6/16/2003

KUFM / KGPR

T. M. Power

The Prescription Drug Sinkhole

The House and Senate have been wrestling with how to build a prescription drug benefit into Medicare so that senior citizens in their final years do not have to choose between food, shelter, and prescription drugs. Congress is unlikely to go very far towards solving this problem.

The problem with protecting seniors’ access to prescription drugs is the same problem that all of the rest of us face: the swelling use of prescription drugs and their skyrocketing cost. All insurance programs are buckling under the burden of rising prescription drug claims.

There are at two major reasons for this.

One is of very recent origin. The Food and Drug Administration approved direct advertising of drugs to consumers in 1997. Since then, television, magazine, and other media drug promotion has exploded. $2.5 billion was spent on this type of advertising in 2000. Some drug companies have larger marketing programs than name-brand-oriented firms such as Nike. The United States and New Zealand are the only two countries in the world that allow this promoting of prescription drugs directly to citizens.

This advertising drives prescription drug cost up for several reasons. The most obvious is that drug companies have to recover those marketing costs in the price they charge us for their drugs. In addition, they use this advertising to keep people from accepting much cheaper generic or other alternative drugs. Patients now tend to tell their doctors what drugs they want to take, based on the partial and misleading images and slogans the ads provide.

This advertising has the power that it does because of another trend in medicine: We increasingly turn to prescription drugs and surgery not to fight the effects of disease but to enhance our lifestyles. In the process we convert what used to be accepted as normal variations in our conditions of life into diseases that we need drugs or surgery to eliminate.

We straighten our and our children’s teeth so that we have beautiful smiles, but we give a medical explanation for those procedures. There are drug therapies if our children are too short or too skinny or too heavy. There are drug therapies if we or our kids are too shy, too active, too subdued, of too anxious. We have sports medicine programs. We have cosmetic surgery. We have medical fertility programs. We have drugs to enhance sexual performance and pleasure. We can change genders if that is important to us. Headaches, muscle pain, clogged sinuses, etc. need not slow us down or interrupt our normal routines any more. There are drugs to help us sleep as well as to help us stay awake.

For every lifestyle, for every negative experience in our lives, for every peak experience we wish to pursue, medicine can now assist us.

That makes medical intervention no longer a matter of emergency and unusual tragedy. Medicine is now becoming just another consumer field where we can shop for things we think will enhance our lives.

In this setting, as with clothes or other consumer goods, if we do not have to pay for what we want to consume, it is not clear that there is any limit on how much we might decide to consume. Consider what the situation might be if we had clothes insurance that allowed us to get new clothes for free any time we felt that the clothes we currently had were inadequate. Or consider expanding car insurance so that you did not have to have your car totaled in an accident before it was replace free of charge. You just had to convince a car salesperson that you current car was inhibiting your lifestyle and you would get a new car.

These examples suggest why it is no longer clear how conventional medical insurance can be made to work. Medical insurance was premised on the assumption that the vast majority of people would not ask for a medical procedure unless it was absolutely necessary for their continued functioning. Medical care was assumed to be painful and dangerous, turned to only in dire circumstances. But that is no longer the case. People now want to consume medical services and drugs for a variety of personal reasons. How can we possibly issue insurance in that setting?

We know part of the answer to that: Limit coverage to only those procedures and drugs that are in some sense “medically necessary.” Have a gatekeeper that excludes “elective” medical procedures and drugs. We have tried to do that with cosmetic surgery and sexual performance drugs. But these lines are socially and culturally determined and keep shifting. When a new drug or procedure makes something possible, it tends to become medically necessary, simply because we want it; it makes life more pleasant, pleasurable, or convenient.

Of course, a significant part of medical care remains focused on helping us stay alive and repairing serious damage to our bodies. The key challenge is how to effectively and fairly distinguish between consumer medicine and biologically necessary medicine. Until we recognize that distinction and act on it, our insurance programs are going to continue to bankrupt us and the nation.