Harvard Doc Takes on Big Pharma
- May 11, 2025
- 4 min read
Teaser/Abstract
"Dr. Jerry Avorn, a professor at Harvard Medical School and a senior internist at the Harvard-affiliated Mass General Brigham healthcare empire, is the sort of person who loves to bite the hand that feeds him. Hence his searing and witty new book, Rethinking Medications, which gives it to you straight about how our nation's healthcare system — with Harvard Medical School at or near the center of the universe — is failing us miserably when it comes to the medicines we take."
Source: Everything is N1303K, Substack, May 12, 2025. Author: Donald Maurice Kreis, consumer advocate, public utility lawyer, and member of ICER's New England Comparative Effectiveness Public Advisory Council (CEPAC). Note: This is a third-party book review, not authored by Dr. Avorn. All quoted passages are taken from the reviewer's direct quotations from Rethinking Medications.
SUMMARY
Donald Maurice Kreis — a New Hampshire consumer advocate whose family includes a daughter with cystic fibrosis — reviews Rethinking Medications through a pointed dual lens: as a critique of pharmaceutical pricing writ large, and as an urgent case for preserving New Hampshire's Prescription Drug Affordability Board (PDAB), which the state House had stripped from the budget at the time of writing. The review centers on the book's treatment of drug pricing — particularly the Vertex Pharmaceuticals case study — and Dr. Avorn's explanation of how and why drug prices in the US are structurally untethered from any measure of clinical value. The review also covers the QALY debate and the pharmaceutical industry's political campaign to block evidence-based drug valuation at both the federal and state levels.
BACKGROUND
Kreis introduces Rethinking Medications as a book by a Harvard physician willing to criticize the very system that employs him — noting that Dr. Avorn's ultimate institutional boss, Harvard President Alan Garber, sits on the board of Vertex Pharmaceuticals, the company Dr. Avorn uses as a central pricing case study. The review focuses primarily on Chapter 13 of the book, titled "Old Whines in New Battles," which addresses how drug prices should be set based on comparative clinical value — and why an act of Congress makes that method illegal for much of the federal government.
KEY FINDINGS
The "Because I Can" approach to drug pricing. Kreis quotes the book's account of a pediatric pulmonologist confronting a Vertex Pharmaceuticals executive about the $300,000-per-year US price of Trikafta, the cystic fibrosis drug. The executive's response, as reported in Rethinking Medications, captures the pricing dynamic precisely: the shareholder sitting in that same chair earlier that week had asked, "How dare you charge only $300,000 a year for our drug? Why not $400,000 a year, or $500,000?" Dr. Avorn calls this the "because I can" approach to pharmaceutical pricing — the same phrase used by a different drug company executive who justified a different massive price increase by noting that there was no legal mechanism to stop him.
What the right metric looks like: QALYs. Dr. Avorn argues in Chapter 13 that the correct method for determining drug prices is the quality-adjusted life-year (QALY) — a measure that accounts not only for how many years a drug adds to a patient's life but how that additional time is actually experienced. As he asks in the book: "What if the six months of life added by [a] new cancer drug were marked by frequent vomiting, hair loss, weakness, and occasional infections, as often occurs with some cancer treatments? Should that half a year of life be counted in the same way as a treatment that offered the same life extension, but one marked by robust good health?"
Why QALYs are "politically radioactive." Dr. Avorn documents the pharmaceutical industry's political campaign against QALY-based drug valuation, including its use of patient advocacy organizations — some functioning as astroturf groups — to oppose the method on the grounds that it discriminates against the sick, elderly, disabled, and minority patients. He identifies PIPC (Partnership to Improve Patient Care) as one such group and describes the campaign's core argument as illogical but politically effective: "Protecting the elderly, disabled, and minorities was a more convincing rallying cry than protecting the revenue stream of pharmaceutical companies." Kreis connects this directly to the Boomer Esaison Foundation's campaign against QALYs in CF drug pricing decisions.
How Congress made evidence-based pricing illegal for federal payers. An act of Congress effectively prohibits much of the federal government from using QALY-based cost-effectiveness analysis in drug pricing and coverage decisions. Because federal payer prices tend to anchor prices throughout the entire market, this prohibition has cascading effects on what everyone — insured and uninsured alike — pays for drugs.
Prescription Drug Affordability Boards as a state-level response. With Congress unable to act, the National Academy for State Health Policy developed model legislation enabling states to create PDABs to establish upper payment limits for the most expensive drugs. Eleven states had adopted PDABs at the time of writing, including Colorado and New Hampshire. The Colorado PDAB's 2023 deliberations over Trikafta represented the first time any PDAB anywhere attempted to assess whether a drug was unaffordable — though Kreis notes the Colorado board declined to address whether the drug was unaffordable to the healthcare system as a whole, focusing instead on whether individual patients could access it (partly because Medicaid enrollees faced no direct cost). New Hampshire's PDAB, meanwhile, had been stripped from the state House budget and was facing elimination.
IMPLICATIONS
The review's argument — drawn from Dr. Avorn's book — is that the political and commercial forces preventing evidence-based drug valuation from being applied in the US are both identifiable and addressable. The tools exist: the QALY metric is used routinely by every other wealthy country to negotiate drug prices that reflect clinical value. The obstacle is political. State-level PDABs represent one mechanism for circumventing the federal prohibition. Their survival is therefore not a technocratic budget question but a substantive policy choice with direct consequences for how much patients, employers, and governments pay for the most expensive drugs in the American market.