Sunday, February 21, 2016

Nancy Tomes's "Remaking the American Patient"

Nancy Tomes is SUNY Distinguished Professor of History at Stony Brook University and author of The Gospel of Germs: Men, Women, and the Microbe in American Life.

She applied the “Page 99 Test” to her new book, Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers, and reported the following:
My book is about when and why we started expecting patients to act like consumers. Why in order to get good medical care do Americans have to shop for it with such determination and skill? Contrary to popular assumption, the transformation of patients into consumers did not start with the coming of the Internet, or even the rebellious baby boomers of the 1970s. In fact, the use of the term “consumer” to mean “patient” dates from the 1920s, when the many ways that modern consumer culture, advertising, and medicine influenced each other became glaringly apparent, both in the doctor’s office and the drug store.

Page 99 appears in a chapter titled “the New Corner Store,” about the transformation of the old style pharmacy into the new style drug store of the 1920s and 1930s, the ancestors of today’s CVS and Walgreens. It follows a chapter titled “The High Cost of Keeping Alive” about why Americans were starting to complain about the size of their doctor’s bill. Interwar drug stores tried to position themselves as a convenient alternative to a costly doctor’s visit. On page 99, I am discussing consumer concerns about prescription drugs. Some patients were starting to demand that prescriptions not be written in Latin, so they could understand them better. But surprisingly, the price of prescription drugs was not a big source of concern. People used far fewer of prescription medicines than today, and their prices were still low in comparison to over the counter products. The big uptick in drug prices only started in the 1940s, as powerful new drugs under patent protection came on the American market.
But perhaps because the cost of prescription drugs remained comparatively small—on average only a few dollars--- the economic sleights-of-hand going on in the prescription department attracted less hostile commentary than did the changes in doctors’ billing practices. Since so many drugs were more or less equivalent, no single seller could raise prices very high without losing trade, and the cost differential between prescription and over-the-counter drugs remained relatively small. Moreover, prices for prescription medications did not vary as dramatically as did physicians’ fees. Pharmacists relied on standardized systems for calculating drug costs, such as the Evans Rule, used by the National Association of Retail Druggists and named in honor of its pharmacist inventor. In essence, these systems doubled the cost of the ingredients to cover containers and overhead and added a set rate for the labor of compounding the prescription, with an ultimate goal of achieving a profit of between 10 and 20 percent.
On page 99, I also discuss how pharmacists developed ciphers to ensure consistency in their pricing.
At a time when patients could repeatedly get the same prescription filled, so long as it was for non-habit-forming drugs, pharmacists also had to be careful not to vary prices, lest the refill cost be higher than the original. Instead of putting the price right on the label, pharmacists substituted ciphers: in the early 1900s, the phrase “COME AND BUY” stood for the numbers one through ten, so a dollar would be written “C.Y.Y.” In the late 1930s, the National Association of Retail Druggists had replaced the overt commercialism of the earlier code with a more neutral cipher, “PHARMOCIST,” in which a dollar would be written “P.T.T.” In another indication of price sensitivity, physicians and pharmacists developed codes to recognize very poor patients for whom the customary pricing should be waived. Explained Remington’s, “It frequently happens that physicians desire to indicate that a patient is poor and is a proper subject for charity”; in such cases, doctors would write the letter P in the lower corner of the prescription, “or if very poor PP.” Continued the text, “It is customary and humane to regard these marks if assured of their genuineness.”
How quaint this language of “customary and humane” sounds today. Drug companies and pharmacists once operated in a business culture where keeping prices low mattered even for prescription drugs. What happened to that world? In the rest of the book, I show how and why the pharmaceutical industry changed so that the “high price of keeping alive” came to apply to prescription drugs as well as physicians’ services. How did we get to a world in which Martin Shkreli can mark up the price of a drug by 5000 percent? Read Remaking the American Patient and find out why.
Learn more about Remaking the American Patient at the University of North Carolina Press website.

--Marshal Zeringue