Medicines and the media: news reports of medicines recommended for government reimbursement in Australia

The news media are an important source of information on health and medical advances for consumers. However, the quality of media coverage is variable, with concerns about exaggerated claims of benefits, inadequate coverage of harms, a lack of information on treatment costs, and limited use of independent expert opinion to interpret the balance of benefits and harms for consumers [1‐4]. Reporting about medicines varies in its focus and impacts. Newspaper stories around the time of marketing of a new medicine can increase public awareness, [5] and may promote patient requests for the product [6, 7]. Business news reports relate to share prices and projected profits for pharmaceutical companies; while adverse publicity on drug safety can have dramatic negative effects on market values [8, 9].

Australia’s Pharmaceutical Benefits Scheme (PBS) is a publicly funded insurance scheme aimed at providing universal affordable access to prescription medicines [10]. Approximately 80% of the prescription medicines used in Australia are subsidised under the scheme [11]. The private prescription market for medicines not listed on the PBS is estimated to be around 5% of total prescriptions, the remainder funded by other Commonwealth and State programs [12]. All patients contribute a per prescription co-payment until reaching a threshold after which a ‘safety net’ comes into effect; the safety net serves to protect individuals and families with high medication needs [13]. The Pharmaceutical Benefits Advisory Committee (PBAC) is an independent statutory body that makes recommendations to the Minister for Health on the drugs and medicinal preparations to be subsidised on the PBS or included in the National Immunisation Program (NIP). In doing so, the PBAC considers the safety, efficacy and cost-effectiveness of the proposed medicine [10]. Where the PBAC has rejected the application, the sponsor may re-submit any number of times, generally with revised clinical data or clinical claims, changed utilisation estimates or alternate pricing proposals.

Two recent Australian case studies (trastuzumab for breast cancer, Herceptin®) and HPV cervical cancer vaccine, Gardasil®) suggest a media role in increasing political pressure to influence decision-makers [14, 15]. The pressure was directed at the Federal Government to commit substantial public money to subsidise an otherwise expensive and mostly unaffordable drug (trastuzumab), and to include the new HPV vaccine in the NIP.

After three rejections by the PBAC for listing for late stage cancer during the 1990s, intensive lobbying before the 2001 Federal election resulted in public subsidisation of trastuzumab in a special program independent of the PBS [14]. In 2006, a “crescendo of media demands” for trastuzumab to be available for early stage cancer preceded PBS listing. Reviewing 43 television news and current affairs stories regarding trastuzumab, MacKenzie et al. concluded “the dominant discourse across the news coverage was that Herceptin was a ‘wonder drug’ made unaffordable to the majority of women with HER2 breast cancer by government indifference, labyrinthine bureaucracy and unacceptable, cruel financial parsimony”[14]. The initial decision to reject funding of the HPV vaccine led to over 300 newspaper articles and calls by consumers, health professionals and politicians to intervene in the decision-making process [15].

Given these and other examples of media influence on the formulation of health policy, [5, 16] we examined the numbers of stories published in Australian newspapers on medicines seeking public subsidy and their timing in relation to PBAC decision-making. We expected there would be increased levels of media reporting in the months leading up to PBAC meetings, these would be highest in the month of the PBAC meeting, and there would be limited media coverage after the positive recommendation to list the medicine on the PBS. In addition, we sought to characterise the reports in terms of mentions of the PBAC and its decision-making, drug costs and budgetary impact of the listing decision.

We identified medicines considered by the PBAC for PBS listing in 2006 and 2007 [17]. We searched the ANZ Proquest Newsstand database [18] from 1 July 2005 to 30 June 2008 to find Australian newspaper articles pertaining to these medicines. At the time of this study, the database included more than 40 newspapers, covering the major daily and weekend newspapers of all capital cities and major regional centres [18]. Using generic and trade names, we searched the database for mentions of the medicine in the headline or text of reports and retrieved the full text of each identified article.

We counted the numbers of stories appearing in the six months before, the month of the meeting and six months after the PBAC meeting. Each story was coded for the number of times the medicine name was reported (1, 2 or ≥3 mentions), assuming that more mentions would reflect a greater medicine focus in the newspaper report. Stories identified in the three year time window (2005–2008) were coded for reference to the PBS (either use of the term PBS or reference to Government subsidy or medicine subsidisation), and medicine costs (either patient costs if it was not subsidised, or Government costs for providing subsidised access).

Each story was coded by two raters, with differences in categorisations resolved by consensus or by adjudication using a third reviewer where agreement could not be reached. Descriptive statistics are used to summarise the data.

In addition to the quantitative analysis of the news reports, three case studies where there were larger numbers of newspaper articles published around the time of the PBAC recommendation are used to illustrate the content and tenor of some reporting.

Most of the medicines considered by the PBAC in 2006–2007 generated little or no newspaper coverage. Medicines that were the focus of media reports included biological agents (monoclonal antibody therapies) and treatments for high profile diseases such as breast cancer, prostate cancer, ADHD, leukaemia and multiple sclerosis. Mentions of government subsidy and cost to the patient were more frequent for high-cost medicines (e.g. pemetrexed). We found no evidence of increased intensity of newspaper reporting close to the time of PBAC meetings.

