The heartburn drug Nexium, the object of a half-billion-dollar
marketing campaign to move people off the prescription medications
Top 10 Pharmaceuticals
Prilosec slipped from the number-one to the number-two selling
prescription drug last year after its patent was about to expire and
maker AstraZeneca shifted its promotional muscle to the "new Purple
The Life Cycle the Purple Pill
Worldwide earnings from the Purple Pill grew annually from the time it
was introduced in 1988 until just before its patent expired last year.
See sales chart
A physician's sample container of "the new Purple Pill."
ertrude was sitting with her husband in their Lowell living room, watching the
nightly news, when the man on the moving cliff found her during a commercial
break. "I'm every man," the serious, gray-haired guy said, nodding confidently.
"And every woman," continued a blonde standing on the adjacent cliff, "whoever
suffered from frequent, persistent heartburn." Over the course of 60 seconds,
waves crashed, sunlight pushed through an overcast sky, and rock formations
reconnected hydraulically. A dozen cliff-top baby boomers of every race spread
the word about Nexium, as capsules of "the new Purple Pill" rained from the
Like most of the TV commercials for prescription drugs that keep Brokaw,
Rather, and Jennings on the air every night, the Nexium spot ended with the
suggestion "Talk to your doctor." But Gertrude didn't have to. Her primary care
physician had already brought up Nexium with her at her last visit. "Hey, that's
the drug my doctor just switched me to," she told her husband. "It must be
The 79-year-old, who didn't want her last name used, is a longtime sufferer
of serious heartburn. So she's among the many who hail the miracle powers of the
original Purple Pill, Prilosec. That drug stripped misery from the lives of
millions and became the world's best-selling prescription drug - and the number
one medication prescribed for seniors - taking in $6 billion a year. Prilosec is
so good, and patients so attached to it, that doctors jokingly call it "purple
crack." It's an expensive habit, about $4 for each daily pill, or $1,500 a year.
General Motors alone spent $55 million on Prilosec for its workers last year.
The drug has been the ultimate cash cow for its maker, AstraZeneca.
But by now the cow should have run dry. The main patent on Prilosec expired
more than a year ago. Under normal circumstances, that would have triggered the
arrival of a generic version on the market, followed by a host of generic
rivals. With so much low-cost competition, we would all be enjoying lower drug
costs. But that didn't happen. Through lawsuits, the makers of Prilosec have
managed to keep the generics at bay while unleashing a half-a-billion-dollar
marketing blitz to move people off Prilosec and onto Nexium, their costly,
patent-protected new Purple Pill, which even their own studies show to be barely
more effective than the original.
How and why AstraZeneca has been able to keep the purple profits flowing
sheds more light on the nation's prescription drug crisis than reams of policy
papers and congressional testimony. The same tactics are being used by just
about all the big pharmaceutical companies, which are under intense shareholder
pressure to maintain their best-in-business profits as the patents on about 20
blockbuster drugs expire over the next couple of years.
That explains the ads for the new drug Clarinex that are everywhere, right
down to the white CVS bag your last prescription came in. Schering-Plough has
been feverishly working to move the itchy-eyed onto Clarinex and off its
omnipresent Claritin, whose patent expires next month. Ditto for Forest
Laboratories' new antidepressant, Lexapro, the spawn of Celexa, whose patent is
set to expire at the beginning of 2004.
But given the sheer numbers involved and its still-evolving nature, the
Purple Pill may be our best case study of the forces driving up prescription
drug costs. It's the story of a wondrous medical advance that brought relief to
millions and significantly reduced the need for surgery. But it's also the story
of the steroid-injected marketing muscle that has ensnared, among others,
Boston's most respected hospitals and the exhaustive legal maneuvers that have
delayed competition, helping to drive up costs for you, me, and Gertrude.
"This is a locomotive that's barreling down the tracks, and you either get
out of the way, get on board, or get squished," says Dr. James Richter, a Boston
irst things first: This prescription drug crisis you hear everyone squawking
about - it's really so avoidable. We Americans are on pace to spend nearly $200
billion on our meds this year. That's more than the federal government paid last
year for education, agriculture, transportation, and the environment combined.
