Really good post!!

Sure it is fairly obvious that doctors are being incentivized to prescribe specific drugs, but the key for me is why this is happening, whose fault is it, and whose duty (if anyone) is it to stop it?

I am surprised there haven't been more 'Big Pharma must go' responses here - just the one, where the poster didn't seem too objective, as you noted...

I don't think Pharma companies are bad. Many are publically held, all of the large ones are, and they have a duty to their shareholders. The impression I get is:
1) Early research is primarily driven by the science - finding targets and novel MoAs with limited consideration at this stage of commercial potential
2) Around PhIIa, commercial and market access are very heavily involved, and decisions are made now according to very different criteria. Otherwise promising therapies may be stopped as there is no business case for them. A shame, but as above, these companies are profit-making enterprises
3) At launch, commercial run the show and the goal is maximizing company value. It seems that regulations here are ever tightening - in my view it is not up to the pharma companies to make the laws, it is up to them to obey them or if they so choose, to have their own rules which are more stringent than the laws

A key problem in my view is also the general public, who by and large want everything but are not prepared to pay for it. There seems to be an expectation that companies develop new treatments and then just give them away - that is not a sustainable model

On the positive side I am noticing a slow move towards new models that are outcomes-based - companies get paid for outcomes, not pills. This makes sense, but I think there is tons still to be worked out and it will at best be a series of very slow steps

Could go on forever, but I don't actually know much about this - will stop now before I say something totally wrong...

Cheers