Holden, my 3-year old son, was truly out-of-sorts for a week after we arrived in New Zealand. He was consistently cranky, refused to walk the city sidewalks, and frequently directed abusive behavior toward his sister and the hotel furnishings. Disturbed, we convened a family summit on how to make him right.
Holden suggested “bad guy” toys, and his sister proposed gummy worms, but ultimately we settled on the parental preference: pharmaceuticals. My wife, based on prior ex-perience, was concerned that Holden had an otitis media, and I was concerned about waking up at 4 a.m. and lugging a 30-pound child to and from the immigration office to complete visa pa-perwork.
So we agreed on a compromise: a few drops of Auralgan for his ears. We decided on this de-spite the lack of evidence that Holden actually had an ear infection, and despite a strong suspi-cion that moving halfway around the world might have a significant psychological impact on a 3-year old.
I was pleasantly surprised to find a local pharmacy that carried Auralgan but taken aback when the pharmacist began to quiz me about my choice. She was (rightfully) dubious about Holden's diagnosis, and it wasn't until I explained that I was a physician (and that I believed in the placebo effect) that she finally relented and allowed me to pay $20 for a small bottle.
Afterwards, it occurred to me that this interaction would have gone quite differently back home, where purchasing over-the-counter medications usually only elicits questions like, “Do you have a Rite Aid Saver Card?” or “Plastic or pa-per?” I soon started noticing other differences as well. One was quite striking: the near absence of drug advertising. No billboards for antacids, no magazine spreads touting erec-tile dysfunction cures, and no wacky television commercials with beavers, Abraham Lincoln, and insomnia prescriptions. I noticed a simpler approach to prescriptions at work in the ED — fewer choices, shorter medication lists, fewer narcotics, and for the children: “play therapists” to supplement pain control during procedures.
I heard far fewer concerns about the medications that patients could or could not afford to pur-chase.
It became clear that medications are less prominent in Kiwi society than in America. Why might that be? First off, direct-to-consumer pharmaceutical advertising is legal in both countries, but it is uncommon in New Zealand. Kiwi television ad time is reserved for truly im-portant products like the popular savory spread Marmite. (Did you hear there's a short-age?) Americans, however, cannot avoid drug ads. U.S. pharmaceutical companies spend more than $5 billion a year on them, and the typical American will spend around 16 hours each year watching television snippets for drugs. But, more importantly, the structure and incentives regarding prescription medications are distinct. A premium is put on choice and novelty at the expense of, well, expense in the United States. Sure, drastic differences exist be-tween insurers and public assistance programs, but as a nation we spend a lot of money on pre-scription drugs, something like $300 billion, which works out to about 13 percent of all health care costs, the highest rate in the world.
New Zealand has a smaller pharmaceutical budget and unified approach under a national for-mulary. Created in 1993 in response to rapidly rising drug prices, the Pharmaceutical Manage-ment Agency (PHARMAC) recognizes what we all know. A handful of medications perform equally well for some common conditions, and some of these are cheaper generic brands. A patient with high cholesterol, for example, has many choices of “statins” — Lipitor, Mevacor, Crestor, etc. We know they all work through the same molecular mechanism.
PHARMAC, with input from multiple physician-staffed committees and subcommittees, nego-tiates with the makers of those medications to get the best value for the money. The result is that a narrow list of medications (often just one) becomes the subsidized choices for that condition, and patients pay a nominal pharmacy charge when they are prescribed one of these (between $0 and $3). Rather than seven statins to choose from, the Kiwis have just three (which seems enough to me).
Of course, a customer who truly wanted a different statin could almost surely pay more to get it. Many large U.S. insurers function in a similar manner for formulary and nonformulary medications. But because PHARMAC is negotiating for an entire market of 4.5 million people, they have a reasonable chance of striking a good deal with the drug makers. And, financially, at least, PHARMAC has been a success, reporting saving $4.7 billion since 2000 while increasing its purchasing power threefold since 1993. This success has allowed the organization to expand funding of specialized and novel medications (for exceptional circumstances). One example is that it funded dabigatran to prevent strokes in patients with atrial fibrillation. (This, of course, may turn out to be a mistake, but more about that another time.)
It is difficult to argue with the cost efficiency, but not everyone is keen on the PHARMAC model or its decisions. A recent funding switch regarding glucometers for diabetics had some worried that the newly subsidized glucometer will not work well for everyone and not be worth the projected $10 million in savings. In the words of one parent to New Zealand's television network, TVNZ: “We are sheep farmers in a rural area. If I have to call for an ambulance for my daughter, the first thing they are going to ask me is what her blood sugar levels are. If I haven't got an accurate meter to tell them, the consequences will be dras-tic.”
Despite flares like this, it generally does not seem like having fewer pharmaceutical choices bothers the average Kiwi. I asked an Auckland pharmacist if her customers seemed happy with the medication choices they had. “Well, sure they do,” she replied, “but they don't have much of a choice about that, now do they?” And I must admit that, as a physician, it is sometimes rather nice to have a short and sweet list of prescrib-ing options. This approach seems to lessen the risk of gratuitous medication prescribing, and it places less emphasis on pharmaceuticals, with the Kiwi perception of health being, if you will, less drugged out.
This is not to say that one approach or perception is necessarily superior to the other. Indeed, the Kiwi approach would probably not be possible without the American one. Pharmaceutical companies need markets for new drugs, after all, and we all benefit from them staying in the business of making lifesaving treatments such as vaccines, insulin, and antibiotics.
So, you may be wondering, did those eardrops help Holden? We'll never know the answer. Ultimately, his mom and I demurred, and went with bad guy toys and gummy worms instead. I am happy to report that this worked quite well. Could it be that those who haven't been fully indoctrinated into the “pill for every problem” life-style might be onto something? Maybe we can all do with a little more “play therapy.”