As a medical educator and practicing primary care general internist at our academic medical center, I have probably attended literally hundreds of pharmaceutical company-sponsored lunches and grand rounds over the course of the last 14 years. No doubt, I have received scores of pens and pads branded with the names of dozens of different proprietary pharmaceutical products. I have probably collected hundreds of similar items while walking the exhibit halls at major national medical meetings over a dozen years.

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Manufacturer: Sanofi-Synthelabo, Inc. Drug Class: Platinum antineoplastic agent Description: Oxaliplatin for injection is an organoplatinum complex in which the platinum atom is joined with 1,2-diamino-cyclohexane (DACH) and with an oxalate ligand as a “leaving group,” an atom (or group of atoms) that is displaced as stable species and takes the bonding electrons with it. Oxali-platin undergoes nonenzymatic conversion in physiologic solutions to active derivatives via displacement of the labile oxalate ligand. Several transient reactive species are formed, including monoaquo and diaquo DACH platinum, which co-valently bind with macromolecules. Both interstrand and intra-strand platinum-DNA cross-links are formed. These crosslinks inhibit DNA replication and transcription. Cytotoxicity is nonspecific for the cell cycle.

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Manufacturer: Eli Lilly Drug Class: Antifolate antineoplastic agent Description: Pemetrexed for injection exerts its action by disrupting folate-dependent metabolic processes that are essential for cell replication. By inhibiting dihydrofolate reduc-tase, thymidylate synthase, and glycinamide ribonucleotide formyl transferase, it interrupts the de novo synthesis of both purines and pyrimidines. As a single agent, it is active against a variety of solid tumors.

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Cetuximab (Erbitux™) for IV Use Only

Manufacturer: Imclone Systems, Inc./Bristol-Myers Squibb

Drug Class: Recombinant, human/mouse chimeric monoclonal antibody

Description: Cetuximab binds specifically to the extracellular domain of human epidermal growth factor receptor (EGFR). Produced in mammalian (murine myeloma) cell culture, cetuximab is composed of the fragment variable (Fv) regions of a murine anti-EGFR antibody with human immunoglobulin G1 (IgG1) heavy and kappa light-chain constant regions. Cetuximab binds to EGFR (HER1, c-ERB-1) on both normal and tumor cells and competitively inhibits the binding of epidermal growth factor (EGF) and other ligands (i.e., transforming growth factor-a). The binding of cetuximab to EGFR blocks phosphorylation and activation of receptor-associated kinases, resulting in inhibited cell growth, induced apoptosis, and decreased production of matrix metalloproteinase and vascular EGF.

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These four measures alone, however, will be inadequate to meet Medicare’s longer-term commitment to future beneficiaries. Closer examination of the impending baby-boomer avalanche highlights both the difficulty and the urgency of revitalizing its ability to do so. During the 1990s and continuing through this decade, Medicare’s annual enrollment growth has been minimal as two million seniors age in each year while a few less die.

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Private health plans, namely Medicare health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in assuming responsibility for all medical costs of their enrollees, do offer real opportunities for savings. That potential is leveraged by the fact that more than 80% of Medicare’s costs are incurred by the sickest 20% of enrollees,⁶ a popula­tion whose costs have been successfully managed by HMOs for a decade with the use of Disease State Management (DSM) Programs. Traditional Medicare, in contrast, began experimenting only two years ago with small DSM demonstration projects that it hopes will duplicate this success.

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Helping these underserved constituencies will require supplementing the aging traditional Medicare with more functional and durable enhancements. For a prototype of just such a model, we need only turn to a decades-old, soundly financed, and hugely popular All-American Plan. This plan is offered by a nationwide, heavily unionized employer with more than two million retirees. All retirees and their spouses are offered the choice of traditional Medicare or a variety of private plans with richer benefits, including drugs. Under its defined contribution (i.e., Premium Support) format, the employer contributes a fixed percentage of the premium for a chosen plan.

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