On April 28, ACP held the annual Global Forum in San Diego on “Profits versus Patients: The Global Threat of Rising Drug Prices.” This was the 16th annual Global Forum, which serves as a platform for all internal medicine societies worldwide to come together and discuss topics of importance to internal medicine specialists and subspecialists.
At the forum, several panelists gave an overview of mechanisms of pharmaceutical drug pricing in their respective countries. There was a consensus that pharmaceutical pricing constitutes an overall health threat to patients and that there needed to be a unified voice, including physicians, professional bodies, and patient advocates, to engage governments and pharmaceutical companies to find better ways to provide equitable access across the globe.
ACP's Ryan D. Mire, MD, MACP, President; Sue Bornstein, MD, MACP, Chair, Board of Regents; Darilyn V. Moyer, MD, MACP, FRCP, FIDSA, FAMWA, FEFIM, Executive Vice President and Chief Executive Officer; and Mukta Panda, MD, MACP, Chair of the Global Engagement Committee, each welcomed the Forum participants. Dr. Panda also introduced two new ACP initiatives, the Global Member Awards and the Global Physician Scholar Program.
Moderator Isaac Opole, MD, PhD, FACP, ACP Regent, started the discussion, noting that the problem of drug pricing must be considered from an ethics perspective and that the pharmaceutical industry's significant contributions to major therapeutic advances have not yielded concomitant improvement in health care and longevity globally, creating a mismatch between their profit motive and the public health interest.
Following Dr. Opole's introductory remarks, the Forum proceeded with a distinguished panel of international physicians.
The panelists were:
- Ricardo Gómez Huelgas, FACP (Hon), FEFIM, President, European Federation of Internal Medicine
- John Kolbe, MBBS, FRACP, FACP (Hon), President, International Society of Internal Medicine
- Natalie Maynard Gamboa, MD, FACP, Representative, Costa Rican Society of Internal Medicine
- Diana A. Payawal, MD, FPCP, President, Philippine College of Physicians
The first question posed to the panel was as follows: “To assure access to essential medications, some agencies have advocated for price transparency and price controls. What actions have different governments taken to ensure access to medications for all citizens?”
Dr. Gómez Huelgas kicked off the discussion by pointing out that while Europe is complex and its countries have different health care systems, there are general rules that each country or region must follow. In general, the European health system is a public health system and all citizens in the same region have the same access to medication, said Dr. Gómez Huelgas. Within the past few decades, governments have taken measures to try to reduce drug costs, such as promoting the prescription of generic biosimilar medicines and introducing algorithms for prescription in electronic medical records to promote rational use of drugs. Dr. Gómez Huelgas said that these measures, however, are still insufficient for controlling rising prices, stating that he had recently approved a prescription for $2 million for a single shot.
Dr. Payawal reported that a decade ago the Philippine government passed the Cheaper Medicines Act, which was aimed at ensuring access to affordable quality medicine and led to a decrease in prices. Even so and even with universal health care, she said, out-of-pocket costs remain high. In terms of improving access to medicines, the government has implemented other measures, such as promotion of generic drugs, public sector importation of cheaper medicines, centralization of procurement of drugs for public hospitals and clinics, and the establishment of village pharmacies. These measures have lowered medication prices between 27% to 42%, Dr. Payawal said. Dr. Payawal also explained that the World Health Organization (WHO)'s External Reference Pricing has helped control drug prices.
Increased competition in the local market can bring prices down without price capping, and availability of generic medicines has significantly contributed to price reduction, Dr. Payawal explained. Other measures that the government is considering include promotion of competition, explicit allocation of medicines, and financial assistance from state-owned corporations and agencies for catastrophic illness, she noted. Finally, there are incentives to local governments to invest in primary care with medicines as an integral part of the program. In summary, the system is not lowering prices artificially but through competition and use of generics, she said.
Dr. Kolbe gave a brief background of the medical system in New Zealand, which he said could be regarded as socialized medicine. Inpatient care is provided in public hospitals, and more than 80% of outpatient care is provided through the public system. Medication access is managed by Pharmac, an agency that determines which medications are subsidized for use in hospitals and in the community. Any newly registered drug is assessed based on objective clinical evidence provided by a subspecialty committee, a more general committee of physicians and experts, and a consumer committee that provides an initial assessment recommending funding, after which the application goes through a cost utility analysis. In that process, questions that are addressed include the medicine's efficacy versus currently available therapies, the cost and additional benefit provided, and whether the treatment will contribute to the overall health of New Zealand. Pharmac negotiates prices for high-priority medications with pharmaceutical companies, although the process may not be entirely transparent at this stage, Dr. Kolbe said. He stated that overall the process enables free and equitable access to all funded and subsidized medications, although there can be delays, limited choice of drugs, and restrictions on some high-cost prescriptions.
