A letter to the CEO of Boerhinger Ingelheim–on Pradaxa

I remember in high school, as an assignment, I wrote a letter to a prominent business person.  I will try it again. In 2010, this would be an e-letter.

To: J Martin Carroll
CEO of Boehringer Ingelheim Corporation: The makers of the recently-released exciting new oral blood-thinner, dabigatran (Pradaxa).

Dear Sir,

To start off on a positive note, a hearty congratulations is in order. Developing a safe and effective replacement for warfarin (Coumadin) is a remarkable achievement. Simply awesome. Cheers. “H/t” and all that.  (Ed note: Presently, dabigatran is FDA-approved only for non-valvular AF.)

But before the celebration progresses much further, I wish to offer-up an idea for making your potential blockbuster into a bona fide blockbuster, in the real-world of American medicine.

My suggestion is that Boehringer Ingelheim lower the price of dabigatran!   Ridiculously low, not 250+/month, that’s not that low–how about 40-50/month? Surely, you have heard this plea before, and undoubtedly there were intense strategy sessions on how to price the drug for maximal profit. 

But sir, I have five reasons why this benevolent strategy might work:

First, do it because your company’s motto is “Value through Innovation.” 

Now, I realize you might refer readers to the recent Annals of Internal Medicine paper which suggested—via mind-boggling statistics—that dabigatran “could” be the most cost effective strategy for stroke prevention in AF.  The problem with that study is that even if those mathematical models are correct (and they depend greatly on pricing), the cost savings is to the ‘healthcare system,’ not to the individual patient at the pharmacy counter with a credit card.  Remember, stroke prevention is only one facet of AF therapy; most AF patients are on a few other medicines as well. (And they have monthly cable TV and iPhone bills to pay.)

Second, although your advisers may not have told you this very forcefully, there are many patients on long-term warfarin who do great. They eat a stable diet, don’t take new drugs without checking first, and don’t mind a trip to the warfarin “finger-stick” clinic once a month. They might switch to dabigatran if it were cheap, but not so much at 300/month.

To this, you might respond that dabigatran was proven more effective and safer than warfarin in the RE-LY trial.  This is true, but what if a patient asked me this, 

“Hey Doc, I looked at RE-LY too. You saw that the warfarin-treated group was only in therapeutic [blood-thinning] range 65% of the time. I have been in range for years…so do you think dabigatran is still better for me?”

>>Makes one think of this dreamy trial: What if dabigatran (or any new oral blood-thinner) were compared head-to-head against a cohort of well-educated motivated warfarin-treated patients who were equipped with an INR home-monitoring device which facilitated staying in ideal blood-thinning range all the time? <<

Third, to a business novice, a lower price makes sense because what you lose in margin, you would gain in volume—and in warfarin-replacement the volume would be a lot larger at 50/month than 300/month.  Since you know this angle better than me, let’s move on.

Fourth, building the largest possible volume of patients on dabigatran is time sensitive. There are formidable competitors on the horizon, and the likely next one is once daily—Rivaroxaban. BI has a head-start, but as I see it, the more brand loyalty you accrue the larger the hurdle for upcoming competitors.  

Fifth, it would be a really cool thing to do, for humanity. Think of all the goodwill BI would accumulate. And it is well known that goodwill is good for the heart.  I see that that your company wins a number of “best-places” to work awards; so you all seem to get the goodwill thing.

Sincerely,

John Mandrola, MD