Today I was watching TV when an ad for a drug named Triplix came on. You’ve probably seen it, or at least similar ads, too. Rugged-looking blue-collar Joes with serious faces gaze at the viewer and say something to the effect of “I thought I had my cholesterol under control…but diet, exercise, and a statin alone weren’t enough. That’s when my doctor told me about Triplix!”
I had seen this ad before, but for some reason it really bothered me this time, perhaps because I have been thinking about healthcare costs a lot lately. Triplix is a new drug recently approved for use in addition to statins to lower bad cholesterol and triglycerides. The catch, however, is that all research with the drug shows that while it fulfills its claim of lowering those blood markers, there is no decrease in heart attacks or heart disease compared to just taking a statin (Source 1, Source 2). It even tells you this nonchalantly in the ad, I’m assuming because of some FDA disclosure requirement.
This one short ad encapsulates several deep-rooted problems with our health care system. First off, Triplix is hardly alone in being an FDA approved treatment that either works no better (or only marginally better) than existing, cheaper treatments. Take a look at cardiovascular stents, mesh implants that go in blood vessels to keep them open and maximize blood flow, which doctors in recent years have begun dispensing like candy. One inconvenient fact is that this expensive surgical procedure doesn’t have much long term benefit: many recent studies have shown no reduction in heart attacks or extended lifespan compared to those on drugs alone (Source). So basically, Triplix is a drug designed to be taken with another complementary drug (statins), but has no increased benefit over just the statin. Stents are very expensive surgical devices that are no more effective than routine drug intervention.
Unfortunately in this country, we have gotten used to accepting that more is better, and more expensive is much better. Any talk of restricting insurance and/or Medicare reimbursement for drugs like Triplix or surgeries like stent implants is attacked as “rationing,” “socialized medicine,” or worse. Critics raise the specter of G-Men interfering with your personal doctor-patient relationship. I could not find a lot of specific information on Triplix online, but I assume as a new drug for a high-demand disease it is fairly expensive. If it is not preventing heart attacks, heart disease, or helping people live longer, it is sinking lots of money down the toilet. You might say, “But my insurance company pays for it, so who cares?” The increasing cost of our healthcare system is driven primarily by expensive new drugs, surgeries, and tests. When people waste money on non-effective drugs like Triplix, all of our premiums get raised, more people get declined, and the number of uninsured goes up.
Second, these treatments have risks. Stents require vascular surgery that carries anesthetic risk and the possibility of complications. Triplix can cause problems with muscle and kidneys. These are not insignificant, and if the benefit does not counter this risk, why are we using these treatments? They are not only expensive but possibly harmful.
Third, direct-to-consumer drug ads in general just piss me off. You are marketing complex drugs to lay people. They have no idea how the drug actually works, the impact of side effects and drug interactions, or how to assess indications and prognosis. In my opinion, there is no reason for such ads besides profit for drug companies. Such ads have led to people storming into their doctors offices demanding drugs and treatments they may not need. How many times a day are we told to “Ask your doctors about the purple pill”? If you were a doctor and a patient was demanding a treatment he or she probably didn’t need, but might help and could make you some money, what would you do? It’s not that doctors are greedy assholes, they are human and if they can make money by a treatment that might be of some benefit, of course many relent and write the script.
Fourth, we need to ditch the idea that lawsuits and defensive medicine are the main reason for over-prescription of treatments. This revealing New Yorker article by a Harvard surgeon points out the fallacies in this argument by showing how health care spending in many areas of Texas that aggressively capped medical malpractice lawsuit rewards remained high with little benefit to patient health. The reasons for this are complex and beyond the scope of this article, but the take home point was that over-medicating and over-operating weren’t tied to medical lawsuits.
Finally, I wish the debate could change in such a way that people understand rationing is not only inevitable, but happeningright now. Insurance companies routinely deny people coverage for experimental and non-beneficial treatments. But they still cover a lot of ineffective medicine and surgery. There are limited dollars in the economy, and we can’t afford to keep carting every person with a headache out for an MRI, or to put everyone with heart disease on 8+ drugs. Rationing can be done in different ways, but is necessary due to limited medical and financial resources. Just because we are a wealthy country does not change the limited resources principle–it only stretches the limits of what we can afford and what we can’t.
In fact, the Mayo Clinic, one of the world’s best hospitals, agrees. They think an independent panel of doctors need to frequently evaluate what we spend money on, and only reimburse the things that have value, and lead to improvements in patient length and quality of life. They disliked the initial health care reform bills coming out of Congress, but brightened up at the proposal of IMAC, a panel that would evaluate what Medicare and Medicaid reimbursed, which would also have the effect of influencing insurance companies. Unfortunately, this idea, one of the best parts of the proposed health care bills, is being attacked by both parties and will likely be killed.
Until proponents of health-care reform are able to make the case for using available research to shape what gets funded and prescribed, and are also able to overcome the label of “rationing,” there will be no improvement in US healthcare. In a way it doesn’t even really matter who foots the bill, insurance companies or the government–if we keep spending on wasteful treatments our system will bankrupt itself without making us any healthier. Doctors also need to stop being afraid of research and “evidence-based medicine,” and use it as a way to inform their practice, not hinder. If a physician continues to use treatments shown to be of little benefit, he is harming his patient and costing all of us money.
Until then, I will continue to grimace every time I see that damn Triplix ad, which cheerfully informs us it doesn’t actually work.