Dr. Maynard Gamboa reported that the Costa Rican health care system is socialized through La Caja Costarricense de Seguro Social (Costa Rican Public Healthcare System), which offers coverage to about 96% of the population. However, the funding is insufficient, so pharmaceutical treatments are chosen from a drug list based on the WHO's list of essential drugs There is a committee to decide which therapies should be included, for example approving rosuvastatin instead of lovastatin, so access is often limited, especially when medications have to be prescribed by a specialist, Dr. Maynard Gamboa explained. Patients may choose to go to court to prove that they have a need for a treatment that is not included on the list, she said. Private health care is available but not widely used, since prices are high. While laws and regulations over the years have aimed to reduce prices and promote competition, many of these measures have not worked, and pharmaceutical companies have found ways to bypass them, she said. Other factors that have negatively affected drug pricing include the pandemic, which caused problems with transportation and storage, and the decline in currency value against the dollar, Dr. Maynard Gamboa said.
The second question the panel addressed was as follows: “Physicians often offer cheaper alternatives to patients when medications are priced out of reach. Should physicians refuse to prescribe or boycott medications that they feel are not ethically priced when alternatives are available, and what would be the impact of such an approach?”
Dr. Payawal said four ethical principles underpin these decisions: maleficence, beneficence, autonomy, and justice. If pharmaceutical companies do not conform to these principles, physicians would be justified to boycott their products, she stated. Dr. Gómez Huelgas noted that it's important to find a balance among the rules of market and trade, profits, intellectual property, and human rights, with patient benefit and equity as mandates. Physicians must choose the best therapy at the lowest price, resist pressure from pharmaceutical companies, and provide high-value, evidence-based, personalized medicine that focuses on absolute benefits and healthy clinical outcomes, he said. Dr. Gómez Huelgas also noted that these values must be incorporated into education and training and that medical societies and organizations have a responsibility to promote educational activities that are not sponsored by the pharmaceutical industry.
Dr. Maynard Gamboa commented that in Costa Rica, physicians generally try not to recommend medicine outside of the official drug list so as not to encourage court challenges. Physicians may offer patients the option to buy brand-name drugs at the pharmacy, if they can afford it, she noted. She said that the prevailing view of medicine is Costa Rica is paternalistic and patients often leave treatment decisions to their doctors, so physicians must weigh costs and benefits, pros and cons, in order to make the best choice.
Dr. Opole summed up the discussion by noting that there appear to be both systemic and socioeconomic control over pharmaceutical prices and suggesting that physicians can also exercise some control by ethically prescribing medications that the individual patient and the health care system can afford.
The third question the panel addressed was as follows: “Should pharmaceutical agencies be required to practice within an ethical framework and be required to price their products ethically?”
Dr. Payawal said she agreed with capping prices at a certain level and called for stakeholders to work together to control prices. Teamwork will be required among the government, the patient, and the clinician, she said. Dr. Gómez Huelgas agreed that doctors must push pharma companies to control prices. “Understandably, companies exist to make money, but they also have the social responsibility to give these new high-cost products to low-income countries or to people with low socioeconomic status,” he said. He noted the need for rich countries to commit to supporting low-income countries, not only the politicians and the pharma companies, but also professional associations, patients, and doctors.
Dr. Kolbe agreed and noted that pharmaceutical companies are answerable to their shareholders. He raised the question of whether restricting companies' behavior and profits would affect their investment in pharmaceutical development. He also stressed the power of the patient's voice in this debate and said that physicians and others may want to consider recruiting them as advocates and involving them in the process.
Dr. Maynard Gamboa noted that pharmaceutical companies sometimes see only numbers, not patients, and don't realize the human costs of high pricing and lack of access. She called for more transparency around differing prices for medications, noting that inequities among low-, middle-, and high-income countries can only be addressed if everyone is aware of them.
Dr. Opole next asked the panelists for their opinions on how ACP can advocate for patients while continuing to promote research and development of new drugs.
Dr. Maynard Gamboa noted that ACP has more political power than associations in other countries and can use it to advocate with Congress to promote research and innovation. She also recommended providing patients with accurate information regarding drugs and drug pricing.
