It's a matter of choice

No matter what way you slice it , consumers want choice. It doesn't matter if the products are cell phones, automobiles, gas, electronics, internet, TV, radio , food , and I think you get the picture. So too do industries want choice. For example and I'll build on my earlier post. Retailers want choices. They want to decide which products they carry and which they don't. The manufacturer can create awareness of a product prompting the end consumer to ask for specific products, but it is the retailer that decides if they will indeed carry the product.

The end consumer can decide to shop at a store which carries a particular brand or they can choose to go elsewhere. That is the power of choice.

Now what if your choice was restricted in some way? Here is a far fetched example of this . Let's say a Municipality creates a bylaw that restricts your choice of automobile to only North American company manufacturers. What would be your reaction be to this? I believe the outcry would be huge. That was a far fetched example but let's look at a more realistic model of restriction in choice. What if you were restricted on choice of prescription pharmaceutical? This is a very interesting case , as you probably know that this , does exist. The crisis in healthcare spending being the key reason . The issue with such restrictions are varied as the impact on choice is felt in several silos in Health care. The obvious one is the end consumer's choice is restricted, but lets examine the implications of this further.

If we start with the Physician as writing a prescription , most often they have been detailed on newer products and will write a brand product. (Only Brand Name Pharmaceutical companies call on Physicians) The prescription goes off to pharmacy where the formulary is enforced. So, if a product is not covered the pharmacist and patient have to go through a number of issues ,which can include ,the patient footing the bill, a call back to the physician, increased paperwork for the physician, perhaps even another visit to the physician. In essence the restriction has added cost to the health care field . So who in this scenario feels the most restricted. I suggest it is the physician and the Patient. They want choice.

World of retail

In that world, shelf space is key. Eye level is where everyone wants to be and manufacturers actually count facings (number of units displayed) as they pay for such space. If a large manufacturer comes out with a new line of product or even a line extension of one product, they must pay the retailer to carry it (a listing allowance) then they must pay them for the amount of space they want, and at what level (eye level being the most expensive). Then they have to work out a deal for a promotion or end isle display etc all with volume expectations and more cost.

Now consider the retailers and drugs. The front of the store runs like above, but behind the counter, the brand manufacturer does not pay a listing allowance or anything like the above scenario. At least not to my knowledge. The store is obligated to carry the new product if a physician writes it. These products are the most expensive so they drive up the retailers inventory level and cost of goods sold. If the new product is accepted by the physician community, and takes off in sales, a larger space is required to store the product but still no manufacturer financial support for this. Unlike the front of the store, there are some extra fees the retailer charges the customer for; i.e. dispensing fees. Really the retailer is dictated to by the manufacturer of the patent protected products.

Once the product is off patent however, there is competition and the retailer gets rebates by the generics. It becomes much like the front store scenario with listing allowances, incentives or rebates. The cost of goods goes down as these products are less expensive but so too does retail sales. If they lower the price of these products they have to make up the sales dollars elsewhere as investors would hammer them if retail sales decline year over year. (a catch 22). So unlike the front store, where manufacturers pay for shelf space etc in the hope to increase sales and market share of their product, these manufacturers know that the overall market is going to decline or not grow as physicians switch to other promoted agents. And the cycle continues.

Power of promotion

An interesting Article from PharmExec.com back in August, discussed the situation with Statins in Belgium.

Belgium's statin stalemate

I think it clearly demonstrates that , whatever controls are placed on pharmaceuticals, you must bring physicians and pharmacies on side. If a drug with ample scientific research, major market share , and physician preference goes off patent, should we not encourage its continued usage? It is all well and fine to attack the pharmaceutical industry for their promotional activity but why not look at how we treat drugs that have faced the patent cliff. Currently , there are over 1000 drug plans across this country. Physicians can't and don't know which third party plan any patient has! There is a level of frustration with plans as controls most often mean more paperwork, callbacks, delays in therapy , etc. They have an obligation to give the best standard of care they can and that includes the best drug they believe available. The pharmaceutical companies direct the education toward their new products (some of which offer little or no advantage over existing medications) Perhaps it is time that we look to changes in how the conversion over the patent cliff is handled by the plans. Put in place, physician focused positive techniques rather than the negative methods currently used or a combination of these as controls are necessary too. To do this , Payers need to direct some attention to helping the primary decision maker (The Physician) .

The above example from Belgium clearly shows that you can lower prices but the primary decision maker must be part of the solution.

Health Care at the Forefront

I'm just back from a trip to Bethesda, Maryland and Washington, D.C., where Health care issues are front page news each and every day. Last night ABC had a one hour special featuring Oboma as he answered questions from a group of people at the East wing of the White house . It was really interesting and I think he spoke very clearly about the challenges to this reform. But, I was left thinking about how this issue is not a US issue , it is an issue facing virtually all countries. Here in Canada our Industries and governments are sharing in the pain. provincial budgets are hovering around 50% going to health care. Corporations, organization , unions, and private payers are all struggling with the rising cost of drugs. There does not seem to be any sort of Federal direction on reform and the provinces are individually dealing with the public side of things .

