President Trump made headlines recently after signing several executive orders aimed at lowering the costs of prescription drugs. The overarching goals of the executive orders are noble, but questions have risen regarding the actual impact these orders will have on the prices of life-saving medications. I had the privilege of speaking with Harvard Medical School professor Dr. Jerry Avorn about the impact the executive orders would have on drug prices as well as the work he is doing to reduce the costs and improve the quality of drugs prescribed by doctors. In addition to his role as a Professor of Medicine at Harvard, Dr. Avorn was the founding Chief of the Division of Pharmacoepidemiology at Brigham and Women’s Hospital and is the author of Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs.
On July 24th, the President signed four executive orders, which he says will “massively reduce the prices of prescription drugs, in many cases by more than 50%.” However, experts are not so sure that this wishful statement can become a reality. The Wall Street Journal quickly came out with an article titled “Expect Little from Trump’s Drug-Price Move,” and Dr. Avorn began our conversation by saying that “These executive orders are clearly an attempt for the President to say that he is doing something, but making a speech about a plan to issue executive orders is not the same as enacting good policy. The themes found in the executive orders have been around for years, yet the President has not implemented anything of consequence. There are administrative, legal, and policy reasons why I don’t expect much to come out of any of these executive orders.”
The issues outlined in the orders, however, are worth diving into. One of the orders is aimed at cutting profits for Pharmacy Benefit Managers, or PBMs, which are middlemen who administer prescription drug plans for over 270 million Americans. PBMs contract with pharmacies and health insurance companies to negotiate drug prices for employees’ health plans, and they claim to save money for consumers and reduce waste in the system. However, PBMs notoriously play games that reap massive profits. As Dr. Avorn says, “It is impossible for a patient or prescriber to know how much a drug actually costs, and this nicely suites the needs of PBMs because PBMs can say, ‘We are saving a lot of money for people… but we won’t tell you how much!’”
One of the other executive orders signed by the President involves a proposal to import drugs from Canada—where many drugs are much cheaper. Canada has not agreed to such a measure, and when I asked Dr. Avorn whether this plan would work, he said, “If we take a step back and look at the volume of medications used in the U.S. compared to the volume used in Canada, our country could rapidly deplete the supply of drugs in Canada. I know that Canadians are worried about this. So, while I don’t believe it should be illegal to import drugs from other countries, it is an incomplete method to deal with the problem.”
Our conversation then moved towards what Dr. Avorn is famous for inventing. In the early 1980s, Dr. Avorn invented the practice of Academic Detailing, which is an educational outreach program in which healthcare professionals, such as physicians, pharmacists, and nurses, are trained to provide prescribers with the latest research on the most cost-effective prescription drugs, rather than having physicians rely so heavily on receiving drug information from sales representatives who work for drug companies. Sharing the origins of academic detailing, Dr. Avorn said, “When I was in medical school, I noticed that there was a tremendous difference between the ability of academics to make a case for using a specific drug vs. the effectiveness of drug company representatives in influencing doctors to prescribe a medication. The problem with sales reps is that their job is to sell their product,” even if it’s not the most effective drug on the market. “Ideally, we don’t want doctors to learn what drugs to prescribe from sales reps who are trying to promote their company’s products. So, I thought: What if we take the sophisticated communications tools that drug companies deploy so effectively, but instead use them to give doctors the latest and best facts about drugs’ comparative efficacy, safety, and cost effectiveness?” He called the practice Academic Detailing.
To test the effects of an academic detailing program, Dr. Avorn said, “We conducted a randomized trial in four states in which we trained pharmacists to visit doctors and discuss certain drugs from a non-commercial, academic standpoint. We found that such a program could save $2 for every $1 it costs to run, and physicians really do improve their prescribing practices.” His initial studies were published in The New England Journal of Medicine.
After more randomized trials started coming out showing how successful academic detailing programs are in improving the prescribing practices of doctors, Dr. Avorn said that, “Countries, such as Australia, got in contact with me and said that they want to set up an academic detailing program across their continent. The Veteran’s Administration (VA) also set up a nationwide academic detailing program, so it really caught on in a gratifying way.” Much of that work is now conducted by a non-profit he helped found, and for which he serves as an unpaid clinical consultant. It’s called Alosa Health, named after the genus of fish that swim upstream, like salmon. When I asked Dr. Avorn what is holding back some parts of the country from embracing academic detailing services, he said that implementing the program is easiest in an integrated health system, such as the VA or the Kaiser system, compared to the fragmented system that dominates our nation. Dr. Avorn added that, “Until lawmakers actually solve the problem of unaffordable drugs, physicians can at least help each other understand what medications are the most effective. If there are several drugs that are comparable in efficacy, but one or two are far costlier than the others, we can help prescribers choose which drugs are the most cost-effective… all while the politicians are twiddling their thumbs trying to figure out what to do from a policy standpoint.”
When I asked Dr. Avorn about other ways in which we could reduce the costs of prescription drugs, he started by pointing to the patent laws that drug companies manipulate, saying that “We must not allow drug companies to use legal trickery to extend their patents well after they have expired.” Dr. Avorn also discussed how there is currently legislation that reduces the negotiation power of Medicare and Medicaid in choosing drugs and drug prices, adding that fixes to such issues are often blocked by pharmaceutical lobbying groups. Importantly, Dr. Avorn finished by noting that the persistence of these issues has not been caused by partisanship, saying that “It’s not just Republicans or Democrats… it’s both. In the Obama administration, we made very little progress on drug pricing, so it’s not about who’s in the White House. Rather, it’s about trying to get sound public policy to overcome what pharma lobbies want to happen.” President Trump has called the absurdly high prices of drugs “unfair,” and his administration has promised to “stop it fast.” It is unclear, however, whether the President is strong enough to battle Big Pharma’s loud voice in Washington.
3 thoughts on “Prescribing Smarter: A Conversation with Harvard Medical School Professor Dr. Jerry Avorn”
Good article, Sunjay, addressing a very difficult issue. Seems to me there are three issues here, the Executive Orders, Pharma profit structures, and physician prescribing.
I think the Executive Orders are a good effort but they have a basic weakness, the next Executive can countermand them. So they are seldom fully implemented before a future Executive with a different agenda countermands them. So I too am skeptical that they will have the impact desired.
Pharma order structures here in the US have been completed to recover research and development without planning any of that cost on foreign purchasers. That’s been allowed as a result of the spreading the wealth on Capitol Hill by big Pharma.
I really like Dr. Avorn’s Academic Detailing. That seems to be a great way to assure that cost benefit is a consideration as the doctor makes his decisions. I know doctors are busy and the approach of the sales rep has never focused on cost benefit. Everyone knows the latest drug had to be the best but it often is unaffordable to the patient.
Good article, Sunjay. Keep up the good work.
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Mr. McLendon, I appreciate your thoughts on the article! I see what you are saying with the challenge of implementing executive orders. And, I’m happy to hear that you like Academic Detailing–I think it’s a wonderful service.
Thank you for always taking the time to read my articles and share your thoughts.
One sentence fell victim to autocorrect. It should read, Pharma profits here in the US are computed to recover research and development cost without placing any of that cost on foreign purchasers.
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