The Business and State of Prescription Drugs.

DATE July 13, 2000 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Dr. Michael Winniford and Dr. Peter Ubell discuss
prescription drugs, their benefits, side effects and prices
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

We're lucky to be living in a time when there are new prescription drugs on
the market for treating arthritis, heart disease, depression, migraines,
digestive disorders and other problems. But some of the new drugs are very
expensive and many people don't have any insurance to cover the costs. For
example, Medicare doesn't cover prescription drugs, and about a third of the
people on it don't have supplemental insurance to fill in the gap. How to
address this problem is one of the big issues in the presidential race.

We've invited two doctors to talk with us about the new prescription drugs
and
the new questions they've raised for doctors and patients. Dr. Peter Ubell
is on the faculty of The Center for Bioethics at the University of
Pennsylvania. He's the author of a book about health care rationing called
"Pricing Life." Dr. Michael Winniford is a cardiologist and professor of
medicine at the University of Iowa in Iowa City, where he directs the
University Heart Care center. I'll let them describe their medical
practices.
Let's start with Dr. Ubell.

Dr. PETER UBELL (The Center for Bioethics, University of Pennsylvania;
Author,
"Pricing Life"): I practice at the Philadelphia Veterans Affairs Medical
Center, so almost all my patients are male and elderly. And I would say my
typical patient has congestive heart failure, coronary artery disease--which
means a history of heart attacks--high cholesterol, high blood pressure and
a
touch of diabetes. A lot of chronic illnesses that require a lot of
medications.

GROSS: Dr. Winniford?

Dr. MICHAEL WINNIFORD (Professor of Medicine, University of Iowa; Director,
University Heart Care Center): I'm a cardiologist. I practice at the
University of Iowa, hospitals and clinics here in Iowa City, largely a rural
practice. Many of my patients--most of my patients come from small
communities and farms surrounding Iowa City. They're generally elderly,
they
have heart disease, various kinds of heart disease, including heart failure,
coronary artery disease, angina, heart arrhythmias. They--it's a typical
adult cariology practice.

GROSS: Well, let's start with the good news. Dr. Ubell, what are some of
the
new medicines that are on the market now that have been very helpful to you
and your patients?

Dr. UBELL: I think there are old and new medicines that are very helpful.
We're finding out new things about old medicines even. An old water pill
called spironolactone we found out recently helps people with heart failure,
which I have put many, many more patients on recently. There are wonderful
new cholesterol pills around that have very few side effects that are really
helping reduce the chance that people have strokes and heart attacks. New
pills for diabetes that have really been very helpful for my patients. And,
of course, the Viagra has been a new pill which has helped a lot of people
around.

GROSS: Dr. Winniford, what's been helpful for your patients, new medicines?

Dr. WINNIFORD: Well, a number of new things. There are a class of drugs
called glycoprotein IIb-IIIa inhibitors, which is a new type of blood
thinner
or anticoagulant drug that has proven to be extremely helpful in patients
who
have unstable angina, patients who are undergoing coronary angioplasty
procedures. Class of drugs called ACE inhibitors, which have been proven to
be very useful in patients who have congestive heart failure. There are new
cholesterol-lowering medications which are extremely useful in lowering LDL,
or bad, cholesterol, retarding progression of coronary disease. And some
new
anti-arrhythmic drugs, drugs that prevent serious, life-threatening heart
arrhythmias, which have proven to be extremely valuable.

GROSS: Now are most of these medicines that you both mentioned expensive?

Dr. WINNIFORD: Many of the ones that I mentioned are quite expensive. The
blood thinners that I reffered to, the glycoprotein IIb-IIIa inhibitors, are
extremely expensive drugs. These are generally drugs that are used in the
hospital setting. Some of the outpatient drugs that I mentioned, in
particular some of the new anti-arrhythmic drugs, some of the

cholesterol-lowering drugs, are quite expensive.

GROSS: What's expensive? Give us an idea of how much per day a patient
might
spend on one of these medicines.

Dr. WINNIFORD: Oh, a patient might spend as much as $2 to $300 per month
for
a prescription for some of these medications. Total prescription cost per
month may be as high as $3 or $400 for patients who have advanced heart
disease and are on multiple medications, including the ACE inhibitors, the
lipid-lowering drugs. More typically, a prescription for a lipid-lowering
drug might be in the $50-to-$100-a-month range.

GROSS: And can you prescribe most of these expensive medicines for your
pateints? Can they afford it or do they have medical coverage that will
cover
the prescriptions?

Dr. WINNIFORD: Well, unfortunately, many of them can't afford it. About a
third of the patients in the Medicare program really have no supplemental
coverage for their drugs and their drugs really come out of pocket. For
patients who are on fixed incomes or patients who are poor but perhaps don't
quite qualify for Medicaid, they have real problems affording these
medications. And I would say that that is a serious problem in our ability
to
manage these patients.

GROSS: Dr. Ubell, you work at a veterans hospital, so they have some kind
of
coverage. Does the coverage cover the kind of medicines you want to
prescribe?

Dr. UBELL: And most of my patients don't have to pay very high
out-of-pocket
costs for the medicines, which is wonderful for me. I can prescribe all
these
pills and give them the benefits. There are some pills that aren't
available
for me to prescribe to them because in an attempt to hold down its costs,
the
Veterans Affairs Medical Centers are limiting what drugs we can prescribe
for
our patients.

