Do you think the health care system in the United States is better than it was 40 years ago?
A simple way to gauge the health of a country, and to compare the health of that country to others, is to look at average life expectancy. If we were to apply that metric in 1980, when I started my medical practice in Roseburg, the U. S. average life expectancy was about equal to eleven other wealthy countries. However, between 1980 and today, the U.S has fallen further and further behind.
By 2019, prior to Covid, life expectancy in the U.S. had fallen relative to that in other countries so much that 500,000 Americans were dying each year more than the death rates of the citizens of those other countries.
To exclude poverty as a factor in these numbers, a study looked at the health of privileged Americans – white citizens living in counties that are in the top 1% and top 5% of income. Although this population had better health outcomes than other U.S. citizens, it still had worse outcomes than average citizens of other developed countries.
Combine this data with the fact that we in the U.S. are paying an enormous excess over those other countries on health care. As Americans, we are spending an excess $2.3 trillion a year on health care – and getting poorer results.
For me, this raises three questions:
What should the primary goal of American health care be? In my mind it should be to maintain and improve individual and population health most effectively and efficiently. If true, we must then answer the following two questions:
Why are we failing so miserably to achieve this goal?
Why are doctors and other health care professionals willing to go along with this dysfunctional system?
One of the fundamental reasons for the disparity between the health of American and the health of people in other wealthy developed countries is that our medical-industrial complex has taken control over what doctors and the public accept as medical knowledge. That capture includes me and you.
Have you ever recommended a patient increase their cholesterol lowering medicine to meet benchmark numbers? Me too. Do you understand that the endpoint of many of the studies used to support our recommendation weren’t really appropriate to determine benefit of statins? Are you aware that when peer-reviewed articles are published in medical journals – even the most reputable medical journals – the peer reviewers don’t have access to the actual data from the clinical trials being reviewed? Do you recognize the influence drug companies have over our trusted medical journals and the way you and I prescribe?
I like statins. I take one. But it is humbling to acknowledge my recommendations to increase the dose of that statin drug is based entirely on incompletely vetted commercially sponsored and influenced medical journal articles. Does that sound harsh?
A 2005 article in the New England Journal of Medicine noted that 80% of clinical trial agreements allowed drug companies to own the data produced by the research. In recent litigation involving Pfizer – although Pfizer is no different than other drug companies in this respect – internal Pfizer documents stated in stark language that “Pfizer-sponsored studies belong to Pfizer”, and “the purpose of data is to support, directly or indirectly, marketing of our product.”
That shouldn’t surprise you or me. Big Pharma is comprised of for-profit companies. Their job is to maximize returns to their investors. Accusing drug companies of being greedy is like accusing zebras of having stripes. It’s who they are.
Let me provide another example. I am a proponent of using GLP 1 drugs for diabetes. Does it matter which brand I choose? If I consult UpToDate I am told that if the patient has ASCVD, I should use a GLP agent such as Trulicity based on cardiovascular outcomes study results. What wasn’t publicized or shared with doctors in these studies is NNT (numbers needed to treat). In the case of Trulicity, you would have to treat 327 people for approximately 3 years to prevent one non-fatal heart event. The cost of treating those 327 people over that time is $2.7 million. Would that information make a difference to you?
Did you realize these brand name drugs cost three and a half times more in the U.S. than in other wealthy developed countries? More shocking is the rate of increase in prices. In 2008, the average annual price of a new drug in the U.S. was $2,115. In 2021, this annual price had risen to $180,000. In 2022, the average annual price was up to $257,000.
The result in the U.S. is that 96% of our biomedical research money is spent on medical drugs and devices and only 4% on how to make the population healthier or how to deliver health care more efficiently and effectively. The highest profit does not come from studying systems of care or promoting healthy diets and lifestyles. How did this happen?
Two important laws helped to bind academics to the biotech and pharmaceutical industry. In 1980, Congress passed the Stevenson-Wydler and Bayh–Dole Act. The Stevenson-Wydler Act pushed federal agencies to transfer technologies they helped invent to the private sector, leading many universities to create technology transfer offices. The Bayh–Dole Act allowed small businesses to patent inventions created with federal grants, allowing universities to license products their faculty created.
Within a year, many top academic centers and their faculty had signed lucrative licensing deals with pharmaceutical companies. Now, it was not only possible for medical investigators to have their research subsidized by businesses whose products they are studying, or act as paid consultants for them, but they are sometimes also principals in those businesses or hold equity interest in them.
The distinction between academic research and industry marketing eroded. Whatever boundaries between universities and industry that had previously existed nearly disappeared, as academic interests became almost indistinguishable from corporate interests.
The capture of science by industry, government and propagandists has only increased since the 2005 NEJM article, which also cited that 50% of clinical trial agreements allow the sponsor (drug company) to “write up the results for publication and the investigators may review the manuscript and suggest revisions.”
While it may be irresponsible for medical journals not to require transparency from drug companies, it makes perfect business sense. Their financial viability depends on these companies. When an editor of one of the world’s most respected journals was asked why his journal didn’t require drug companies to submit all internal clinical study data, while redacting proprietary information, the editor responded, “that would be a death spiral for the journal.”
It was a rare moment of transparency. The editor understood the problem. But medical journals need to publish these major clinical trials to maintain their prestige and continue to sell reprints back to the drug companies. The sale of reprints is a big deal. In 2005, the Lancet made over 40% of its income from selling reprints. Reprint purchases can add up to more than $2 million each. The revenue medical journals earn from reprints is a big incentive to publish studies with positive findings. It’s like buying Hunter Biden’s art. A small distance between value and bribe.
There is an answer to this. It would require the evidence base of medicine to be accurate and complete. It would require independent transparent peer review, allowance for open discussion, and avoidance of the conflicting interests of financial motives or political agendas.
This would require federal legislative incentive and initiative. I have no idea how this will occur when the only bipartisan agreement on this subject among our political leaders is that it is fine for legislators to accept huge contributions from drug companies.
The strategy developed by tobacco companies in the 1950’s has evolved into a medical-industrial complex that has a stranglehold on American health care. Its foundation is money. Its strategy is control of information. In Part III of this series, I will speak to another malignant force that, from government agencies to academic institutions to trusted journals, has degraded credibility in whom we can trust.
Tim Powell MD