While overall, most newspaper stories were not published in close proximity to the PBAC consideration for listing there was heightened media activity for a number of specific drugs. Whether the newspapers are actively mounting and promoting campaigns or are the agency for the campaigns of other interest groups is less clear. For both infliximab and pemetrexed, there were well-organised patient groups and disease associations, with petitions delivered to Government. In addition to reporting, at least one media outlet suggested a public campaign as the only chance; [27] and the subsequent successful listing was attributed in part to listening to the public view. In some cases the advocacy is clearer with one newspaper (Sunday Herald Sun) congratulating itself on the success of its media campaign to have treatment with trastuzumab subsidised by the Government; [58] Breast Cancer Network Australia was confident their pressure had “won the day”[59].

In a study of the representation of prescription medicines in UK newspapers, Prosser concluded that the media often constructs a discrete, contradictory, and frequently oversimplified set of characterizations about medicines - the contrast of marvellous medicines and dangerous drugs [60]. Our selected case studies illustrate the potential for this, with super effective, wonder drugs like pemetrexed, infliximab, trastuzumab (marvellous medicines) and the potential dangers of medicines to treat ADHD. In the case of ADHD, even the diagnostic criteria are contentious, [61] and the use of the terminology of drugs of addiction and the language of battle [60] (ADHD war) will tend to reinforce negative public opinion. Health care professionals seeking to mount a public campaign against perceived over-prescription of these medicines will have also contributed to the negative reporting of these medicines [62]. The effect of the media spotlight and the emotional content of the discourse was sufficient to interfere with the work of clinical experts trying to develop guidelines for use of these drugs.

While the costs of medicines to both patients and the Government featured in many of the stories, there were few challenges to pharmaceutical companies to justify the prices being asked for some of these medicines. There were few references to the decision-making processes used by the PBAC, with its emphasis on evidence of benefit and formal assessment of cost-effectiveness [10]. For pemetrexed, there was little discussion of the potential cost implications of the expected growth in patient numbers of 600 per year to 18,000 cases by 2020 [41] or the projected gain in life-expectancy (proven to offer two or three extra months of life) [63]. Interestingly, there were references to the comparatively cheaper ADHD medicines as costly tablets, [55] generating a bill of almost $10 million per year that taxpayers were forced to pay [46].

In the newspaper reports included in this study, there was little recognition that the formal and independent processes for the listing of drugs on the PBS had served the Australian taxpayer well. The system is acclaimed internationally and is generally believed to provide a consistent and defensible framework for decision-making delivering prices for new medicines lower than most other countries. Among the media reports about failure to fund the HPV vaccine and the pleas to the Health Minister to circumvent the PBAC’s advice in relation to the HPV vaccine, [64] few reports acknowledged that vaccine listing on the NIP was achieved with a substantial reduction in price from the manufacturer [65]. An offer of a price reduction, repackaging to reduce waste and more clinical data led to the final approval of pemetrexed [42]. Intensive lobbying lead to the 2001 decision to fund trastuzumab in a program separate to the PBS; this mechanism to provide medicine access has subsequently been described as “a mistake best not repeated” [59]. Applying different decision-making criteria for specific diseases creates difficult precedents for both government and the PBAC.

The case studies for infliximab and pemetrexed illustrate the use of identifiable victims to put a human face on the disease and its consequences. Apart from engaging reader attention, it also invokes the “rule of rescue”, i.e. the imperative people feel to rescue identifiable individuals facing avoidable death, [66] and can increase the likelihood of achieving the objective of gaining access to expensive medicines [14].

Our study was limited to newspaper reports of medicines drawn from a single news database, ANZ Proquest Newsstand. While the repository does not include all newspapers available in Australia and does not include online and television news stories, the scope and size of the readership of the included newspapers means that the discourse observed in these articles is likely to be reflective of the information and views offered to the Australian public. There was often syndication of stories to other news outlets, or use in more than one edition of a newspaper; we counted these as separate stories as an editorial decision had been made to reproduce the story and the readership was likely to be different. There were few useful classification frameworks available to guide our analysis of article content; our experience was that a numerical count of drug mentions was not always a good guide to article focus and content.

The results of this study suggest that mostly the PBAC can apply its rigorous evidence-based assessments away from the public gaze, however there are some decisions that have to be taken in a politically and emotionally charged environment. The media have a legitimate right to report and to give voice to the range of viewpoints. Some diseases lend themselves to more sympathetic attention than others (breast cancer and mesothelioma compared to bowel cancer; [67, 68]) however media prominence is a poor basis for decision-making. These funding decisions will become increasingly difficult as the manufacturers of new and expensive medicines seek public subsidy of agents that offer sometimes small clinical gains over existing therapies. In this environment, the media can play an important role in improving public understanding of the issues around resource allocation. Guidelines from professional associations such as the Australian Press Council, [69] use of checklists for journalists on key elements to include in their stories, [70, 71] and dedicated specialist health journalists [71] may all help in improving the quality of health reporting.

List of all drugs included in the study by number of articles referring to the medicine: