Marketing genius/National dysfunction

[Scanner]

First of all, let me say I was motivated by a profit motive here so my motives weren't pure.

My patient is an insulin diabetic, hypertensive, and a few other musculoskeletal health problems. Her famiy doctor recommended a fish oil supplement - any OTC was fine. She went to her endocrinologist and he recommended prescirption Levaza. All Levaza is is a fish oil.

I was so curious, I had her bring in the leaflet and looked up the strength of the fatty acids. Essentially the fish oil supplement I sell in my office for $35.00 is actually a few mg. stronger - all intents and purposes, essentially the same though. It just doesn't have the "health claim" that it prevents cardiovascular disease. Between Medicare taxpayors and her portion, she pays $90/month for fish oil.

I tried to tell her it's the same exact stuff and she could save her reimbursement for the meds she really needs (insulin being one) but she said she was real satisfied and doesn't mind her and the taxpayor paying for the supplement.

I am not too surprised, I guess. . .I have seen the psychology of the "prescription" with Americans for 14 years. . .but I actually thought saving $660/year would entice her.

Not only that, she didn't even have to go through me. . .she could get a bottle of it at BJ's or Walmart cheaper than me.

Teaches me a lesson I keep learning over and over. . .with the exception of saving advicee's, never market on price or saving money with healthcare. People like to spend money on healthcare I have concluded. They equate it with value.

Also, it also teaches me how dysfunctional our healthcare system still is with taxpayor money though.

[Frugal]

I agree with you. I have used fish oil. It is expensive. Helps my spouse's cholesterol (or so I hope).

[Joan.of.the.Arch]

I thought there was a prescription synthetically produced omega-3 fatty acids. I actually might be interested in that, as I fear (don't have actual facts) that perhaps the production of omega 3 supplements from fish contributes heavily now to a huge decline in fish in the cold parts of the northern oceans. However, just last night, I noticed on a TV ad that Lovaza (spelling?) is derived from fish. But maybe there is another prescription omega-3s that is synthetic.

Oh yeah, the ad also said that the Lovaza omega-3s are esters of omega-3s. Did you take that into account when comparing Lovaza with your product? I think I'd need one of those prescription inserts for the info.

Um, I also might be interested in switching to a prescription omega-3s because 1.) I'm already paying big bucks for a health plan that is supposed to include prescriptions, yet, they keep cutting coverage out the very meds/ supplies we already use. I keep getting less and less for more and more. It would be nice to reverse that if only for a single product. However, no doubt Lovaza or any other prescription omega-3 would be on the highest tier pharmacy coverage. 2) I do have some greater confidence that prescription meds are produced to verifiable standards of purity and concentration (even though we know that there are sometimes violations, even to the point of product recalls. ).

As is, I go to the drugstore with a calculator, trying to get the most omega-3s immersed in the least extraneous other oils, at the best price (per omega-3 mg). I have to take into account so many differences, in concentration, total omega-3s per pill, total number in the jars, whether I have a coupon, whether the product is buy-one/get-one that week, and also quite importantly, the claims made for distillation. It can easily take me 15 minutes to find the best deal for my preferences. And I cannot just find one product and stick with it because the products keep changing.

So your patient wants Medicare to cover her omega-3 supplement, and I might like for my private insurance to cover it. Maybe. But whatever, I want a good product at a good price for me. I know lots of people won't stop to compare the prices at the grocery store. Not too many will take time to do the kind of comparison I do at the pharmacy for fish oil!

But are you saying she could actually come out ahead by buying it over the counter instead of by prescription?

[Scanner]

I thought there was a prescription synthetically produced omega-3 fatty acids. I actually might be interested in that, as I fear (don't have actual facts) that perhaps the production of omega 3 supplements from fish contributes heavily now to a huge decline in fish in the cold parts of the northern oceans. However, just last night, I noticed on a TV ad that Lovaza (spelling?) is derived from fish. But maybe there is another prescription omega-3s that is synthetic.

I am frankly not sure what you mean by synthetic. Do you mean taking some let's say vegetable oil and then bubbling through some gases or something to arrive at an Omega-3?

I don't think there are any synthetic fish oils out there. They all are pretty much from fish.

Oh yeah, the ad also said that the Lovaza omega-3s are esters of omega-3s. Did you take that into account when comparing Lovaza with your product? I think I'd need one of those prescription inserts for the info.

Just another name for EPA and DHA - they should all be in any fish oil you take.