Dr. Kolbe stated that professionalism is at the root of this issue, as physicians have a responsibility to help reduce health inequalities and advocate for equitable allocation of health resources. While physicians are very comfortable advocating for individual patients, more general advocacy can be challenging, Dr. Kolbe said. He recommended that individual physicians do their part by supporting organizational advocacy, like that of the College.
Dr. Kolbe stressed the College's influence in this area as a respected institution and noted that the challenge is devising a policy that most members are sufficiently happy with to actively support. “Clearly the ACP has put a stake in the ground indicating that it is dedicated to the reduction of health inequities,” he said. “It would seem to me that affordable and equitable access to medications is an integral part of that and a part that it would be very legitimate for the College to be involved in.”
Dr. Gómez Huelgas stated that the main value of scientific societies is prestige, which must be maintained by remaining independent of pressure from politicians and pharmaceutical companies. He noted that this is particularly problematic for medical societies in Europe, which get most of their funds from pharmaceutical sponsorship of activities. Dr. Gómez Huelgas also stressed inequities associated with access to new technologies and treatments and said physicians have an ethical and social mandate to combat not only disease but social drivers of health, such as poverty, discrimination, food insecurity, and climate change. “Price is not the whole problem. Price is part of the problem,” he said.
Dr. Payawal noted that treatment for hepatitis C is dramatically less expensive now that the drug is available generically and stressed that costs are a huge consideration in treatment for cancer. She also challenged ACP to have more of a voice in Asia, including more interaction and collaboration with those in the Asia/Pacific region. Dr. Opole agreed and said he felt a larger ACP presence in Africa is necessary as well.
Dr. Opole then opened the floor to questions and comments from other attendees.
Thomas G. Cooney, MD, MACP, Immediate Past Chair of the Board of Regents, expressed concern regarding potential manipulation of the voice of the patient, using the example of new Alzheimer drugs in the United States, where patient representatives who testified to the FDA during the approval process were essentially funded by pharma. Dr. Cooney noted that he wanted to be respectful of the patients, who were very passionate and directly impacted by the disease, but said their involvement in the regulatory process was problematic, because pharma was not only funding them but also strongly influencing them. He noted the need to use the patient's voice in an uncorrupted manner.
George M. Abraham, MD, MPH, MACP, FIDSA, ACP's Immediate Past President, noted that same concern regarding potential conflicts of interest affecting panels that determine formularies or courts determining which medications are included or covered.
Dr. Kolbe said that the process he described in New Zealand has built-in safety mechanisms, including management of conflicts of interest and independent assessments of funding by committee. The cost utility process is handled internally with no opportunity for external pressure, he explained. He also noted that it is often easy to determine whether a patient advocacy group has been funded by pharma and said that well-meaning, highly motivated, dedicated patient groups should not be dismissed. He suggested that the College could have the moral high ground in discussions of pricing by focusing entirely on benefit for patients rather than physicians.
Dragan Lovic, MD, PhD, President, Serbian Association of Internal Medicine, and Johanna Adriana (Adri) Kok, MD, FACP, Immediate Past President, International Society of Internal Medicine, described how competition among pharmaceutical companies has brought down prices in Serbia and South Africa, respectively. Dr. Kok also noted that when costs of HIV drugs were prohibitively high in South Africa, the Minister of Health stepped in to allow most patients access at a reasonable price.
Lorenzo Diaz Salazar, MD, FACP, Representative, Honduran Society of Internal Medicine, noted that regardless of available resources, all countries have doctors with patients who need them. He issued a call to action to internal medicine physicians to initiate change and band together to speak with one voice, noting that “when we start with change to our own regions, we can change the world.”
Omar T. Atiq, MD, FACP, ACP President-elect, and Eileen Barrett, MD, MPH, MACP, SFHM, Chair-elect of the Board of Regents, offered summarizing comments from the discussion. Dr. Atiq thanked the attendees and said it was heartwarming to be among colleagues who think similarly from across the globe, who are pained by the pain of patients, and for whom the patient-physician relationship remains sacred. “This is just the beginning of the discussion, not the end of it,” he said.
Dr. Barrett closed by reminding attendees of the message from the previous day's keynote address by Vineet Arora, MD, MACP. “We are doctors for the world, and the world needs us to speak up right now,” she said. “When we do the hard things, we get them done when we do them together.”
The 2024 Forum will be held on Thursday, April 18, at Internal Medicine Meeting 2024 in Boston. More information about the meeting is online.