|
Pricing DrugsSteven Morgan and colleagues (May/June 03) are overly critical of copayments and deductibles and overly enthusiastic about reference pricing. Prescription spending in British Columbia has grown faster than in other Canadian provinces since reference pricing was introduced there.1 They observe correctly that research-based drugmakers vigorously oppose reference pricing but were quiet when provincial plans increased copayments or deductibles, even though both approaches shift costs from taxpayers to patients. Why the different reaction? If the drugmakers were as politically powerful as the authors claim, they would lobby for complete government control over prescription drug spending and then focus on "capturing" the civil servants who manage prescription drug benefit programs.With valuable insight, Panos Kanavos and Uwe Reinhardt (May/June 03) use behavioral economics to hypothesize that reference pricing might signal relative value to patients and prescribers, whatever the accuracy of a formulary committee’s judgment. Neoclassical economics also tells us that reference pricing will lead to underuse of a restricted drug. Because reference pricing charges zero for the reference drug and a 100 percent copayment for the difference in price between a restricted drug and the reference drug, it distorts relative marginal prices against the restricted drug, whereas coinsurance or tiered copayments do not.
Fraser Institute Vancouver, British Columbia NOTE
The authors respond: Claims that British Columbia’s reference drug program was not successful are spurious and misleading. The program is perhaps the most thoroughly studied drug reimbursement policy in Canada, and independent evaluations show that it produced considerable savings without undue harm to patients or the health care system.1 Although the reference drug program cannot take all of the credit, only two of nine other provinces have experienced slower drug cost growth since it was implemented in British Columbia. Per capita prescription drug spending in the province grew $155 (78.7 percent) from 1995 to 2002, well below the $212 (84 percent) national increase.2 The jury is in on referencing: It works. By charging patients the marginal cost between products with, at best, marginal differences, referencing controls the impact of "me-too" drugs that have long been a source of unnecessary cost escalation.3 Of course, because drug cost escalation represents revenue growth for manufacturers, firms vigorously oppose referencing or any other policy that does more than shift ever-escalating costs to patients. The influence of drugmakers is considerable. Although some direct pressure is placed on civil servants, Graham’s concern about formulary committee judgments portends a more common form of capture—that of clinical and economic experts by the pharmaceutical industry.4 Well-intentioned policymakers, like prescribers and patients, are greatly influenced by experts’ claims. Owing to the often enigmatic nature of clinical and policy "evidence," expert opinion is influential even when spurious or misleading. Manufacturers are well aware of this, which is why so many experts find themselves beholden to firms that "sponsor" their work.5 The relationship between funding source and clinical trial conclusions is but one example of the effects of such capture.6 Thus, in addition to political will, Graham reminds us to add that prospects for pharmacare policies that promote affordable access to appropriate drug therapy hinge on the availability of truly independent experts who can critically evaluate products and policies. Alas, they are an endangered species.
University of British Columbia Vancouver, British Columbia NOTES
| ||||||||||||||||||||