It matches the highest prediction of what it would cost to topple Saddam Hussein
with a full-scale attack on Iraq. Talk about a war on drugs. In any rational
world, that sum would not just cover our current pill habit but would also allow
us to pick up the drugstore tab for all those senior citizens paying out of
pocket for their high blood pressure and arthritis pills. We could spare them
the indignity of those Greyhound-bus narc-runs to Canada to score their cut-rate
Cardizem and Celebrex.
Who's responsible for the fact that prescription drug spending continues to
rise 15 to 20 percent a year, doubling every five years? The big pharmaceuticals
have certainly lost much of their "best and the brightest - making life better
for you" luster. That's perhaps inevitable when you pour more money into
peddling your newest product than Nike does its sneakers. But there's plenty of
blame to go around. The government allows drug companies to control the testing
of new drugs, designing trials to suit their interests, not the consumers'. HMOs
and hospitals, under their own bottom-line pressures, make deals that help the
drug manufacturers move patients to new, expensive drugs when cheaper, older
ones might do fine. Doctors operate in a world where drug maker freebies like
Red Sox tickets, Four Seasons dinners, and Arizona golf outings somehow seem
normal instead of the outrageous graft they are.
Now go to your bathroom and look in the mirror. There's a good chance that
you're one of those shareholders demanding higher profits from the
pharmaceutical companies, even if you don't know it. (Think about those
pharmaceutical-dense mutual funds you're counting on to pay your kid's college
tuition.) Now open the medicine cabinet. Do you see a bottle of Clarinex? Or
maybe there's a vial of Vioxx, the new drug you pressed your doctor to prescribe
for your arthritis, because it did wonders for Dorothy Hamill. ("Look how easily
she can lace up her skates now!") Forget the fact that several studies have
questioned whether it's any more effective than over-the-counter Advil. Or maybe
there's some Viagra on the shelf. And let's just say you're half Bob Dole's age
and haven't been treated for prostate cancer.
"We're in this perfect storm of forces that conspire to make it a very
expensive time," says Dr. Thomas Lee, medical director for Partners Community
HealthCare, the largest physician network in Massachusetts. He ticks off some of
the factors driving up costs. First, all that research after World War II didn't
begin to bear fruit until the 1980s and 1990s. Now we have effective medicines
for all kinds of conditions, including ways to treat impotence and depression
that don't involve a couch. Second, we've got all these baby boomers passing
through middle age and either getting chronic disease or doing everything to
avoid it. "Baby boomers don't want to accept that they will ever die," says Lee.
Just since 1995, his Partners group has seen a nearly one-fifth increase in the
number of patients taking medication regularly. And last, we've got
pharmaceutical companies trying to get the maximum market for the drugs they
spent so much to develop. "They're not interested in fine-tuning to make sure
the people who get the new expensive drugs are those who will really benefit
from it," Lee says. "They want everyone for whom there is a reasonable
his is how it used to be: The boss would keep four bottles of Maalox in his
desk. Every three hours, he'd grab one from his bottom drawer and take a swig.
Short of surgery, there wasn't much else he could do to treat his heartburn,
which is the main symptom of gastroesophageal reflux disease.
Food travels from the mouth, down the esophagus, and through a sphincter
muscle to get into the stomach. Because the stomach is filled with acid potent
enough to take the rust off your car, the sphincter is supposed to relax only to
let food and drink in. But for the 25 million Americans who suffer chronic
heartburn, the muscle relaxes way too often. So the acid regularly flows up into
the esophagus, causing a noxious burning in the upper abdomen and lower chest,
especially after eating that third slice of deep dish pepperoni pizza.
In 1977, the Tagamet revolution began. Whereas the common antacids like
Maalox and Tums neutralized acid, prescription Tagamet blocked it. It made a
huge difference. Still, there was a group of people who needed something more
powerful than Tagamet and its successors, included in a class of drugs that came
to be known as H2 blockers.
In 1989, that power came in spades and in the unforgettable shade of purple.