GROSS: So what's an example of a drug you'd like to prescribe but can't and
have it covered?

Dr. UBELL: It's not as simple as that, actually...

GROSS: Oh. I guess it never is.

Dr. UBELL: ...because--it never is. So what we can't do is we can't
prescribe them unless we've proven that the patient really needs them, and
which requires going through administrative hoops, filling out forms,
calling
up the pharmacy. I might have to prescribe a less expensive cholesterol
medicine and prove that it doesn't work before I can prescribe the more
expensive one.

GROSS: And, Dr. Winniford, in your practice in Iowa City, how do you deal
with wanting to prescribe expensive medicines to patients who can't afford
to
buy them?

Dr. WINNIFORD: Well, it's a real problem. I think what most of us do is we
use generics whenever we can. There are, fortunately, many generics that
offer the same clinical effect, same beneficial effect. Oftentimes they may
not be as convenient to take because they must be taken three or four times
a
day, whereas there may be a brand-name drug that could be taken once a day
or
twice a day. Compliance is, therefore, a problem on some generics. But in
many cases, there isn't a generic equivalent that can be prescribed. We do
tricks like prescribing a larger dose and having the patient cut the pill in
half. Oftentimes the cost of the larger dose is not twice the cost of the
smaller dose and, therefore, you can save money that way. We try to use
samples when we can. You're quite limited in how many samples you can give
a
patient at a clinic visit. All of those things help, but unfortunately, we
are still left with too many patients who simply cannot afford to fill
medications, fill prescriptions that they must take in order to keep their
chronic disease under control. And this creates serious problems.

GROSS: What kinds of problems?

Dr. WINNIFORD: Well, the major problem is exacerbation of the disease that,
had they taken the medication, would have been under control. This results
in
unnecessary hospitalizations. A good example is patients who have
congestive
heart failure, chronic condition, a weakening of the heart muscle. We know
that with effective medical therapy, we can keep many of these patients out
of
the hospital. One of the most common causes for hospitalization in that
group
is difficulty with medications, failing to take medications as prescribed.
Certainly for patients who can't afford their heart failure medications,
they
end up back in the hospital far more often than those who take their
medications regularly. And this has tremendous cost implications. It
results
in a marked increase in cost, far greater than the amount of money saved by
not taking the medications.

So that's really one of the major problems, is an exacerbation of the
chronic
disease that would have been very well-managed had they taken the
medications
that were prescribed.

GROSS: Dr. Ubell, you were bringing up a related problem earlier, before we
started recording, which is something that happens in some managed care
programs. Why don't you explain the problem.

Dr. UBELL: Well, often, to try to hold down their costs, managed care
organizations will negotiate with the drug companies and they'll--if there
are
several drugs within a class of drugs, like these ACE inhibitors we were
talking about, ramipril and Bamipril(ph) or something like that, and they're
just the same as each other. You find out which company will give you the
better price and that's the one you make available to patients. A year
later,
the next fiscal year, you're negotiating again. Now maybe Bamipril's
cheaper
than ramipril. So all of a sudden, patients have to be switched, and maybe
it's not the same number of milligrams. I will write prescriptions for
people, you know, `Bamipril, 10 milligrams (instead of ramipril, 20
milligrams)' to try to remind them, but they still get confused. Maybe they
take both medicines for a while and get too low of a blood pressure or a
side
effect of some kind. Maybe they just throw their hands up in the air and
they
don't take any medicines because they'e so confused.

I even had one patient where the next year, I had to put them back on the
first one, where the prescription still read `instead of Ramirpil, take
Bamipril' and now they're going back on ramipril. I mean, it was so
confusing. Every 12 months, they're going back and forth.

GROSS: Well, here's a problem related to that. Chances are pretty good if
you're taking a lot of potent medicines that something along the way will
cause some side effect or another. And if you're not a doctor and you're
taking all these medicines, you have a side effect, you're not going to know
which drug is causing it and, therefore, you won't even know which
specialist
to ask about it, because you might be seeing three specialists, plus a
general
practitioner, and they're each aware of what they've prescribed, but they
might not even know much about the medicines that the other doctors
prescribe.
Dr. Ubell, what advice do you have about who to talk to when you're taking
all
these medicines and you need to track down which is causing the side effect
and what you're supposed to do about it?

Dr. UBELL: That's a great question. I'm a primary care doctor and I
certainly have patients on medicines that I'm not super-familiar with.
Perhaps the rheumatologist put them on a new arthritis pill, but I usually
tell patients to try calling me first. I give them my number and I talk to
them, and if I don't understand what's going on, I might see them in the
office or I might call up the rheumatologist myself or something, but it's
often a good place to start, if the primary care doctor, hopefully, is the
one
keeping track of everything you're on and has at least some surface
knowledge
of what could happen.

GROSS: And are you confident that you have a list of everything that
patients
are on?

Dr. UBELL: I do just because our system prints out--it's available and
everyone gets it through the same pharmacy, and it's great if you're in the
kind of health system that's organized like that, so that people can keep
track of what medicines you're on, but not every patient's in that kind of
system.

GROSS: Dr. Winniford, what kind of problems does this present for you?

Dr. WINNIFORD: That's a serious problem. It's a particular problem in a
system where patients may go to, as you say, multiple specialists that are
in
different practices, don't share common records, like you might find in the
VA
system, for example. I think there are some things that patients can do to
minimize the impact of the problem that you describe. Certainly I would
agree
that having a primary care physician who has a complete and accurate list of
your medications is extremely important. The primary care physician really
ought to be the pilot here and ought to be in a position to know exactly
what
the patient is taking.

I think other simple things like getting all of your prescriptions filled at
the same pharmacy is important. We have patients who may go to one city or
one town to see one physician. They'll get a prescription. They may get
that
prescription filled at a pharmacy in that town and another prescription
filled
elsewhere and, therefore, there's not even a single pharmacy that can
provide
a complete and accurate list of the patient's medications. And then another
simple thing is to remember to bring all of your medications with you when
you
go see the physician so that the physician can actually see the medications
that you're taking rather than to rely on a list that may be outdated or on
memory, which sometimes fails.

Dr. UBELL: And it's a great idea, and it's stunning when they remember and
you see them bringing a grocery bag full of pills. It reminds you visually
of
just how many medicines they're on. And often you get another chance to
look
it over and see if they really need to be on every one of those pills.

GROSS: My guests are Dr. Peter Ubell, who practices medicine at a VA
hospital
in Philadelphia and is on the faculty of the University of Pennsylvania
Center
for Bioethics; and Dr. Michael Winniford, director of the University of
Iowa's
Heart Care Center. We'll talk more about prescription drugs after a break.
This is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, we're talking about prescription drugs,
the
new, often very expensive prescription drugs, and particularly the impact of
all this on the elderly. My guests are Dr. Michael Winniford, who's a
cardiologist, a professor of medicine at the University of Iowa in Iowa
City,
where he directs the university's Heart Care Center; Dr. Peter Ubell, who's
an
assistant professor of medicine. He's on the faculty of the University of
Pennsylvania's Center for Bioethics.

Let's talk a little bit about generic drugs. Doctors will often recommend a
generic drug when it's available instead of the higher-priced brand-name
drug.
Now generics aren't always available. Dr. Ubell, why aren't generics always
available?

Dr. UBELL: Well, drug companies spend a lot of money developing new
medicines
and they then get patents and protections so that for the first 17 years
after
they've patented a medicine, no one else can make that chemical and sell it.
Now that doesn't usually give them 17 years on the market because some of
those years get eaten up while they're testing it and refining it. But
pretty
much they end up with a decade or so where they can charge what they want
because there's no competition, no one else can make that particular
chemical.

GROSS: And after those 17 years are up, then other companies can make their
versions of the drug.

Dr. UBELL: Right, at which point then they can come up with the version
that
you only have to take once a day instead of three times a day, and then that
gets patented for a few more years, and they definitely work very hard to
try
to extend that protection because it means a lot of money.

GROSS: Mm-hmm.

Dr. WINNIFORD: I think another factor related to the underuse of generics
has
to do with drug promotion and drug advertising. Typically, the brand-name
drugs are the drugs that get heavily promoted, heavily advertised to both
physicians and to the public, and I think oftentimes physicians feel like
that, as a result of the heavy promotion and advertising, that the
brand-name
drug is somehow superior to the generic. The patient may feel that if
they're
getting a generic, they're somehow getting shortchanged because they're not
getting the brand-name drug that they've heard about and, I guess, come to
believe it is superior in some way to the generic drug.

GROSS: What are your thoughts about that, Dr. Ubell? Do you think patients
are getting shortchanged if they use the generic? Are the generics often or
ever inferior to the brand name?

Dr. UBELL: Almost never inferior. They're really--they're tested and
they're
looked--they're supposed to be chemically equivalent before they're allowed
on
the market. And so I have no problems prescribing those for myself or for
my
family.

Turning a little bit earlier, Dr. Winniford talked about how we often
provide
samples to patients as a way to help them get medicines they could otherwise
not afford. And it's a strange bind it puts us in because the only--the
samples we get, we get them from the sales representatives from the drug
companies, and they're only giving us samples for medicines they're trying
to
push, and they're only trying to push the medicines that they're making a
lot
of money on. So one of the little sneaky effects of this is we get very
familiar with those pills. Maybe we start giving out free samples of this
new
medicine for a while, and pretty soon when someone comes in, that's the
prescription we're writing. And so, in effect, to try to help people afford
their medicines, we get in the habit of giving them very expensive
medicines.

GROSS: Let's talk a little bit about the proposals currently before
Congress
for financial coverage for prescription drugs for the elderly. Many people
on
Medicare have supplemental drug coverage, but I think the figure's about a
third of people on Medicare do not have any prescription drug coverage at
all.
The Republican plan to just, you know, pare this down to the essentials, the
Republican plan calls for the insurance industry to cover prescription drugs
for people on Medicare, whereas the Democratic plan calls for Medicare
itself
to cover the prescription drugs. And then there are other differences in
how
much they'd cover and what the caps are, etc.

And now a Republican in the Senate, Joe Roth(ph), is calling for some kind
of
compromise between the two plans. Dr. Ubell, do you have any opinion about
whether you'd rather see the insurance industry or the government handle
prescription drug coverage for people on Medicare?

