An Open Letter to Jerry Avorn

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  • 03/29/2006

The New England Journal of Medical Opinion is running an editorial about the Medicare drug benefit by one of the Harvard Medical School’s Repository of Liberal Thinking on Healthcare, Jerry Avorn. The article is entitled “D is for Defective” and can read by going to And if the article is not enough stimulation, the NEJM has a real treat for you: an audio interview with Dr. Avorn so you can experience his smugness in stereo. I wrote a letter to Avorn challenging him to crawl out of his elite cocoon and debate me on Medicare Part D. Fat chance.

Dear Mr. Avorn:

I read your editorial on the Medicare drug benefit (Part D for Defective) in the NEJM with great amusement. It reminded me of what Mark Twain once said: Get the facts straight and then distort them as you please. Then again, you don’t even get the facts straight.

Perhaps that’s because you rely solely on media accounts of the program design and implementation instead of information readily available about these issues as far back as November of 2004. You would then know as an article in Health Affairs pointed out that the the president “proposed an outpatient prescription drug benefit to be offered under a new voluntary Part D of Medicare … Medicare would pay half the cost of covered drugs The drug benefit would be administered by a [private] pharmacy benefit manager.” To help seniors maintain more generous private-sector coverage, “the president’s proposal had incentives for employers to keep [drug coverage]. Medicare would pay employers 67 percent of the premium subsidy costs it would have incurred if retirees had enrolled in Part D instead.”

This is what you are railing against and you claim that it is a product of “heavy input from pharmaceutical and insurance industries, with predictable results.” In fact, the program described in the Health Affairs article was Bill Clinton’s. It was supported by virtually every Democrat. At the time, President Clinton noted that his program, “competitively selects private benefit manager to deliver the benefit to enrollees in the traditional program,” and instead of “government negotiating directly for prices (price controls) the new benefit has privately-negotiated discounts, gained by pooling beneficiaries’ purchasing power, for all drug expenses.”

Did I miss your _expression of outrage about Medicare chaos at that time?

Note that both the Clinton and Bush plan enrolled all seniors to avoid what is known as adverse selection. That means — though you are a single payer fan and should get the drift — that if the drug benefit was only offered to those without coverage the risk pool would be filled with the sickest and most poor. Enrolling everyone and providing subsidies to encourage employers to retain coverage was a way to spread risk and promote wider participation.

I agree the goal was to enroll those 11 million seniors — including the 7 million that are low income or spend more than $3600 in medicines to enroll. And it seems they are. Nearly 8 million have already, about half of them being those in greatest need and deriving the greatest benefit. By the time May 15 rolls around I will bet you a donut that most of the people that need it will be enrolled. That will be in stark contrast to the dismal record of the state plans you and Ron Pollack said were just as good. Again, since you only seem capable of getting your facts second hand, let me give you information on those state pharmaceuetical assistance programs from the Commonwealth Fund. It found that in 2000, 15 state program enrolled only 19 percent of eligible people, or less than a million. Overall, after a quarter century of operation, the state plans had enrolled an average of 30 percent of all income eligible seniors. No wonder that when it came to shifting Medicaid seniors over to Medicare, states in some instances dropped the ball.

As for the donut hole, you should know that seniors have a choice of choosing plans that fill it completely. Indeed, more than 20 percent have. And then they also can choose to join a managed care plan which eliminates your other concern, that the drug benefit is carved out and handed off to a separate entity that would appear to be only interested in saving the costs of the drug. But you never seem to endorse that. Rather, you call for government controlled, universal drug coverage with technocrats — perhaps using programs developed by you — deciding which drugs to use and which to refuse to administer. And you call for price controls as well. You call them negotiations. But we have seen how negotiations work in the VA, Canada and elsewhere. Name me one system where drug prices are negotiated and the government is the single payer where the government also does not withhold access to medicines or refuse to pay for them regardless of benefit.

In this regard your pretense of scientific objectivity is just that and nothing more. For all of your pompous prattle about evidence based prescribing, your support of government direct negotiating undercuts such an approach. The VA formulary only includes 22 percent of all FDA priority review medicines on its formulary. It excludes Gleevec, Alimta, Humira, Avastin, etc. You blather on about the ALLHAT study when specialists in hypertension community have largely rejected the one size fits all approach you have read into it. Further, in an era of personalized medicine, which you never mention since it does not square with your command and control approach to prescribing, large scale randomized trials are scientifically deficient since they by definition exclude inclusion of any mechanistic understanding of how a drug works or how that mechanism (as a result of genetic polymorphisms) may shape treatment and drug response in subpopulations. Yet, your whole campaign to make drug choices based on safety, efficacy and economic value depends on the creation of a government agency that would fund larger and longer comparative trials that would by definition have no room for the personalization of medical care. So much for allowing doctors to “choose the most appropriate and cost-effective drug…”

I would challenge you to a debate on these issues but I doubt you would give up the intellectual free ride you have been given by your friends in the media. I don’t doubt that you actually believe that you possess some absolute truth about all health matters. And I don’t doubt that many of your allies feel the same way about themselves and that the sentiment, when you are all together, is mutually reinforcing. But that does not constitute reality or even truth. If you ever feel the urge to step outside the circle of hubris to discuss these matters, please let me know.


Robert M. Goldberg, PhD.
Vice President
Center for Medicine in the Public Interest


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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