Prilosec was the first proton pump inhibitor, or PPI. H2 blockers stop acid at
one of three possible sites in the cells of the stomach, but PPIs block it at
the final site of production. They're a fail-safe means of turning off the
stomach-juice spigot before it backs up into the esophagus. "Prilosec gave
physicians a sense of power, a sense that we can cure you," recalls Dr. James
Reichheld, an Andover gastroenterologist.
Still, Prilosec was really just a niche drug when the Swedish company Astra
AB (it later merged with the British firm Zeneca) teamed up with the US firm
Merck to launch it in the United States. The US Food and Drug Administration
approved it for just two indications, or uses, for which there was a
particularly limited pool of customers. Heartburn wasn't one of them. And there
were fears, later shown to be unfounded, that the drug might have cancer risks.
As most drug manufacturers do, Astra continued clinical trials to win
approval for new indications to put on the Prilosec label - it eventually
reached eight - and increase its customer base. (Remember, Viagra was originally
developed to treat angina; that whole erection thing was just a pleasant
Prilosec continued to grow. Then, in 1997, the FDA tied a bow on a big fat
gift to the pharmaceutical industry: relaxed rules for drug advertising. It's
not that direct-to-consumer advertising was a new phenomenon. Back in 1708,
Boston apothecary Nicholas Boone bought the first patent-medicine ad, announcing
in the News-Letter that he would be selling Daffy's Elixir Salutis for
four shillings and sixpence a bottle. It's just that, prior to 1997, drug makers
were required to disclose so many side effects on their ads as to make TV spots
unworkable. The new FDA rules allowed them to make their claims unimpeded, as
long as they offered a phone number or Web site or referenced a magazine ad
where consumers could get the fine print.
Prilosec was the perfect drug to market on TV. Millions of people have
gastric problems, and many were no doubt feeling the pain right as the
commercial flashed on the screen in front of them. Here was this incredibly
effective new medication waiting to change their lives. And when they later
found themselves sitting on a doctor's padded exam table, they didn't even have
to recall the drug's name. All they had to remember was its color.
Soon, Purple Pill ads were everywhere - on TV, on the Web, even on the floor
of New York's bus terminals. Hall of Fame pitcher Jim Palmer was telling anyone
who would listen how the drug had saved his broadcasting career. All those
forces helped catapult Prilosec to the top. In 1998, it became the first drug
ever to hit $5 billion a year in worldwide sales, and it didn't stop there.
Here's the thing: Unlike many hyped drugs, Prilosec is a wonder drug that
actually deserves its title. In dozens of interviews for this article, even
critics of the purple juggernaut got around to saying: "It's a very good drug."
But that doesn't mean a slew of people couldn't do fine on something much
ive drug companies their due. Discoveries in many areas, such as cholesterol and
high blood pressure, are lengthening lives. Jeff Trewhitt, spokesman for the
pharmaceutical trade group PhRMA, points out that 10 years ago we had no
medicines on the market for Alzheimer's; now we have four and 17 more in the
human clinical testing stage. All these advancements are helping keep our
parents around long enough for them to really get to know our kids, and the drug
companies deserve our profound thanks for that.
Still, somewhere along the way, true innovation seems to have become less
important to many pharmaceutical companies. How else to explain the
proliferation of "me-too" drugs, which are not replicas like generics but
patent-protected variations of another company's popular drug? Two-thirds of the
prescription drugs approved by the FDA in the last decade were modified or
derivative versions of medicines already on the market, according to the
nonprofit National Institute for Health Care Management.
Prilosec's success prompted several competitors to come forward with their
own PPIs: Prevacid (TAP/Abbott), Aciphex (Eisai/Johnson & Johnson), and Protonix
(Wyeth). And, of course, Prilosec me-too'ed itself last year with the launch of
It's probably not surprising that me-toos have become so irresistible. Trying
to come up with genuine breakthroughs is a lot harder, riskier, and more
expensive. A recent study from Tufts University's Center for Drug Development
found that it costs an average of $802 million to develop and win approval to
bring a new drug to market in the United States.