Dr. UBELL: Well, I think if one of the goals is to lower costs of medicines
for patients, then all you need to look at is which proposal the
pharmaceutical companies are fighting the hardest, and you'll have a good
sense of which proposal would lower costs more. And they certainly don't
want
to see the government get into this. And it really is because that's a
really
big group to negotiate with and would have a lot of power and would probably
lower costs.

Insurance is usually something based on risk. You pay a certain amount of
money, and you might get sick, you might stay healthy. And on average, the
insurance company will come out with a little money at the end of the year.
Most Medicare enrollees are on a lot of medicines. To insure for the cost
of
medicine isn't really insurance. It's really to pay for their medicines.
And
so, why would an insurance company want to do that?

GROSS: Right, because you're saying that they know sooner or
later--probably
sooner--they're going to have to pay a lot of money for the prescription.

Dr. UBELL: Absolutely.

GROSS: That seems kind of inevitable.

Dr. UBELL: Absolutely. And the more if becomes affordable, the more and

more pill people will be put on because they're a lot of very good medicines
around.

GROSS: Dr. Winniford, any thought on whether, as a doctor, you'd prefer to
see the government or the insurance industry handle prescription drug
coverage
for senior citizens?

Dr. WINNIFORD: Well, I think both proposals have some merits. First of
all,
I'm just delighted to see that there's actually some action being taken at
this point. It's been far too long when prescription drugs have been
excluded
from Medicare coverage. I think the concerns that many physicians would
have
about having Medicare take over prescription drugs, or have the prescription
drugs folded into the Medicare program, is the possible consequence of a
restriction on the physicians' ability to prescribe medications that they
think their patients really do need. So provided there is protection for
physicians to do the right thing by way of their patients, the Medicare plan
seems reasonable.

Cost is a problem. It's going to increase the Medicare cost considerably.
There's also some cost shifting that occurs as--when you fold prescription
drug coverage into the Medicare plan. As you say, two-thirds of Medicare
patients have some form of coverage for prescription drugs. If we simply
move
that over to Medicare, then that's going to increase the costs of the
Medicare
coverage. It will subsequently reduce the costs of coverage provided by
insurance companies, employer plans, HMOs.

Dr. UBELL: Certainly, any things we try to do to increase the ability for
Medicare enrollees to get medicines affordable is going to have a downside.
It's going to reduce pharmaceutical company profits. And the downside of
that
is they'll have less money to invest in new research. And we just have to
recognize that and decide just how important is it to have the new drugs.
And
what if it slows down 10 or 15 percent how quickly we get medicines? Is
that
worth it if more elderly or Medicare enrollees will get medicines? And then
it'll have a downside of meaning some medicines probably won't be available
to
everybody because they're simply very expensive and they are alternatives
that
are almost as good and half as expensive. And perhaps they can pay for that
out of pocket.

Now many managed care organizations have what they call `tiered pharmacies.'
They'll pay the full expense of the first tier of medicines. You have to
pay
a certain number of dollars for the second tier. And the third tier is
largely out of pocket. And that still gives physicians freedom. It means
you
have to talk to patients about when you prescribe a third-tier drug and
decide
if they really want to pay for it.

GROSS: We'll talk more about prescription drugs with Dr. Peter Ubell and
Dr.
Michael Winniford in the second half of the show.

I'm Terry Gross, and this is FRESH AIR.

(Soundbite of music)

GROSS: Coming up, we continue our conversation about prescription drugs
with
Drs. Peter Ubell and Michael Winniford. And Ken Tucker reviews "The
Marshall
Mathers LP," the new album by rapper Eminem.

(Soundbite of music)

GROSS: This is FRESH AIR. I'm Terry Gross.

Let's get back to our conversation about prescription drugs, their benefits,
side effects and prices. My guests are Drs. Peter Ubell and Michael
Winniford. Dr. Winniford is a cardiologist and professor of medicine at the
University of Iowa in Iowa City, where he directs the Heart Care Center.
Dr.
Ubell practices medicine at the Philadelphia Veterans Affairs Medical Center
and is on the faculty of the University of Pennsylvania's Center for
Bioethics. He's also the author of a book about health-care rationing
called
"Pricing Life."

Let's talk about a proposal that the Food and Drug Administration is
considering now, which is to take some prescription drugs and transform them
into over-the-counter status. And the drugs under consideration here
include
some cholesterol-lowering drugs, birth control pills, some antibiotics. And

I'm not sure what other drugs are in this category.

Dr. Ubell, from your point of view, good idea?

Dr. UBELL: I'm terrified about the thought of antibiotics being over the
counter because I think physicians already prescribe too many antibiotics,
and
I can only imagine that it would get that much worse. We have a major
epidemic of resistant bacteria and other types of infections. And resistant
means that you give them the old antibiotic that used to work and it no
longer
works 'cause they've seen them, they're laughing at them now 'cause they've
seen those antibiotics for the last 10 years and they don't fear them
anymore.

GROSS: The bacteria don't fear them anymore.

Dr. UBELL: They don't fear them because they've seen them and they've had
time to adapt. Bacteria are very quick to change. When they get penicillin
thrown at them often enough, they find a way to dodge that bullet. And so I
think that would be terrible to have antibiotics over the counter.

GROSS: What about birth control drugs or cholesterol-lowering drugs?

