I think we agree that drug re-importation is a dangerous sham. To briefly comment on other topics you raise… You don’t have to convince me that physician detailing and direct-to-consumer marketing are misbegotten practices that corrupt the patient-physician encounter and ought to be eliminated. As a matter of fact, the “modest proposals” I described in my comments regarding your 8/13 remarks on “Politics and drug importation” included calls for the eliminating both. My call for redirecting drug company dollars spent on detailing and marketing to an educational institute for continuing education that describes drug comparability and highlights important differences in efficaciousness and side effects would necessarily depend on just the sort of head to head drug trials you describe as being needed. Clearly you’re also amenable to the notion that drug makers are gaming the patent system.

But let’s talk about prices, the motivating factor for patients who are trying to fill their prescriptions across the border. Why are prices lower in Canada? It’s not because pharmaceutical companies think Canadians deserve a break for having to put up with the cold. It’s because Canada, like virtually every other developed country, has price controls. Allowing re-importation just borrows those price controls, but it does so in a way that (1) does not admit to further regulation in a political climate that is averse to regulation, (2) ensures that only some rather than all Americans will benefit from the savings, and (3) introduces countless hazards to the delivery chain. That’s why I call drug re-importation a dangerous sham.

My reading of your comments suggests that you think only aggresively marketed and other “latest and greatest” drugs are exhorbitantly priced here in the States. I don’t watch a lot of TV, but I can’t remember ever seeing Abbott Laboratories advertise Norvir, and it has been around long enough that including it among the latest and greatest is something of a stretch. And yet, this year the price of Norvir quadrupled, in this country anyway. Like a lot other patients with other medically treated chronic conditions (hypertension, arthritis, diabetes, etc), HIV+ patients who need this drug to survive might go looking to Canada because they can’t afford not to, not because some ad-man has convinced them that they need something they don’t or because of inappropriate physician prescribing practices (where this dialogue started).

I’d like to hear more about your views on regulating drug pricing in this country. And by all means, let’s hear what you’ve got to say about restricting drug marketing. We regulate energy pricing (and have catastrophic examples of what can happen when energy pricing is deregulated). We restrict non-print advertising for tobacco and liquor. Why shouldn’t we do the same in another setting where market forces are not truly operational and the public interest is clearly being compromised? I just hope you’ll spare me the tired old story about drug innovation disappearing if the pharmaceutical companies can’t bleed us dry.

The best family doctor I ever had, apparently quite unlike you, had the courage to tell his patients not only that they weren’t the best candidates for the latest wonder drugs, but he actually had the audacity to tell patients who didn’t need medication that he wasn’t going to prescribe any. That is, unlike the doctors you apparently believe represent the norm, he was willing to do his job. Contrary to your earlier suggestion, he had a thriving practice. And this in one of those horrible “single payer” systems, with even fewer economic disincentives toward prescribing “wonder drugs”.

The pharmaceutical companies sell the notion; doctors perpetuate it – their offices are typically dripping with branded promotional merchandise from pharmaceutical giants – and yet the fault for the situation is the patient’s? Physician, heal thyself.

any good computer software to help us get real “cost to patient” data when we are writing our scripts?

We should be better as physicians about picking for cost effective medicine, but it becomes quite difficult when patients are asking for things by name and feel cheated if they don’t get it.