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ebmdatalab / price-per-dose

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Gouging: model within-DT gouging #23

Open sebbacon opened 7 years ago

sebbacon commented 7 years ago

This guy suggested alimemazine, dicycloverine and topical betamethasone with either neomycin or clioquinol as examples on twitter.

See also discussion at #40 and this notebook

sebbacon commented 7 years ago

To drill down in the Fusidic Acid example:

After fusidic acid eyedrops were acquired by AMCo, the price rose from £2.09 in May 2013 to £29.06 in April 2016, according to the NHS tariff book.

When Concordia bought AMCo for £2.3bn last September [2015] from private equity group Cinven, John Beighton, AMCo chief executive, boasted to analysts that the UK was “a prime market [for] being able to move prices”. source

After the generic medication hit £29.06 per 5g in 2015, some clinical commissioning group medicine experts recommended against the use of fusidic acid drops as the first-line treatment due to high costs and an increased risk of adverse effects source.

Prescribing dropped in June 2014; spending increased from Sept 2014, peaking in Feb 2016 since when it's been decreasing.

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Mystery: why are we still seeing prescribing of Fucithalmic under 1103010H0BBAAAA when it was discontinued in August 2014? (see #30 for more such examples)

sebbacon commented 7 years ago

Phenytoin Sodium is an epilepsy drug which has had relatively constant prescribing rates but a sudden increase in costs in October 2012. It is clear that Flynn's campaign to convince doctors to start prescribing "generically" was very successful, starting from that date:

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Interestingly, the generic presentation has always been more expensive than the branded, and has just (as of May 2017) returned to the pre-gouging price-per-unit, presumably in response to the December 2016 CMA judgement (and record fine):

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US-based Pfizer, one of the world’s biggest pharmaceuticals groups, sold the UK distribution rights for phenytoin sodium capsules to Flynn, a privately owned Hertfordshire company, in 2012. Pfizer continued to manufacture the drug and, according to the CMA, supplied it to Flynn at prices between 8 and 17 times higher than the US company had previously charged for the product in the UK.

Flynn then sold the drug to customers at prices between 25 and 27 times higher than those historically charged by Pfizer for a drug used by 50,000 UK patients.

This led to an increase in the amount spent annually by the NHS on phenytoin sodium capsules from £2.3m before 2012 to just over £50m in 2013.

source

  • In total, between Oct 2012 and March 2017, I estimate this strategy netted Flynn/Pfizer about £114m (spreadsheet with data here). If we deduct the record-busting fine for anti-competetive practices, they still made about £25m profit
  • Epilepsy Action put out a press release encouraging patients not to accept any other medicine, with a helpful inclusion of the Flynn Pharma helpline.
  • The "generic" version continues to be manufactured by Pfizer, and even has the brand "Epanutin" stamped on it.
  • Phenytoin sodium is in Category C of the Drug Tariff (drugs not readily available as a generic, price based on a particular manufacturer)
  • dm+d shows Epanutin ceased to be available in Sept 2012, except in 50mg capsules, which were discontinued in September 2016.
  • The generic is Phenytoin. There are 3 BNF codes for the generic: 0408010Q0AAAAAA, 0408010Q0AAANAN and 0408010Q0AAAWAW, but all prescribing data is listed under the former. Phenytoin 100mg capsules are currently available from 7 different suppliers within the UK. (What would the incentive be for other suppliers to wholesale rather than Flynn?):
  • Flynn Pharma Ltd
  • Alliance Healthcare (Distribution) Ltd
  • A A H Pharmaceuticals Ltd
  • Actavis UK Ltd
  • Ennogen Healthcare Ltd
  • Sigma Pharmaceuticals Plc
  • DE Pharmaceuticals
  • Despite Epanutin being listed as not available to prescribe in dm+d, it continues to be prescribed in primary care, presumably at the 50mg dose which has remained available right until Sept 2016; we should be able to check this in the next data releases. This was made available via Waymade Healthcare as a parallel import. Until Feb 2016, "Alliance Healthcare (Distribution) Ltd" were selling high-priced capsultes (the Flynn ones, presumably).
  • Update (Aug 2017): the import of cheap Spanish Epanutin was subject of a Court of Appeal ruling in April 2017. The name of the branded generic is Phenytoin Sodium Flynn - the company name is included due to the narrow therapeutic index. Flynn then launched an expensive campaign to explain to doctors that Phenytoin Sodium Flynn is exactly the same as Epanutin. The inclusion of a trade mark within the branded generic name then prevents any parallel importers from packaging imported Epanutin as Phenytoin Sodium Flynn. This presumably does not stop doctors from continuing to prescribe Epanutin.
sebbacon commented 7 years ago

So, first generate a list of BNF codes for singleton products: all VMPs where there are exactly two available AMPs, which have no more than one currently available AMPPs, and one of them has been discontinued. sql here - could do with more work.

Upload to BigQuery as a tabe singleton_codes, then to get a list of those products with relatively high prescribing:

WITH
  singletons AS (
SELECT * from `ebmdatalab.tmp_eu.singleton_codes`)
SELECT
  p.bnf_code,
  p.bnf_name,
  COUNT(*) AS count,
  SUM(net_cost) AS net_cost
FROM
  `ebmdatalab.tmp_eu.prescribing_2016_09_01`  p
INNER JOIN
  singletons
ON
  singletons.bnf_code = p.bnf_code
GROUP BY
  p.bnf_code,  p.bnf_name
HAVING count(*) > 4000

Some notes about it here

sebbacon commented 7 years ago

Using the third method (just look at products which only have generics available), sorting them by proportion-they-ve-gone-up-in-12-months gives more interesting results. SQL here

zip of output

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