Dr. UBELL: I'm pretty nervous about those, too. I think we need to make
sure
that birth control pills are easily available to people, but there are
things
that often need to be done--examinations that should be done. You want to
make sure that people are counseled on how to use them correctly. And
certainly, if it's--a young woman who's taking birth control pills needs to
have Pap smears done regularly and be monitored for cervical cancer. And
that's often something that, because they have to come to a physician or at
least to a clinic to get the pills, then they're looked at for those kinds
of
diseases.

GROSS: Dr. Winniford, your thought on taking prescription drugs and making
them over the counter?

Dr. WINNIFORD: Well, I certainly share Dr. Ubell's concern about the
antibiotics. The other thing that I'm concerned about as we shift drugs
from
prescription status to over the counter is you really increase the
opportunity
for adverse drug interactions. Patients are on multiple medications; they
then go get an over-the-counter drug that may have a potential toxic effect
on
the liver. For example, you mentioned cholesterol-lowering drugs.
Cholesterol-lowering drugs can cause liver damage in a small percentage of
patients. If they're taking other medications, it may also have that effect
and you have a potential drug interaction. And this is not always evident
to
the treating physician because a lot of times, patients don't consider
over-the-counter drugs to be drugs. They may fail to tell you about an
over-the-counter medication that they're taking. They may not include those
drugs on their list of prescriptions. They may not bring them in to the
doctor, so that's a real concern.

GROSS: A lot of drugs now are advertising on TV, magazines, newspapers, and
it, you know, makes you aware of medicines that you didn't necessarily know
existed. And I'd be interested in hearing how patients are responding to
these ads and whether they come into your offices and ask for the things
that
they've heard on TV or read about in the magazines. And if they're asking
for
it, if you think that's a good thing or not. Let's start with Dr.
Winniford.
Your thoughts?

Dr. WINNIFORD: Well, I think it's a mixed blessing. I think that there are
good things and not so good things. Certainly in some respects, having
drugs
advertised to the public has lowered the threshold or increased the
acceptance
of those medications for patients who need it. A good example is the
cholesterol-lowering drugs. It's really not very difficult these days to
convince a patient to take a cholesterol-lowering medication because they're
very familiar with the drugs. They've heard them advertised on TV. They
know
about celebrities that take these drugs. And so they're really quite
accepting of these medications. I personally have not had a lot of trouble
with patients coming to my office and asking or demanding to be started on a
medication that they heard about or read about. I think most patients are
fairly savvy when it comes to advertising. They know that not every drug
that's advertised is necessarily for them. And in my experience, most of
them
have been very reasonable and have accepted my explanation that a certain
drug
that they may have heard about or read about is not really for them. So I
have not had a problem with it creating unrealistic expectations. I do
think
it does help improve acceptance of some medications.

I think the major concern, both on the part of my patients and on the part
of
most of the physicians, is the impact of advertising on drug costs. I think
most patients are smart enough to know that advertising costs a lot of
money,
and that money has to come from somewhere, and very likely it contributes to
the high cost that patients have to pay for medications. And I think that
makes a lot of patients mad.

GROSS: Dr. Ubell.

Dr. UBELL: I love it when my patients come to me with any questions they
have. If they get--a TV ad strikes them and they want to ask something
about
it, I know something that's on their mind that I might not have known was on
their mind otherwise. They're trolling the Internet sometimes and come up
and
they ask me about possible side effects of medicines they're on. I love it
when they do that. Even if they're wrong, it's a great chance for me to do
some patient education, and again, to learn what's on their minds. So I
love
it. I'm never threatened by it. And I've not run into problems of patients
who won't hear what I have to say. I'll draw a little picture and show them
why something else might be better than what they heard about, and that
almost
always works.

GROSS: And are you concerned, like Dr. Winniford is, that the price of
advertising is driving up the price of prescription drugs?

Dr. UBELL: I can't--I mean, I think you need a pretty fancy economist to
figure that out because, you know, if you develop--it costs a lot of money
to
develop medicines and if they're not sold, then they lose that money. And
so
I honestly can't--it costs money to advertise, but it gets the product out.
I can't figure that out.

GROSS: OK. Now according to a study quoted in The New York Times, a
pharmaceutical company spent $11.5 billion last year on marketing drugs to
doctors. Now you've talked a little bit about the freebie samples and how
that's both--has both a positive and a negative side. What are some of the
other ways that pharmaceutical companies try to market their medicines to
you,
Dr. Ubell?

Dr. UBELL: They fail to market them well to me because I don't talk to
sales
representatives. But...

GROSS: Do they call and try to set up appointments, or is it just 'cause
you're at the VA that they don't (unintelligible).

Dr. UBELL: No, I just--that's just my personal policy because I don't feel
like I get balanced information that I can use. But typically, they start
in
training when people are exhausted, underpaid, underfed, and they start
giving
lunches and just meeting with medical people training to become physicians
or
they're physicians but training to get licensed. And they start talking to
them about their products. Pretty soon you find out that the medical
residents know some obscure little side effect of the generic--old generic
medicine and that's why they prescribed a new medicine. And they've got
that
little article in hand to show that to you, and that's an article that was
handed to them by a sales representative. And then it just kind of sneaks
up
from there.

