Take Your Pills, All Your Pills
SourceURL:http://www.gadsdentimes.com
By ANDREW POLLACK
New York Times

Joseph A. Brocato's weekly self-injections of a drug to treat hepatitis C
left him so feverish and fatigued, he said, he often thought of quitting. He
didn't, thanks to a nurse who urged him by phone to stay the course.

The nurse, Colleen Dinsdale, did not work for Mr. Brocato's doctor. Rather,
Ms. Dinsdale was paid by the drug's maker, Roche, and its distributor,
McKesson. Each month that Mr. Brocato took the drug, Pegasys, and its
companion pill, ribavirin, meant $3,000 in sales most of it paid by his
insurance company. His share was a $50 co-payment.

The take-your-medicine program is part of a sales and marketing strategy
that is gaining urgency for drug makers experiencing slowing sales. As it
turns out, the industry leaves billions of dollars on the table or the
pharmacy shelves annually because people do not take their drugs as often or
as long as prescribed.

And so the hand-holding with patients like Mr. Brocato, who recently
completed his yearlong course of therapy. "They don't ever let a week go by
that they don't contact you, not just to say you are coming up on a refill
of your drug but just to say, 'How are you feeling?' " said Mr. Brocato, a
57-year-old auto parts deliverer who lives in Dundalk, Md. He said he called
Ms. Dinsdale so much that he programmed her number into his cellphone.

Stimulating sales this way is the focus of other industry initiatives,
including television advertisements like one by AstraZeneca in which a
doctor asks a series of patients if they are taking their Toprol-XL
hypertension pills daily. "You can't forget," the doctor gently scolds.
"High blood pressure can make your heart work harder than it should, every
day."

Lending credence to such efforts are many studies showing that failure to
take medicines as prescribed can cause patients to develop more serious and
costly complications later. So as industry tactics like wining and dining
doctors draw scrutiny, spurring people to take their pills is a less
controversial way to increase sales, one that the industry says is in the
best interests of patients and insurers.

Still, the efforts are not without detractors. Some medical experts worry
about consumers' privacy or the possibility of undermining doctor-patient
relations. There are also questions about the industry's motives.

"They're about brand loyalty and not about public health," said Dr. Jerry
Avorn, a professor at Harvard Medical School and the author of "Powerful
Medicines," a book critical of pharmaceutical marketing and regulation.

Dr. Avorn nevertheless said that low patient compliance with prescriptions
was a big problem for the industry and public health. "I'm often surprised
to hear drug companies worry about increasing their market share from 7
percent to 9 percent for a particular disease, when the 500-pound gorilla
issue is that half the people who were prescribed those drugs aren't taking
anything," he said. "A ton of money is wasted on paying for drugs which
people use so irregularly that they get no clinical benefit."

The World Health Organization, in a report in 2003, called noncompliance a
"worldwide problem of striking magnitude." It estimated that in developed
nations, half of patients did not take medicines for chronic diseases in the
prescribed manner.

Insurance companies have their own programs to get customers to take their
medicine. But it is the drug companies that feel the most direct impact when
patients fail to finish or renew prescriptions.

"We talk about this in terms of the leaky bucket," Anne M. Faul, director of
pharmacy strategy and analysis at GlaxoSmithKline, said on a recent Webcast
organized by Frost & Sullivan, a consulting firm, and sponsored by McKesson.

GlaxoSmithKline, which makes the diabetes drug Avandia, is offering to pay
for employer groups in 10 cities to replicate an experiment that started in
1997 in Asheville, N.C.

In that test, Asheville municipal employees with diabetes were encouraged to
take treatments for their disease, through efforts by pharmacists and
diabetes educators and by the waiver of co-payments. As a result, the
patients' control of their blood sugar improved and the city's overall
medical costs fell. Spending on drugs alone, however, increased.

Research finds various reasons that people do not take their medicines.
Forgetfulness accounts for about one in four cases, according to a survey of
10,000 people in 2002 by Harris Interactive and the Boston Consulting Group.
Another reason is that patients may feel no urgency about taking daily pills
for conditions like osteoporosis and high cholesterol, in which drugs do not
relieve any immediate symptoms but reduce the risk of future problems.

Other reasons, cited by the survey and other specialists, are ones the drug
industry's inducements cannot necessarily resolve like complaints that the
drugs cost too much or do not work or cause unpleasant side effects.

Kay Wissmann of Chicago said she stopped taking tamoxifen, intended to
prevent a recurrence of breast cancer, because it made her feel terrible and
exhausted. "That's one of the things oncologists don't realize, because
they've never taken the medications themselves," she said.

Even though she had a relapse of cancer, she said that not taking the drug
was the right decision.

AstraZeneca, which sells tamoxifen under the brand name Nolvadex and another
breast cancer drug, Arimidex, helped pay for a meeting of a group of cancer
patient organizations in Washington in November to plan a compliance
initiative. A paper is now being prepared and discussions are continuing on
possible remedies, said Terri Ades, director of cancer information at the
American Cancer Society.

Some companies let patients enroll in a program that provides information
about their disease as well as reminders to take their drugs. Novartis, for
example, recently started BP Success Zone for users of its blood pressure
drugs, including Diovan, its biggest product.

Customers can interact on a Web site, through e-mail or regular mail or at
the pharmacy. Patients are offered advice on diet and exercise. They can
also get a free monitor to test their blood pressure.

"You've got to give them some success metric," said Kurt Graves, global head
of the general medicines unit of Novartis.

Participants receive a card that entitles them to discounts on refills. When
the card is used, it provides information to the company on how often
patients renew prescriptions.

In Florida, Eli Lilly is offering the state's Medicaid program a bigger
discount on Zyprexa, the schizophrenia drug, the longer patients stay on it.
It is up to the state to figure out how to keep patients on the drug.

It is the brand-specific nature of some programs that concerns some
specialists. Dr. David S. Sobel, medical director for patient education and
health promotion in Northern California for Kaiser Permanente, a big health
maintenance organization, said drug company compliance programs were not
necessarily bad but that Kaiser preferred to run its own.

"If somebody's in a program for a certain statin and we change that statin,
are they out of the program?" Dr. Sobel said, referring to
cholesterol-lowering medication. "If it goes generic, do they shut down the
program?"

Dr. John Abramson, a physician and author of "Overdosed America," said
another potential problem was that medicines were overprescribed. In such
cases, compliance programs would be inducing people to keep taking pills
they did not need.

Some specialists say there is a potential for abuse in the closer links
being forged between pharmaceutical companies and their patients. In the
past, drug companies generally dealt only with doctors and insurers.

But organizers of the industry programs say that instead of bypassing the
doctor, they are providing services like 24-hour-a-day call centers that
many doctors cannot. "We are an extension of the physician's office," said
Kerr Holbrook, vice president for marketing at McKesson's specialty
pharmaceuticals division, which runs the program that worked with Joseph
Brocato.

Patients generally join such programs voluntarily, so privacy is not an
issue, they say. In some cases the doctors recommend the programs to
patients, saying the company efforts are useful and unobjectionable. "They
have really been hands off with corporate influence," said Dr. Robert G.
Gish, a hepatitis specialist in San Francisco who is a consultant to various
drug companies.

The National Multiple Sclerosis Society, a patient advocacy group, said it
stopped its own compliance programs because the drug companies were doing
such a thorough job.

Still, the programs tend to be for more expensive drugs. "Candidly, the
higher the price of the drug the more likely that somebody is going to do
this," said Ted Dacko, president of HealthMedia, a company in Ann Arbor,
Mich., that runs compliance programs for drug companies and insurers.
"You're not going to be doing this for Tums."


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