Now just recently, at the 2009 Western Premiers’ Conference , the premiers announced they were taking action on Pharmaceuticals and forming a buying group. So It would appear that they will tender for drugs which will increase competition between the Generic companies and now the Brand companies as well. So we will have a large public buying group out west, then the tendering in Ontario and most likely Quebec These three buying groups would represent over 90 % of the public drug spends in Canada. Unfortunately , Atlantic Canada doesn't seem to have moved in this direction yet but perhaps soon. In any event, they will remain a small piece of the puzzle and most likely to see higher prices than with the other larger groups.

So, what about the Private Plans that are actually footing a larger portion of the drug spend across the country? What will these changes mean to them? Most likely higher costs and as we have seen in Ontario , two prices for a particular drug. One price for the public insurance and another higher cost for third party.

Will the Plans react to this? Perhaps. There is an initiative developing in Atlantic Canada that is gaining momentum. But more on that later.

Another interesting , development is with GM and Chrysler. They have their service provider de-listing the generic versions of the following drugs.

Zocor, Vasotec, Fosamax, Neurontin, Zoloft,Diane-35, Adalat-XL, Zithromax.

They will be covering the brand drugs only here. So it is reasonable to assume that a deal was struck for better pricing of these products. It is unclear if the deal is with the insurance provider or with the individual companies. This move has major implications for the pharmaceutical industry , plan payers and insurance.

This is similar to what an Atlantic Canada based provider attempted to do with one pharmaceutical company last year but the attempt failed with pressure from several groups. This move may be smoother as it involves more than one pharmaceutical company, a need for cooperation by the pharmacies due to GM and Chryslers economic position and the sheer size of the business in the Ontario region.

Dependent upon how the deal above is structured, it gives the Brand companies stronger ties with the payer groups, allows them to better manage loss of patent, increases competition directly with the generics. But, It also gives them the opportunity to better manage their core business in the Physicians office.

If one manufacturer is supplying both the Patent drugs and off patent, and is also directing the physician education and marketing to the new products, they then have even more control over the supply chains. If GM and Chrysler don’t make a concerted effort to educate physicians to help then nothing has changed. The Pharmaceutical companies will educate the physicians that they can now get this new product as they just listed it directly with GM. Or help them walk through the process required to have it covered. It points to need of having a voice for GM and Chrysler and their employees directly involved with physician and employee education. Now is the time to initiate this.

No more free Samples

If you were about to purchase a new vehicle, you may want to test drive a number of cars to see which you liked best , felt the safest , liked the gas mileage, had the smoothest ride,  wanted a hybrid, etc.  Then you decide and with the assistance of your financial institute you make your purchase.   Just imagine, instead of being able to test drive a number  of vehicles, you are automatically directed  to test drive only the newer expensive models. If you want to try a less expensive model , you have to go down the street and you have to pay to try these models.  To make matters worse, these models have foreign names that you find confusing .  In fact the dealer may not even know the names!  

Nowadays, your choice of drug may cost as much as a new car over the course of several years.  Or in some case in just one year. 

Well, there is an article on Plos Medicine with the above title , you can click here for the link.  It makes the case for eliminating pharmaceutical samples or even vouchers from physicians offices.  I feel this is too big a change and one which may never occur.  One area not explored by this story is to actually increase the sampling to physicians.  If you read the article this sounds like a wild idea, but, consider that the article talks about samples that are the higher priced new drugs with relatively little number of studies .  So, what if there were samples of drugs with huge volumes of data behind them and that they were lower cost.  Now the physician would have to choose... Do I (A) write this drug that is being marketed by the industry  or  (B) continue to write this product that I have learned so much about.  I know its safety profile and efficacy and can leave the newer agent as my second choice or even third choice.  If evidence is provided to show the new drug does amazing new advances then the Physician may consider it.   

Here in Atlantic Canada  we have tried this very thing in our projects and have had great success with physicians and local pharmacists  but have been met with significant push back from some areas you never would have guessed.  We used a voucher system through the pharmacy to obtain the lower cost meds.  Physicians like the approach and so do patients.  A much larger trial is needed now.  

update

More charges laid in alleged Ontario drug reselling scheme... Canadian Press 

Travel

I had a very interesting and productive trip recently to Saskatchewan and had the opportunity to hear the deputy Minister of Health , Dan Florizone speak about their "Patient First Review " program.  He focussed on the difficulties of running the health system and the specifics to wait times within the system.  He made a humorous analogy to opening three restaurants (the only three in town) and waiting in line to get a table.  It really was an effective way to demonstrate the complexities and issues with wait times.  He cited lack of communication and respect as a major barrier and an abundance of administrative duties as some key areas. They recognize that it is the Patient that actually experiences the full process from beginning to end and they are trying to learn from this.  Fixing one area which may cause disruption in another is not the answer.  They are still struggling to make changes but certainly they appear to be seeking answers.