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DTC-In-Perspective by Bob Ehrlich

DTC Can Impact Coverage

March 18, 2025 0

One of the effects of DTC advertising is its influence on healthcare providers and insurers. Consumers who see DTC ads, of course, ask their doctors about the advertised drugs. But what’s less discussed is how DTC advertising can influence the formulary decisions made by health insurance companies. Insurers—both private and government-controlled—don’t like DTC ads.

Consumers can be a pesky bunch. Insurers don’t want the public pressuring them to cover more expensive drugs. In some cases, they argue that older drugs are just as effective and much cheaper. In others, they insist that newer drugs need more long-term study before widespread adoption. At the end of the day, insurers and the government want to control which drugs are utilized.

DTC creates awareness of new treatments. Consumers want the best options available and hate being told that the latest drug isn’t on formulary. Those consumers then complain to their elected representatives, who in turn criticize insurers for restricting access. The insurers get painted as callous and greedy. That doesn’t let drug makers off the hook either—they’re criticized for high prices.

DTC creates awareness of new treatments. Consumers want the best options available and hate being told that the latest drug isn’t on formulary.

Weight Loss Drugs: A Case Study in DTC Pressure

A great example of this DTC-driven formulary pressure is the new GLP-1 weight loss drugs like Wegovy and Zepbound. Health experts say these drugs could help combat the obesity epidemic. DTC ads for both highlight significant weight loss results. But insurers hate covering these medications, which cost over $1,000 a month. Consumers, meanwhile, are frustrated that only the wealthy can afford them out of pocket. Thanks to DTC, demand has skyrocketed, and the pressure is mounting on insurers to expand coverage.

The Doctor-Patient Dynamic and the Role of DTC

One of the usual criticisms of DTC advertising is that it creates friction between patients and doctors—that patients, uninformed and swayed by marketing, shouldn’t be pressuring doctors to prescribe specific drugs. But there’s another side to this. DTC can also help doctors advocate for coverage when they believe an expensive drug is the best choice for a patient.

DTC as a Consumer Voice in Healthcare

Our healthcare system is a complicated beast, and critics of DTC rarely acknowledge how consumers actually benefit from its influence. The reality is that DTC can help push insurers to cover new treatments faster. Weight loss drugs, for example, will likely see broader coverage sooner rather than later, thanks to the hundreds of millions spent on DTC. At the same time, Lilly and Novo Nordisk will need to lower prices over time to expand access.

We all like to believe that patient care is the top priority when it comes to healthcare coverage. But we know that private insurer profits, government budgets, and drug company pricing all play a role. DTC advertising is one of the few ways consumers can make their voices heard in that equation.

Bob Ehrlich

DTC-In-Perspective by Bob Ehrlich

DTC in Perspective: New HHS Secretary Tom Price

December 2, 2016 0

President-Elect Trump nominated Georgia Congressman and physician Tom Price to head Health and Human Services. This move proves Trump is very serious in his goal of dismantling Obamacare. Dr. Price has offered a plan in the past very different from Obamacare. I think this is move in the right direction and will eventually improve quality at lower cost.

In Price’s plan Americans would have more free market options to shop for coverage. They would be able to buy insurance across state lines, increasing their choices and hopefully getting lower premiums. There would be tax credits for health insurance purchases differing by age. All the government mandates on what a policy must cover would go away.

Bob Ehrlich
“Americans would have more free market options..”
-Bob Ehrlich

Consumers could choose a bare bones catastrophic plan or pay for a comprehensive one. Health savings accounts would increase to shift health care decisions to consumers. In Dr. Price’s view consumers would still be able to purchase coverage with pre-existing conditions but at a premium if they currently do not have coverage. His goal is to encourage continuous coverage and not to have people buy insurance only after they are sick.

Dr. Price basically wants to take the Federal government out of the insurance business by creating more options using free markets. Medicare would stay but Dr. Price wants to allow participants some options to go outside of the system. Critics worry that any options to use money outside of Medicare approved providers would weaken the system. Any inkling that Medicare might be privatized scares Democrats greatly. Republicans want to look at options for younger people knowing that Medicare may not be sustainable long term.

Of course Dr. Price will need to alter his past proposals to whatever Mr. Trump and Congress will agree to. There is no evidence Mr. Trump wants to change Medicare. He also has said recently he likes certain provisions of Obamacare on pre-existing conditions and children up to 26 staying on their parent’s policy.

It is very clear that we will see Dr. Price be implementing a consensus plan that reduces Federal involvement and loosens requirements for policies. The Price philosophy is to give consumers more responsibility for their coverage and they will have more involvement in cost/benefit of care. The idea that someone else pays has created much unnecessary care. We have never really had a free market for health care in recent times. A true free market where consumers have transparency in what they are paying for and at what price will help control costs.

The fear that consumers will be without any coverage is overblown. People who currently have coverage on exchanges will likely have several years to convert to the free market system. While it is true that many Americans can now get subsidized coverage, we as taxpayers are footing a high bill that is rising rapidly. Those who buy on the exchanges who are not subsidized are seeing very large premium increases. Things need to change.

Whether the Trump plan is the answer to providing quality care at reasonable prices will be tested. I do know that the Obamacare plan needs to be dramatically changed as it is unaffordable. Trying free market solutions will get consumers to care much more about what medical services they need and at what cost. More involved consumers using their own money will hopefully lead to a wiser use of services and force providers to compete more on price/quality.

Bob Ehrlich