill to the right patient. 2. The use of surrogate end-points to evaluate the status in a “no cure no pay” setup, will still keep a lot of patients unnecessarily on drugs in the prevention area. This is an interesting and important discussion. But it has nothing to do with the “no cure no pay” setup. This is a “numbers need to treat” discussion and involves overall bioethical and prioritising arguments. Fact is, that if one doesn’t treat at all, of course one can’t get the money back – in that case “no cure no pay” is off the wall as Penston argues. In reality, not every one finds this the right track to follow. [1] Moldrup C . No cure, no pay. BMJ 2005;330;1262-4. [2] Roses A. Quoted in the Independent, 8th December 2003. Competing interests: As stated in Moldrup C . No cure, no pay. BMJ 2005;330;1262-4. |
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Markus Lungen, Health Economist Institute of Health Economics, University of Cologne, Germany, Andreas Gerber
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In a recently published contribution on “No cure, no pay” Moldrup proposes that drugs should be paid for only if the therapeutic effect is fully achieved. Thus, he abandons the classical scheme of offer and purchase of goods. Yet, he is right with his thesis. Let´s reconsider the economic principles that separate products from services. According to economics a patient does buy pills merely as products as he, for instance, similarly purchases a bed. With the purchase of a bed the customer does not buy any warranty of good sleep, but solely a product that might provide him with a subjective benefit that only he knows. From an economic perspective, it is of no importance whether the patient keeps his pills as a kind of trophy or whether he does swallow them. Similarly, it is of no concern for the seller whether a bed is ever used. Henceforth, any purchase merely implies the purchase of a product, but not the warranty of eight hours of recreative sleep, for instance. Indirectly, however, we agree with the author as the pharmaceutical industry intentionally seems to blur the difference between product and result more and more. As in other markets the strategy of sales is coined by notions of life style. Thus, it is more and more conveyed that a status of well-being or personal success may be attained by taking pills. Especially in realms that do not encompass defined diseases or that would remedy somatic disadvantages arising from an unhealthy life style pills become the alternative to own endeavors and sacrifices. Drugs seem to acquire the status of a service. And services rely much more on their success than simple products. This has unforeseen implications for the sales promoting strategies of the pharmaceutical industry. If they promise a success and alter their traditional strategy emphasizing minimal side effects to focusing on effects they will be responsible that effects are attained. So, if effects do not occur services will not be paid for. We do not know whether the pharmaceutical industry has already realized the consequences of their altered sales promoting strategies and when the first court decisions may be awaited. In this regard, the authors of the contribution “No cure, no pay” are absolutely right if they state that we only have to pay for an effect if it is attained. Yet, this presupposes that we did buy an effect and not solely a pill. Competing interests: None declared |
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