Direct to Consumer Advertising: Higher Cost Treatments or Better Informed Consumers?

The AMA wants to ban Direct to Consumer (DTC) advertising of prescription drugs and medical devices. We asked a panel of managed care experts to weigh in on the issue. They offer their take on whether DTC ads lead to higher cost or more informed patients; if a ban is even possible; and the clinician’s role in a managed care setting.
 

Our Expert Panel

• Anthony Morreale, PharmD, assistant chief consultant for clinical pharmacy services and health services research, Department of Veterans Affairs
• Gary Owens, MD, president of Gary Owens Associates
• Norm Smith, president of Viewpoint Consulting, Inc
• Barney Spivack, MD, national medical director, Medicare case & condition management, OptumHealth
• Winston Wong, PharmD, president of W-Squared Group, and formerly associate vice president of pharmacy management with CareFirst BlueCross BlueShield
   

FRMC: Do you think Direct to Consumer (DTC) ads drive demand for more expensive treatments in lieu of less costly treatments?

Dr Morreale: Absolutely, otherwise the companies would not spend millions of dollars on these ads. Although most of these medications work, they are not advertised as cost-effective versus other agents. It costs a lot of money in the form of counter detailing to both patients and providers to let them know what the evidence really shows.

Dr Owens: Advertisements provide a limited view of treatment choices. Consumers see something that looks right for them, and request it. In an FDA survey of physicians, 75% said they believe that DTC ads cause patients to think that the drug works better than it does. Many providers report feeling pressured to prescribe something when patients mention DTC ads.

Dr Wong: There is no doubt that DTC drives utilization, especially when there is no detrimental reason to not prescribe the drug. Patients see the ads, ask their doctor, and the doctor prescribes. If the payer uses step therapy that starts with a generic, that payer is perceived as the bad party that is saying no.

Dr Spivack: DTC advertising increases drug sales for both the advertised drug, and other drugs in the category. Sometimes patients end up with a lower cost alternative—or even a non-pharmacologic option—as physicians use their best judgment. Now that patients and physicians are more sensitized to the costs of drugs, it’s more likely that drug cost will be part of the discussion.

Smith: There are very few classes of drugs that promote a more expensive drug over another. The exceptions are biologics for rheumatoid arthritis and psoriasis, and perhaps the sleep aid Belsomra (suvorexant). And when you look at the newer anticoagulants, they are certainly much more expensive than warfarin, but they are also more effective and safer. I am not sure the American Medical Association (AMA) wants to argue that one.

FRMC: Do you think a ban is appropriate? Is there room for compromise?

Smith: An outright ban would be inappropriate, possibly unconstitutional, and probably impossible. But a compromise that prohibits advertising for, say, 6 to 18 months after launch, might be worthwhile. Such a compromise could also allow input from professional societies. However, this is never going to be a legislative priority.

Dr Morreale: I think a ban on use of specific product names would be a good compromise. Such ads can still inform the consumer about the disease, but let providers decide treatment.

Dr Spivack: I agree. Ads should be allowed only for drugs that have been in use for at least a few years, allowing them to be assessed for safety. This will ensure that more effective drugs and non-drug treatments be promoted, consistent with the goals of the Choosing Wisely campaign.

Dr Wong: As we transition to value-based care, a DTC ban may help practices because they will not have to tell their patients why the drug they saw is not a good alternative.

Dr Owens: I don’t necessarily think a ban is the appropriate way to go, since there is some positive benefit to informing consumers. But you can regulate the balance in the ads. Make them more factual. Get rid of the cute cartoon graphics and shadowy characters, such as animated bladders and bowels following patients around.

FRMC: Whether DTC ads are banned or not, what is the clinician’s role during patient visits?

Dr Spivack: Physicians need to make sure that patients understand the role of medications in their overall management, and are informed about the potential risks and benefits of the prescribed drug or other treatment. Many providers do not focus enough on the patient’s role in caring for his or her chronic condition.

