In an ideal world there would be head-to-head studies where they test competing drugs against each other in the same patient pool…but for various reasons that’s never gonna happen

That seems counter intuitive to me. You'd want to test each new drug against placebo and then compare results. New drug A versus Drug B seems incredibly easy to manipulate as making your new drug "better" in some way. If Drug B is twice a day, then just make your drug A once a day, or 4 times a day. Obviously you have to compare apple to apples so Drug B gets once a day dosage (which means it's less effective) or 4 times a day (so adverse events go up, now your new drug is safer)