Intended for healthcare professionals

Education And Debate

Rethinking prescribing in the United States

BMJ 2003; 327 doi: (Published 11 December 2003) Cite this as: BMJ 2003;327:1397
  1. Andrew Ellner, assistant medical editor (
  1. 1BMJ Knowledge, London WC1H 9JR
  • Accepted 10 October 2003

The United States wants to increase senior citizens' access to prescription drugs at a time when spending on drugs is soaring. Is a national list of essential medicines the answer?

Many elderly people in the United States have no insurance cover for prescription drugs. Currently, one in four elderly people in the United States limit their drug use because of cost.1 The US Congress recently passed a bill that partially subsidises prescriptions for elderly and disabled people while promoting their use of private health insurance plans. Previous efforts to provide drug benefits to this population have been unsuccessful, however, largely because it would be hugely expensive. One way to extend access to drugs while containing costs is to establish a limited or essential list of medicines. This article discusses the benefits of such an approach and barriers to implementation.

Rising drug costs and spending

One of the reasons that US drug spending is rising rapidly2 is shifting demographics. The group aged over 65 is one of the fastest growing parts of the population. This group tends to be more chronically ill and require more drugs. Another reason for the increase is the influx into the market of newer, more expensive drugs for many diseases.

The proliferation of direct to consumer advertising may also be contributing to the rise in drug spending.2 The United States allows adverts in the broadcast media that encourage patients to talk to their doctors about trying brand name medicines. More money was spent in the year 2000 on direct to consumer advertising of the anti-arthritic drug Vioxx (rofecoxib) than was spent on advertising Pepsi, Budweiser beer, or Nike's top shoes.3 But pharmaceutical company spending on consumer advertising is only a small proportion of the promotional budget, most of which is still targeted at physicians.4 The industry …

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