medicine and health

It is often said that doctors are the only professionals that seek to make themselves unnecessary. It sure sounds good. But do we really believe that this is true? Are doctors really out to make themselves obsolete? Although many are driven by higher motives, I found a surprisingly large number of pre-med students willing and even proud to admit that they were in it for the money. Even those that do aspire to higher goals have little choice. Given the high cost of medical education, and the resultant outstanding loans that many young doctors are stuck with, most could not afford to put themselves out of business even if they wanted to. Fortunately there is little real danger of such a situation materializing. That makes it easy to take the high road.

The pharmaceutical industry is "struggling" with the same dilemma. The "struggle" is largely an internal matter though, as pharmaceutical companies are businesses so they can freely state that their primary goal is to make money. As indicated before, they have a duty to make money and their officers are bound by such duty to maximize revenues and profits. That means the true struggle for pharma is one of communication and public relations. It is key to appear to the public as if profits were an afterthought. This is a serious matter and all pharmaceutical companies try to outdo themselves in this important area.

Health care investors can be even more blunt and they often are. It has been remarked by some famous healthcare analysts that there are only two disasters that happen during a clinical trial for approval of a new drug. One is that the drug does not work. Obviously that is a bad situation and the company will have to forgo a major opportunity to make money. The other equally grave disaster is that the drug cures the patients. That may sound counter-intuitive until you realize that drugs that cure diseases cannot make money. To be truly successful, a drug must mitigate a condition enough to make a difference, but not so much that patients can ever stop taking the drug.

It is fairly easy to see that the best drugs are the ones you have to take for the rest of your life. And the best conditions to focus drug development on are the ones where people survive for a very long time after diagnosis. Both of these are necessary ingredients for the so-called blockbuster drug. Blockbusters are drugs that sell in excess of $1B a year and major pharmaceutical companies are set up to pursue blockbusters and blockbusters only. Considering that patents offer exclusivity for about a decade (17 years to be exact but one needs to subtract the years it takes for approval), and that a drug, once developed is practically speaking all profit or margin, it should not surprise us that pharmaceuticals are big business. The top selling drug today is Pfizer's Lipitor, a medication for high cholesterol levels that brings in a nice $12B a year for the company.

Note two things: high cholesterol levels (in nearly all) result in no symptoms or signs, and drugs for high cholesterol need to be taken for life. High cholesterol is a condition that is linked to a higher incidence of heart disease and stroke. It is not an illness per se (again with few exceptions). The linkage was established through population studies. You may note that possession of a car is likely equally strongly linked to almost any predominantly Western disease.

Just as it behooves pharmaceutical companies to focus on drugs that nearly everyone can take for the rest of their lives, it is advantageous for healthcare providers to focus on patients with chronic, but largely stable conditions. Doctors thrive on hypertension, high cholesterol, diabetes, and especially chronic complaints. Although MDs often state that the latter are their least favorite patients, the economics shows them to be essential to the well being of the practice.

In short, healthcare, like so many other things in life, is a playground for consumers and providers. Consumers of services, devices, and drugs. In that sense it is not so different from other areas of the service economy. It is equally sensitive to over-consumption and waste. Which means, unfortunately, that its net impact on health is rather trivial.