And an extreme, there are physicians who regularly visit with sales
representatives, who receive gifts from them. I know of a practice where
they're frequently going from Philadelphia down to Broadway to go to shows
that they get tickets from sales representatives, and that's an extreme.
And
there are other physicians who refuse to interact with sales reps. And then
the way that the marketing works then is usually through peers because
that's
often how you learn what medicine to prescribe. You talk to the infectious
disease expert and hear what medicine should I prescribe for this. And now
you wonder if that expert has been influenced by marketing. It's insidious.

GROSS: Dr. Winniford.

Dr. WINNIFORD: Yeah, I think another way that drug companies will try to
influence prescription habits for physicians is by sponsoring so-called
educational programs, symposium, seminars, where the speakers are
hand-chosen
by the drug company to basically tell the party line. They talk about the
drugs in a very favorable light and may not present a balanced view, may not
adequately discuss alternatives to the drug that the company sponsor
manufactures. And a lot of times those are represented as educational-type
programs where the conflict is really not evident or not admitted. And I
think that's a problem. Certainly, I share Dr. Ubell's concern about the
tactics used by some pharmaceutical representatives that do include all
sorts
of enticements to prescribe their drugs, including tickets to shows, tickets
to sporting events, other inducements that really, in my opinion, are not
ethical.

GROSS: We'll talk more about prescription drugs after our break. This is
FRESH AIR.

(Soundbite of music)

GROSS: We're talking about several issues pertaining to prescription drugs.
I have two guests. Joining us from Iowa City is Dr. Michael Winniford, who
is
a cardiologist and professor of medicine at the University of Iowa. He also
directs the university's Heart Care Center. Dr. Peter Ubell is an assistant
professor of medicine at the University of Pennsylvania and he's on the
faculty of the University of Pennsylvania's Center for Bioethics.

From what you've each told us, it sounds like just managing the
prescriptions
for your patients takes a lot of time, 'cause you not only have to
prescribe,
you have to explain. Then you have to see what else are they on that the
drug
you're prescribing might interact with. Dr. Ubell, you said you write up,
like, lists for patients with explanations and everything in clear
handwriting--you make sure they can understand your handwriting; that takes
time. Now I've read that in a lot of managed health-care programs the
average
visit is supposed to last no more than 8.5 minutes per patient. Dr. Ubell,
do you feel like you can do what you need to do in that amount of time? And
are you under time pressures like that?

Dr. UBELL: Huge time pressures. And it certainly makes it harder to get
around to these very important issues about educating patients. And if that
ends up being what gets thrown out of the visit, then we're--patients are
gonna be even more confused. Sometimes you can give them a special visit to
meet with the pharmacist and--at least in my clinic, they can have a
separate
visit just to over the medications with someone and then who often will give
them a little type of box that organizes their pills by what time of the day
they take them. But that doesn't always get reimbursed in all kinds of
health
plans. And it--so you're always struggling to find that time to help
patients
get educated about their medicines.

GROSS: Is there an average that you're supposed to spend--an average length
you're supposed to spend with your patients?

Dr. UBELL: I have about 15 minutes on average when I see my patients. And
our clinic is not as efficient as some clinics in terms of having multiple
rooms to see patients in at any time, and I go get my patients and walk them
to the room as part of the time. So if you actually looked at the amount of
time in the room, it's not 8.5 minutes, but it's short.

GROSS: So a patient who has to walk very slowly or who has trouble walking
gets less time in the office with you.

Dr. UBELL: We start talking in the hallway, you know?

GROSS: Right. Right.

Dr. UBELL: And you try not to do the confidential stuff in the hallway.
And, you know, when a patient needs it, I run behind. And then my greeting
often begins with an apology for running late and then an explanation that
when they need me, I'll give them the extra time and that's why it's worth
waiting for me.

GROSS: Dr. Winniford, are you under any time pressures?

Dr. WINNIFORD: Not quite like that; eight and a half minutes that's--that
would be tight. Generally, we have about 30 minutes to see patients. We're
seeing generally sicker patients who have specialty problems, cardiology
problems, and so we typically have more time. I would suggest that, really,
education about prescription drugs is, in many cases, the most important
part
of a physician visit. And to shortchange that, I think, really is gonna
cause
significant problems with the patients' ability to understand their
medications, to take them properly. And as I said before, when patients
don't
understand their medicines and don't take them properly, they end up with
unnecessary hospitalizations, unnecessary return physician visits. And all
of
that drives the cost of health care up and, obviously, has an adverse effect
on patients' health and quality of life. So you can't shortchange that part
of the visit. And to do so is really counterproductive.

GROSS: I have a question I'd like your advice on relating to prescription
drugs. I like to know what I'm taking. I like to know what the effects of
it
are. At the same time, I'm kind of impressionable. So if you tell me what
the side effects are, chances are, I'm gonna have one of those side effects.
So I never know whether I should read the side effects beforehand and
risk--and almost, you know, risk that the power of suggestion will give me
the
side effect, or whether I'm better off not reading it, but therefore, being
a
little bit in the dark about what I'm taking. And I know I'm not alone in
reacting this way to prescription drugs. Dr. Ubell, what do you think?

Dr. UBELL: Oh, and I worry about that when I explain side effects to
patients. I worry that I'll induce a side effect by explaining it. And so
I
almost always chase that with a `but I'm sure you won't be the person who
gets
that.' But it's certainly something you worry about. It's just the power
of
suggestion. We certainly use it the other direction all the time. We try
to
suggest that this medicine will really make their pain get better, and part
of
that confidence with which we prescribe the medicine makes it more likely
that
it will reduce their pain. So that power of suggestion cuts both ways.