Why so much? Take a drive out to Waltham to AstraZeneca R&D Boston, the
company's new three-winged structure of Minnesota limestone. Throughout four
floors of bright, impeccable labs, sneaker-clad scientists in white coats are on
the hunt for genuinely novel medicines - not me-toos - to treat cancer and
infection. In a field that has come to be dominated by talk of profits and
patents, the vital work going on behind these glass walls - testing and
retesting compounds, replicating DNA - puts some of the inspiring sheen back on
the pharmaceutical industry.
I ask Hans Nilsson, the Swedish native who oversees the Waltham site, why
it's so hard to hatch a new drug. He walks up to the white board in his office
and makes a series of drawings: enzyme, membrane, cell, tissue, organ, mouse,
cat, dog, monkey, human, cluster of humans. Drug discovery, he says, is the
attempt to make a series of increasingly complex connections to get to the
finish line. If the connection works from, say, cell to tissue, you can move on.
More often than not, it won't, so you have to return to an earlier step. Even at
the end, when you've shown a compound to be effective and safe in thousands of
humans, you might get one whose liver fails because of toxicity caused by the
drug. So you start again. The vast majority of attempts will never get to the
approval stage. The trick is knowing how long to stick with it or when to pack
it in. Research on omeprazole, the generic name for Prilosec, "started in the
late 1960s," Nilsson says. "It was launched 20 years later. Twenty years. You
never know how close you might be."
To those who question how a company like AstraZeneca can justify the
staggering profits it collects from a drug like Prilosec, Nilsson again points
to his sketch. "This is the answer." AstraZeneca spent $2.7 billion on R&D last
year. Then again, the company also reported profits of $4.2 billion.
Still, all the competition from the me-too drugs should bring down overall
health care costs, right? Maybe in any other world. But the exorbitant marketing
campaigns used to launch competitors, like Prilosec me-too Prevacid, tend to
drive up costs. They increase the patient population, sucking up customers who
might do fine on 50-cents-a-day generic H2 blockers and moving them into the
new, more powerful PPI club, whose daily admission fee runs seven to eight times
James Richter, the longtime Massachusetts General Hospital gastroenterologist
who last month became chief medical officer of Caritas Christi Health Care
System, puts it this way: "You go to the rental car counter, and the company's
paid for it, and you can get a Hyundai or a Cadillac. So you take the Cadillac
even though the other would be sufficient."
r. Tim Ferris is sprinting down the corridor of Mass. General's Everett Family
Care clinic, past copper-colored walls a shade darker than his hair, past
several exam rooms where other patients sit staring at the walls, and into the
room where 52-year-old Linda Nicotera waits. His salary is based on his seeing
about 20 patients a day while somehow managing to fit in all of his
"So, Linda, how are you doing?" Ferris begins. The wailing of a 3-year-old
having his blood drawn carries clear across the clinic and into their room.
After dealing with her shoulder pain, Ferris asks, "How about your stomach?
Any problems with the switch from Prilosec to Protonix?"
"No, it's been fine," Nicotera says.
Ferris smiles. Nicotera's previous doctor had put her on Prilosec, and it had
done wonders to cure the pain that had refused to go away even after she cut out
acidy foods, put the head of her bed on blocks, and swallowed gallons of
Mylanta. There was "a hundred percent difference in how I felt after taking the
Prilosec," she says. Since Nicotera has a particularly severe gastric problem,
Ferris knew she wasn't a candidate to come off PPIs altogether. But during her
last visit, he looked at the big drug chart hanging on the wall. It groups all
the common prescription drugs by colored category: the green column has generics
and other cheap drugs; yellow are midrange in cost; and the red zone is the
Mercedes class, where Prilosec and many other blockbusters live. They're the
ones that bust the budgets of the insurer and doctors' groups, which jointly
shoulder the drug costs, and come with the highest copays for patients.
Protonix is in the yellow zone, so Ferris asked Nicotera if she'd be willing
to give it a shot. She's on seven medications - most of them requiring Mercedes
copays - so she agreed.