Um, I also might be interested in switching to a prescription omega-3s because 1.) I'm already paying big bucks for a health plan that is supposed to include prescriptions, yet, they keep cutting coverage out the very meds/ supplies we already use. I keep getting less and less for more and more. It would be nice to reverse that if only for a single product. However, no doubt Lovaza or any other prescription omega-3 would be on the highest tier pharmacy coverage. 2) I do have some greater confidence that prescription meds are produced to verifiable standards of purity and concentration (even though we know that there are sometimes violations, even to the point of product recalls. ).

As far as manufacturing. . .if you buy a supplement manufactured in the USA, although it may not submit itself to FDA standards, there are other quality control standards at the state level that ensure what you are swallowing is what you are supposed to be getting.

Most of the time, recalls and investigations occur in Chinese and beleive it or not, European supplements. Not to say it can't happen here in America though.

As is, I go to the drugstore with a calculator, trying to get the most omega-3s immersed in the least extraneous other oils, at the best price (per omega-3 mg). I have to take into account so many differences, in concentration, total omega-3s per pill, total number in the jars, whether I have a coupon, whether the product is buy-one/get-one that week, and also quite importantly, the claims made for distillation. It can easily take me 15 minutes to find the best deal for my preferences. And I cannot just find one product and stick with it because the products keep changing.

There is also some preference with patients preferring liquids or soft-chew tabs. They have a different cost, higher than capsule format.

I know it's never apples to apples but when I posted this thread, I tried to keep it as apple to apple as I could.

So your patient wants Medicare to cover her omega-3 supplement, and I might like for my private insurance to cover it. Maybe. But whatever, I want a good product at a good price for me. I know lots of people won't stop to compare the prices at the grocery store. Not too many will take time to do the kind of comparison I do at the pharmacy for fish oil!

Well, the patient is an older German rotund woman (to paint a picture) and she doesn't want to "mess around" with anything. Ironically, even with Medicare "covering it" there is still a "donut hole" in which it appears she's paying out of pocket almost as much as an OTC fish oil.

She does say this fish oil doesn't cause "burping" though. . .and that is a main side effect. . .but with the dozens of OTC ones. . .the one I recommend is enteric coated and none of my patients complain (although the ones with liquids sometimes do).

But are you saying she could actually come out ahead by buying it over the counter instead of by prescription?

She spending about $1100 as best as I can figure on "fish oil." Then she's complaining about how much her insulin costs.

The point of me looking into all of this (and it was fascinating to learn about Medicare Prescription coverage) was to see what was charged, what was paid by the taxpayor and the patient.

Personally, I agreed with her family doctor. . .just get an OTC one (or thru me ) but the specialist must have had a call from a pharmaceutical rep that day and she got put on Levaza. The research really helped me as a business person to "set policy" in my practice when dealing with patients and their pocketbooks.

It comes down the question - is it healthy for society to medicalize everything?

If I want a juicy cheeseburger from Red Robin, am I going to need a prescription for that? Will it be reimbursed as "stress relief?" Of course my questions are rhetorical - it's a food product. There should be no patent issued on his or "medicalizing" this substance IMHO.

[disneysteve]

As I recall, the marketing material for Lovaza says that it is something like 16 times more potent/concentrated than the OTC fish oil products. I'd have to research the source of that claim, though.

[Scanner]

http://us.gsk.com/products/assets/us_lovaza.pdf

DESCRIPTION
LOVAZA, a lipid-regulating agent, is supplied as a liquid-filled gel capsule for oral administration. Each 1-gram capsule of LOVAZA contains at least 900 mg of the ethyl esters of omega-3 fatty acids sourced from fish oils. These are predominantly a combination of ethyl esters of eicosapentaenoic acid (EPA - approximately 465 mg) and docosahexaenoic acid (DHA - approximately 375 mg).

Other than for inflammation, DS, I am not sure why you would even want to dose a patient that high with an Omega-3 supplement. There was one moderately well-designed research study that indicated 3x the normal dosage of Omega-3's = the anti-inflammatory effect of ibuprofen (OTC strength).

(or you cna just take ibuprofen). Sometimes I recommend that though as an alternative if I know their kidney functions are borderline.

But 16x? I have never heard of using it at that level.

Why would you want/need it at that level?

[Scanner]

BTW, the enteric coated fish oil I sell from my practice for "health" (not a lipid regulating agent mind you, nudge/nudge/wink/wink) has:

660 mg. EPA
340 mg DHA (a little less)

[disneysteve]

Scanner, I wasn't arguing the point. I was just recalling what reps have said when detailing the product. And I'm just going from memory so I may be getting the details wrong.