GROSS: Dr. Winniford, do you run into this?

Dr. WINNIFORD: I run into it all the time. It's a real problem, especially
now that patients have so much access to information about medications, and
unfortunately, not all of it is as accurate as we would like. They go to
the
Internet, they find sites that talk about side effects of prescription
drugs.
Most of this time, they are getting accurate information, but they really
don't have any way to put the incidence of the side effect into perspective.
And in some cases, they get misleading information. I guess, my general
approach is I prefer a well-informed patient, and I err on the side,
usually,
of explaining in some detail the potential side effects, as Dr. Ubell said,
trying to put the incidence in perspective. But despite that, just as you
say, patients often come back complaining of exactly the same side effect
that
I've just described, and it is a problem. Cough on ACE inhibitors--if you
tell a patient that the medication you give them is likely to cause or may
cause cough, cough is a common problem, patients are gonna have a cough; and
suddenly now their cough is attributed to their medication. So it is a
problem.

GROSS: Medicines--prescription medicines now have expiration dates, and the
expiration date, no matter what the medicine, is usually a year later--not
always, but it's usually a year later.

Dr. UBELL: And is that earlier or later than, like, a Pepsi would expire?

GROSS: I wonder how seriously you take those expiration dates.

Dr. UBELL: I think the best thing about an expiration date is that people
will throw out all bottles of pills so that they won't start treating
themselves a year later when something recurs. Perhaps they didn't finish
the
course of antibiotics. They feel a little cough and they start popping the
last five pills, and that's not a good way to treat things. So if for no
other reason than people are throwing out pills that they're not using. You
shouldn't normally have a bottle of pills that it takes a year to use. It
happens once in a while, but I think that's...

Dr. WINNIFORD: And I think most of us don't really have a good idea about
what happens to medications after the expiration date. As you say, I'm sure
there's a large safety margin built in between the expiration date and when
the medication actually may degrade to the point where it's dangerous or no
longer effective. Most of us don't know exactly what that relationship is,
and so I think most of us generally stick with the expiration date. When
the
expiration date comes, I encourage my patients to toss their pills and get a
new prescription.

Dr. UBELL: I give you an embarrassing example.

GROSS: Yeah.

Dr. UBELL: I had seasonal allergies. My wife started getting some seasonal
allergies this year. So I gave her some very old allergy medicine I had
around that I hadn't finished using up yet. And she wasn't getting better.
So finally, she just said, `Peter, let's get some new medicine,' and then it
worked right away. I just felt awful for letting her suffer a few extra
days.
So they can expire. They can definitely wear out.

GROSS: Dr. Ubell, I read that your father was, or perhaps still is, a
doctor. I'm not even sure if he's...

Dr. UBELL: He's alive. And once you're a physician, you're always a
physician.

GROSS: OK.

Dr. UBELL: But he's not. He's retired.

GROSS: Have you talked with him how the dilemmas that doctors face with
prescription drugs has changed between when he was practicing and now when
you're practicing?

Dr. UBELL: The conversations we have, it certainly--back when he was
practicing things were a lot simpler because there were just so many fewer
medicines to choose from. And for certain illnesses, it was terrible that
you
didn't have many medicines available. For congestive heart failure, when my
dad practiced, there just wasn't much you could do. And it's wonderful what
we can do for patients now. But he didn't have antibiotics. He had a
handful
of antibiotics to think about, not a book full of them.

GROSS: And why is harder to have a book full?

Dr. UBELL: It's a lot to know. And you certainly rely a lot more on going
and looking things up or talking to people who are more expert than you are
in
those areas. And then as you brought up, the interactions. I can't keep
track of which medicines interact with another one and cause side effects.

It's very hard to keep track of.

GROSS: Do you find the Internet useful as a reference?

Dr. UBELL: I don't personally use it for that reference.

GROSS: Dr. Winniford, do you?

Dr. WINNIFORD: I think there are some sites that are useful. I
occasionally
will look on a site to find more detailed information about a medication.
It's not my primary source of reference for pharmaceutical agents. I think
in
terms of how things have changed, I mean, it may be that, really, the reason
we are in the fix that we're in now with regard to prescription drugs and
the
elderly is that back when Medicare was developed, there really--prescription
drugs really weren't that big of a deal. There were relatively few drugs.
The price of drugs was really not very high and it represented a fairly
small
fraction of the overall health-care costs for the elderly. And that may, in
part, be why the prescription medications weren't included in the original
Medicare plan. What we've seen over the last several years is a dramatic
increase in the cost of prescription drugs, so that now it--for the elderly
represents, really, in most cases, the single greatest portion of the
health-care expenditure. And so that's a tremendous change just in the last
several years.

Dr. UBELL: We're paying the price for our success in developing new
medicines.

GROSS: Well, I want to thank you both so much for talking with us about
prescription medicines.

Dr. UBELL: My pleasure.

GROSS: Thank you.

Dr. WINNIFORD: And thank you.

GROSS: Dr. Peter Ubell is on the faculty of the University of Pennsylvania
Center for Bioethics. But he's about to move to the University of Michigan
in
Ann Arbor. Dr. Michael Winniford directs the Heart Care Center at the
University of Iowa.

Coming up, Eminem's controversial new rap CD. This is FRESH AIR.

(Soundbite of music)

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Review: Rapper Eminem's new CD, "The Marshall Mathers LP"
TERRY GROSS, host:

The 27-year-old Eminem, whose real name is Marshall Mathers, and whose other
nickname is Slim Shady, is currently the best-selling rapper in the country.
On the other hand, many people find his new CD contemptible because of it's
misogynist and homophobic lyrics, some of which you're about to hear in Ken
Tucker's review. The new CD is called "The Marshall Mathers LP." Ken says
Eminem's success in the genre is unusual, in part, because he's white. Ken
is
also surprised by the large amount of critical praise this X-rated rapper
has
received.

(Soundbite of music)

EMINEM (Singing): I don't do black music. I don't do white music. I make
fight music for high school kids. Put lives at risk when I drive like this.
I put wives at risk with a ...(unintelligible) like this.

KEN TUCKER: The massive sales figures and critical raves for Eminem's new
release, "The Marshall Mathers LP," have done much to obscure the stench of
his assiduously obscene, tiresomely garrulous music. At first, I thought
the
LP in the title was odd, that Eminem was probably the last rapper this side
of
Gran Master Flash who thinks in terms of long playing records. Then I
realized that even he seems to know it takes forever to play this tedious
thing all the way through. Just as I can admire the sadomasochistic
literary
fiction of prose writers ranging from Jean Jenet(ph) to Dennis Cooper while
still finding the stuff a chore to plow through, so do Eminem's spoken tails
of wife beating and murder, his proclamations of hatred for women and gays
strike me as both self-aware and repetitively repellent.

Marshall Mathers, to use his real name, is no dim-balled know-nothing. He
understands exactly what his provocations are. Shocked turn-ons for a
younger
audience than Jenet or Cooper usually attracts.

(Soundbite of music)

EMINEM (Singing): When I just a little baby boy, my mama used to tell me
these crazy things. She used to tell me my daddy was an evil man. She used
to tell me he hated me. But then I got a little bit older and I realized
she
was the crazy one. But there was nothing I could do or say to try to change
her 'cause that's just the way she was. They said I can't rap about being
broke no more. They didn't say I can't rap about coke no more. Slut. You
think I won't choke no whore till the vocal chords don't work in the throat
no
more. These (censored) are thinking I'm playing, thinking I'm saying this
(censored) thinking it just to be saying it. Put your hands down, bitch, I
ain't gonna shoot you. I'm gonna ...(unintelligible) to this bullet and put
it through you.

TUCKER: Craze for Eminem invariably concentrates on his technical skills.
Neil Strauss in The New York Times is typical, citing Eminem's quote,
"gifts,"
as including, quote, "the ability to make any two letters in a word in
common
rhyme," as well as his rap's, quote, "complex internal rhyme schemes and
rhythmic repetitions." This is the kind of reasoning that's often applied
to
dull folk music. The melodies may be tedious, but the artist composes like,
gosh, a real literary artist, to which I invariably reply, whether the
subject
is Judy Collins or Eminem, `If I want poetry, I'll read it on the page,
thank
you.' I go to CDs or LPs for popular song, which is to say an artful nexus
of
word and music, a synthesis at which Eminem fails. For Eminem to be
effective, to be more than an overrated novelty act, he'd have to expand the
content of those complex rhymes in his engagingly varied vocal delivery with
subject matter less unvarying than his contempt for women and male-male sex.
Here's his attempt at self-justification.

(Soundbite of music)

EMINEM: A lot of people think that what I say on records or what I talk
about
on the record, that I actually do in real life or that I believe in it. But
if I say that I want to kill somebody, that I'm actually gonna do it or that
I
believe in it. (Censored). You believe that, and I'll kill you. You know
why? (Singing) 'Cause I'm a criminal, criminal. He's goddamn right. I'm a
criminal. I am a criminal. My words are like a dagger with a jagged edge.
I'll stab you in the head whether you're a fag or les. Had homo sex,
hermaph,
or a trans ...(unintelligible) pants or dress. Hey, fags, the answer's yes.
Homophobic? No, you're just heterophobic, staring in my jeans watching my
genitals ...(unintelligible). That's (censored). You better let go of 'em.
They belong in my scrotum. You'll never get hold of 'em. Hey, it's me,
Versace. Whoops, somebody shot me. And I was just checking the `male.'
Get
it, checking the `male.' How many records...

TUCKER: I'd say the current master rappers, such as Jay-Z and Mos Def, have
no reason to lose sleep over this twerp, but, unfortunately, as black
artists,
they do. Because once again, the predominantly white media have seized a
white artist to valorize beyond aesthetic reason. The best response to
Eminem
has come from an unlikely, but welcome, corner. Britney Spears, slandered
by
name along with other teen pop stars on "The Marshall Mathers LP," has,
instead of getting mad, laughed off Slim Shady's insults with admirable
derisiveness. Me, I echo her snickers and crank up a better release, such
as
the new Del the Funky Homosapien CD, then I settle in to read some Elizabeth
Bishop. Talk about your internal rhyme. That is one ho who's got it going
on.

GROSS: Ken Tucker is critic at large for Entertainment Weekly.

(Closing credits)

(Soundbite of music)

(Credits given)

GROSS: This is NPR, National Public Radio.
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.