The Invisibleness of Money

Here's a letter to the editor from today's New York Times:

December 22, 2008
Generic Drugs: Let Patients and Doctors Decide
To the Editor:

Your Dec. 10 editorial “(Generic) Drug Resistance” doesn’t mention a critical fact: nearly 7 out of 10 prescriptions in America are now filled with a generic drug.

In New York, pharmaceutical companies cooperated with state officials in fashioning policies for Medicaid and the state employee health plans that have driven generic substitution to more than 90 percent, according to the Department of Health, while protecting patients whose circumstances necessitate brand medications.

The assertion that physicians are “bought off” by pharmaceutical companies insults both the medical profession and the scientists who are working to develop new treatments for patients suffering from chronic and life-threatening illnesses.

America’s pharmaceutical research companies support patients receiving the treatments that are best for them — including brand-name medicines and generics. That said, without innovative medicines there would be no generics.

In the end, these decisions should be made by patients and their doctors, not dictated by pharmaceutical companies or editorial writers.

Ken Johnson
Senior Vice President
Pharmaceutical Research
and Manufacturers of America
Washington, Dec. 15, 2008

The assertion that physicians have often been "bought off" by the drug industry is, alas, all too true. My own specialty, psychiatry, is currently the focus of recurrent revelations about the unseemly conduct of leaders in our field.

What stands out in Mr. Johnson's letter is the absence of any reference to money. It is easy to agree that clinical decisions "should be made by patients and their doctors." But Mr. Johnson avoids the question of who will pay for the conclusions the patient and physician reach.

When drugs are paid for by the individual, preference for a branded product is quite rightly up to the individual. But when drugs are paid for by funds a population puts together for collective benefit - whether via taxes as with Medicare and Medicaid, or via a combination of employer and employee payment as with most private insurance - the collective voice quite properly has a role in allocating the the shared resources.

Note the word "dictated" in Mr. Johnson's final sentence. His rhetoric is subtle. The implication is that any interference with decisions made in the physician-patient dyad would be "dictatorship." But smooth PhRMA rhetoric doesn't print money. Collective funds are limited. Physician and patient autonomy does not, and should not, include the right to commandeer the funds of the commons without any accountability.