From a doctor's point of view, I can tell you that writing a prescription for Lovaza is much easier than advising a patient to take an OTC product for a few reasons. As you know, OTC products come in various strengths and formulations so just sending a patient off to buy any old fish oil capsule isn't really appropriate. Plus, when the patient gets to the store, they will likely be overwhelmed by the choices and walk out with nothing. When I hand them a prescription, assuming they fill it, at least I know exactly what they're getting. When I do follow up labs, I know what treatment it is that I'm evaluating the efficacy of. If the response is inadequate, and I confirm compliance, I know they just didn't respond to Lovaza as opposed to wondering if the problem was the particular brand/strength/formulation that they ended up buying (is the Costco brand as good as the Target brand or the CVS brand or one of the nationally advertised brands?).

Of course, it may well be that there are OTC options that are equally effective and cheaper. I honestly don't know and I'm not aware of any easy to use resource to answer that question since OTC supplements are not FDA-regulated and don't have to do the same efficacy testing that prescription drugs do.

[Joan.of.the.Arch]

Yes, by synthetic I meant the essential fatty acids were catabolyzed from fats, not just purified from sources that contain the free fatty acids. I thought there was a prescription Omega-3 essential fatty acids pill not derived from fish at all. But anyway...

I'm with you basically on not wanting to medicalize nutrition. However, I also resent that some of the most usual sources of Omegs-3s in our human diets for centuries have become poor sources of fatty acids due to the way our food is produced. (Meat animals that do not graze, poultry that does not feed on bugs, seeds, and other bits of plants.)

And yes, I've thought of addressing that by raising my own chicken and eggs, but my little urban plot can only handle so much. Plus, it would not be a chore I'd like. (I've been trying to persuade my spouse that he is interested in raising chickens in a neighbor's yard that I already mow and keep in shape! )

I don't take omega-3s for any cardiovascular benefit, though if it has a benefit, great. I take it for a skin problem, a problem I've had since I was a toddler. The correspondence of my taking omega-3s with that problem clearing up is clear to me. Over eight years, when I have gone through periods of forgetting the fish oil, my problem has come back. When I dutifully remember to take it again, the problem clears again, though it takes weeks to do so. And it was not a skin condition that fluctuated before taking fish oil. It was constant. I don't know what the mechanism of action is (anti-inflammatory generally? being a structural material needed in the cell membranes? who knows?), but I think fish oil's omega-3s are responsible for my improved skin. And it makes me suspect that I've previously had a lifelong deficiency of omega-3s. A deficiency because of the dearth of them in foods that ought to have them.

For anyone who wants to tell me about vegetable sources of omega-3s, I'm a willing listener. I've known for years about purslane, thank you, and I eat it a lot. (Actually I do so because of the widespread claim that purslane is high in omega-3s, even though I've never seen a study cited. So I am skeptical.) I don't know any USAmericans besides my family and a Pashtun-American family who eat it, though I see it in the import grocery. I grow my own and supply the Pashtun family as well.

[Joan.of.the.Arch]

PS
I've just decided to have mackerel for supper! Ha-ha-ha.

[disneysteve]

For anyone who wants to tell me about vegetable sources of omega-3s, I'm a willing listener.

I believe flax seed is a good non-fish source of omega-3s, so cereal, granola, etc. containing flax seed is another option.

[Joan.of.the.Arch]

That would be linoleic acid. (Flax, source of linen, hence the linoleic acid, that's why I can remember this one) I keep it in my freezer for a sort of omletty-pancakey thing that Scanner probably knows about as a low-carber.

[Scanner]

Ds,

Sorry my tone came across argumentative but iI was genuinely interested to see if the reps said it was somehow more therapeutic at that level. And I totally understand your reasoning on the prescription. Those could be argued those are my reasons as well but I do have a conflict of interest admittedly.

Actually, I give my patients a choice - if they are " shoppers" and frugal people like here they can just pay for advice out of pocket on a $300/hour basis or they can just get their supplements thru my office.

Honestly, i have only ever had one person pay for the " unbiased" advice. People have a hard time paying for advice and direction, especially w dr. Google :-).

[Scanner]

Joan,

If you do grassfed meats, then there may be little need for supplementation. However, I am not sure why the FDA hasn't recommended that everyone take an omega supplement the evidence is so overwhelming.

And yes, I follow a " paleo" lifestyle. Meats, fruits, and vegetables - no grain or dairy. My carb count isn't as low as an Atkins diet but it is lower than a grain based diet. Essentially, a hunter gatherer diet.