Ferris knows that most patients are less likely to go along with a switch,
especially if it means leaving the PPI club entirely. When he's not bounding
between exam rooms in Everett, Ferris is poring over data at Mass. General's
Institute for Health Policy in Boston. Between 1998 and 2000, he led a program
tracking 1,000 patients in Partners Community HealthCare who were on PPIs. The
hypothesis was that too many people were on them and many could be moved to
"PPIs didn't exist a decade ago, and they were originally intended to treat
this very rare condition," Ferris says. "But now there are tens of millions of
people taking this medicine that was never intended to treat an entire
population." In Detroit, General Motors, which self-insures most of its
employees and retirees, found that 92 percent of its people on Prilosec had not
begun on a cheaper drug like an H2 blocker.
Ferris's program identified a group of patients on PPIs and asked their
doctors to have them "step down" to an H2 blocker and then perhaps to forgo
medication entirely. Bottom line: The vast majority of the people who were taken
off Prilosec or another PPI managed to find their way back to the drugs. The
program was disbanded. Why did this happen? Ferris had only to think back to his
work at the Everett clinic for the answer. A doctor, desperately pressed for
time, gets a call from a patient he's moved off the Purple Pill and onto an H2.
"Doc, my heartburn is raging. It's worse than ever, and this new pill you gave
me just isn't cutting it." This might be the only problem the doctor can
satisfactorily solve today, so his response is simple. "Go back on Prilosec.
I'll phone in a new 'script."
That's no isolated case. There's a phenomenon associated with PPIs called
acid rebound. Because the medicine puts a brake on the acid-producing pumps in
your stomach, when you stop taking it, that built-up acid can be unleashed, says
Ferris. Even if there's no full-scale rebound, most people have some recurrence
of symptoms because the PPIs were powerful enough to let them resume bad habits,
such as eating fatty foods. When that power's gone, they start paying for their
sins. Ferris and his associates recommended extra doses of the H2 blockers at
the beginning, knowing that rebound is usually temporary. But few people made it
What's clear is that if you want to restrict this expensive drug to only
those people who really need it, you have to start at the beginning, before
they've test-driven the Cadillac. But all those TV commercials make that next to
impossible. Most people have a spouse or a cousin or a mechanic who's on the
Purple Pill and speaks evangelically about it ("I can eat chili again!"), so
they enter the doctor's office knowing what they want. Richter explains how it
works: "They come in and say: 'My husband takes Nexium. Do you think that would
work well for me?' I say, 'Yes, but have you tried Tagamet? It doesn't appear
that you're having symptoms that frequently.' But they say, 'Nexium and Prilosec
seem to work really well.' So I say, 'Fine.' "
Besides cost, there's no downside to taking Nexium or Prilosec. But if it
takes a doctor 15 minutes to talk a patient out of a more expensive drug - and
that's pretty much all the time the doctor has with the patient to begin with -
it's not a practical investment. And this calculation comes from Richter, who
for 20 years has refused to meet with drug company sales representatives, on
principle. Think about how much more quickly a doctor might offer up the new
drug if he had the Nexium golf-scoring software loaded onto his Palm Pilot or if
the Nexium drug rep had just brought by lunch for the staff when he arrived to
restock the sample cabinet.
hroughout the summer and fall, David Calabrese had a ritual to start his day. He
would walk into his Roxbury office and check his e-mail in search of an
announcement that the generic Prilosec had finally been launched. Calabrese is
the pharmacy director for a network of 2,500 doctors associated with Beth Israel
Deaconess Medical Center and several other medical facilities. Last year,
Prilosec was the biggest item ($6 million) on his outpatient drug budget. A
generic offers the promise of cutting that tab by a third in the first year and
much more in subsequent years.
AstraZeneca's Prilosec patent expired in October 2001. So Calabrese and many
pharmacy directors like him across the country - for HMOs, physician groups, and
hospitals - built those expected savings into their drug budgets this year. The
fact that they have not materialized may well help drive up everyone's insurance
premiums next year, he says. It doesn't matter if you never get heartburn. You
could be one of those people who can guzzle a whole bottle of Tabasco sauce and
not so much as burp. You're still affected by the Purple Pill. The overall costs
to the system are that big.
Late one Friday night last month, Calabrese got the e-mail message, but it
didn't say what he had expected. He quickly forwarded it to a few co-workers,
putting "Ugh" in the heading.
AstraZeneca had long ago filed suit against four companies planning to
produce generic Prilosec, claiming infringement not on the main patent but on
secondary ones. The trial began last December in a federal court in New York and
dragged on until June. Most analysts expected AstraZeneca to lose, and the
company's stock took a beating. But after the judge issued her ruling on October
11, the company's stock shot up.
She ruled that three of the four generic companies had infringed on
AstraZeneca's patented method for inserting a "subcoating" between the main
Prilosec molecule and its purple shell. Critics had scoffed at this claim,
pointing to a host of drugs that have similar subcoatings. But a patent is a
patent, the judge ruled, and this one doesn't expire until 2007.
AstraZeneca spokesman Jim Coyne called the decision a "vindication." The
case, he said, "has always been about defending our intellectual property." The
company's chief executive, Tom McKillop, told The Financial Times of
London that the court action clearly paid off for his company: "Our defense
strategy has already given us longer exclusivity over the last few months. And
now it is likely to give us some months more and maybe even a lot longer than
The two generic companies poised for a quick, aggressive launch were shut
out. Earlier this month, they announced that, in exchange for a share of the
profits, they would assist the one tiny firm that the judge said could launch a
generic Prilosec. Still, AstraZeneca may appeal the part of the ruling that gave
that firm the green light. Says Calabrese: "There's a flicker of light at the
end of the tunnel, but I'm not very confident we'll see a generic Prilosec
The world's other big pharmaceutical companies cheered the ruling, and their
stock responded accordingly. Most are in the same patent boat as AstraZeneca.
The 1984 Hatch-Waxman Act awarded drug makers 17 years of patent protection
(later extended to 20 years) for drugs they create. The clock usually starts
ticking long before a drug is launched. These days, when the 20 years is up,
brand-name drug makers do not allow their blockbusters to go off patent quietly
into the night. They file for all sorts of extensions. And they have become
increasingly savvy in obtaining patents for every conceivable feature of a drug,
from its coating to how it combines with other drugs to its color. Other
brand-name companies, like the makers of Prozac, lost their patent infringement
cases. But AstraZeneca's victory is a strong sign that it can pay to take
generics to court.
Meanwhile, all the court delays have given AstraZeneca time to move market
share to Nexium, and that's where hospitals like Mass. General and Brigham and
Women's come in. In exchange for getting Nexium at a fantastic discount, the
hospitals agreed to make it their primary PPI. The switch will save Mass.
General alone more than $300,000 a year. And the price discount is clearly worth
it for AstraZeneca, since patients will be discharged on Nexium, residents will
be trained on Nexium, and doctors across the country will be told that Nexium is
the first choice of world-famous Mass. General.
AstraZeneca spent $478 million last year on its Nexium promotional campaign,
according to IMS Health, and hired an additional 1,300 sales reps just
for the new Purple Pill, according to Scott-Levin Consulting, a health care
research firm. The push has been incredibly effective. Some 42 percent of
Prilosec prescriptions have been converted to Nexium, according to data from the
investment firm Dresdner Kleinwort Wasserstein.
Nexium is actually just one-half of the molecule that makes up Prilosec. The
theory is that it improves the efficacy of a drug when its most effective part
is isolated, in this case the "S isomer." Many specialists doubt this claim.
Nonetheless, this route to a new product is becoming more common in the
industry. Dr. Doug Levine, AstraZeneca's executive director for gastrointestinal
clinical research, says Nexium represents a clear improvement over Prilosec. But
in most of the company's trials, the effects of 40 milligrams of Nexium were
compared against 20 milligrams of Prilosec. In the two instances where they were
compared at equal strength, only one showed a statistical difference, and that
was a 3 percent shorter healing time.
Dr. Jerry Avorn, chief of the Brigham's pharmacoepidemiology division, says
flatly, "Nexium is not at all better in any meaningful way than Prilosec." One
of the nation's leading experts in the study of physician prescribing patterns,
Avorn has made it his life's work to try to outsmart the drug companies. Asked
why his hospital decided to take the Nexium deal, he leans back in his chair,
scratches his Abe Lincoln-style beard, and sighs. Noting that he didn't make the
decision, he says he does understand it. Hospitals are under incredible pressure
to keep their costs down. A deal like this could prevent the Brigham from having
to lay off nurses. "It's not like anybody is taking home extra money in a valise
at the end of the month by doing this," Avorn says. But he acknowledges the "bad
outcome" it produces: a new cycle of patients with unnecessarily higher drug
It's yet another sign of what's wrong with our health care system, he says,
and why fixing it seems so hopeless. "You've got hospitals doing what's good for
hospitals, HMOs doing what's good for HMOs, and drug companies doing what's good
for them," Avorn says. "We've got this crazy patchwork, with everyone against
everyone else, and you end up with these paradoxes like Nexium."
o how do we stop this drug cycle from truly spiraling out of control? For
insurers, the answer seems to be learning to say no a lot more. Most are
implementing aggressive cost-control programs, such as "prior authorization," in
which doctors have to obtain approval from the insurer before putting a patient
on a particularly expensive drug when there are comparable, cheaper drugs
MassHealth, the state's Medicaid program for the poor, spent $25 million on
Prilosec last year. In August, it stopped paying for the drug unless a doctor
could prove that a patient needed it over a cheaper alternative. Harvard-Pilgrim
Health Care, Tufts Health Plan, and Blue Cross Blue Shield have all introduced
their own prior authorization programs. But in a system already larded with
excessive bureaucracy, few see this as the right way out. Avorn calls it the
Also, because each insurer is out there cutting its own deals with all the
various drug manufacturers and pharmacy benefits managers, there's little
consistency in restrictions. Tufts, for instance, drew fire from many of its
members a few years ago when it said no to Claritin. But because it got a good
deal on Nexium, the new Purple Pill is not on Tufts's prior authorization list.
What seems clear is that consumers will soon be much more aware of what drugs
actually cost, because insurers and employers will be passing on a much bigger
chunk of the bill. It won't be a matter of a $25 copay rather than $10. They
will either have to be prepared to pay full freight for the Cadillac or get used
to riding in the Hyundai.
Some answers may lie in Washington, D.C. For years, the drug manufacturers
have protected their interests by sharing their wealth with congressional
campaign committees. But in the face of public anger - anger that will only
intensify as premiums continue to rise and insurers say "No" more often - such
protection only goes so far. Federal regulators recently announced a plan to
crack down on the most flagrant wining and dining of doctors by drug companies.
But it's not at all clear that anyone has the stomach for real revolution, such
as having an independent body with the consumers' interests in mind take over
the entire testing process for new drugs.
There is momentum elsewhere, though. Last month, President Bush proposed new
rules aimed at limiting the ability of brand-name drug makers to stall generics.
And last year, John McCain and Charles Schumer persuaded colleagues in the US
Senate to pass an even tougher measure designed to curb all those patent
lawsuits that the Hatch-Waxman Act unwittingly spawned. Though it's been stalled
in the House, the measure is being pushed aggressively by a coalition of
consumer groups and some of Big Business's biggest guns - General Motors,
Wal-Mart, Motorola - which bear much of today's health care costs. "We've zeroed
in on Prilosec," says Brad Cameron, a Washington lobbyist leading the charge on
behalf of the coalition. "We've got to find a way to close these most egregious
Then again, it may not be wise to bet against the purple powerhouse that has
defied every expectation since its launch 13 years ago. The 39-year-old Cameron
has had heartburn since he was in college. He confesses that when his symptoms
got worse recently, he went to see his doctor. "My best friend's on Prilosec,"
he told his doctor. "It works for him. How about Prilosec for me?"
Neil Swidey is a Globe Magazine staff writer. He can be reached at
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YOUR HEALTH CARE PROVIDER.
"A foolish faith in authority is the worst enemy of truth."
-- Albert Einstein, letter to a friend, 1901
"I know of no safe depository of the ultimate powers of the society but the people themselves, and if we think them not enlightened enough to exercise control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education."
-- Thomas Jefferson, letter to William C. Jarvis, September 28, 1820
“A sacred cow will not protect the herd.”
-- Sandy Gottstein
"What's the point of vaccination if it doesn't protect you from the unvaccinated?"
-- Sandy Gottstein
"Who gets to decide what the greater good is and how many will be sacrificed to it?"