Additionally, there are good resources to help patients learn more about drugs and enhance their health. I suggest people take a look at www.iodine.com.

Dr Owens: The problem for physicians is limited time with the patient. If the patient has a non-life-threatening condition and asks for an expensive drug, there may not be enough time to fully discuss treatment options. The path of least resistance is to hand out the prescription. But for serious diseases it is absolutely the responsibility of the physician to help guide the patient to the most appropriate treatment, regardless of how much time it takes.

Dr Wong: The clinician’s role should not change. The clinician should always make the treatment decision most appropriate for the patient from a quality and cost perspective. The problem is that DTC ads get in the way of that.

Smith: Clinicians should be notified through detail reps and journal ads that a product is about to gain exposure via DTC advertising. They should focus on the value of the drug, and how simply swallowing that pill every day can increase the quality and length of a person’s life.

Dr Morreale: Many clinicians don’t know a new drug’s cost versus benefit versus side effects. This makes it difficult for them to know in which patients a drug might be most appropriate. Additionally, they waste a lot of time trying to talk patients out of those medications. That time could be better spent addressing disease management.

FRMC: Do rising out-of-pocket costs for consumers serve as an incentive to opt for less expensive options, even in the face of proliferating DTC ads?

Dr Morreale: To some degree, and that is why evidence suggests that tier co-pay pricing challenges providers and patients about their perception of what they need to treat their disease.

Dr Wong: I agree. But patients also feel that their doctor will prescribe what is right. While high co-pays and coinsurances are a hindrance, it does not totally negate the potential utilization bump.

Dr Owens: Plus, remember that most of these expensive advertised treatments have co-pay assistance programs to offset out-of-pocket cost. In less severe illnesses, patients may not feel the cost effect in the first place.

Dr Spivack: Patients today are more sensitized to the high cost of drugs and other treatments. There is likely be a discussion of lower cost drugs, or even non-pharmacologic alternatives, for certain conditions.
 

FRMC: In your view, do potential benefits of DTC advertising outweigh the risks?

Dr Morreale: No. I think there are other ways to improve patient knowledge about the disease. For example, you can raise attention about erectile dysfunction without telling the patient that they should ask for a specific drug.

Smith: Certainly in some conditions, such as elevated lipids, reminders to “know your number,” with no product mentions, are not harmful. If the disease is serious and treatment has clearly defined benefits, it’s got to be considered a positive.

Dr Owens: The jury is still out. I don’t think DTC ads improve patient adherence, and they can certainly drive additional cost. Pharma spent $4.5 billion in 2015 on advertisements. That spend would not be present without a return on investment.

Dr Wong: They may raise awareness, but do they really increase compliance? To me, the benefit does not outweigh the risk of higher demand. Raising awareness should be the responsibility of physicians.

Dr Spivack: There is some data that DTC drug ads may increase adherence with drug therapy, increase appropriate use of drugs, physician visits, and discussions of drug treatment, and can lead to use of lower cost non-advertised drugs. Still, on the whole, I agree with the AMA’s proposed ban. Short of an all-out ban, I think stronger regulations are needed. The FDA needs to ensure that valid and clear information is provided to the public.

FRMC: Anything else you would like to add?

Dr Wong: Last week I heard that the DTC budgets are surpassing Research and Development budgets. Think of the price reductions we might see if such ads were banned.

Dr Morreale: Generally, I am not for big government making rules about an industry, but, in this case, I think the problem is that big government already made the rules in favor of an industry that is taking it to the consumer as a result. Congress needs to allow free market competition to happen and not block it, which is the current state of affairs.

Smith: The amount of spending pharma does on DTC has next to no impact on launch pricing. Pricing of the most widely used products is value driven. If the price is too high, companies will be forced to discount more. Markets work. The problem comes when management teams, and their boards, over-
estimate the value of their products.■