Monday, January 28, 2008

Who Gets Free Samples? Not the Needy

A group out of the Cambridge Health Alliance at Harvard have published what appears to be the first population-based survey of the use of free prescription drug samples in the February, 2008 American Journal of Public Health (subscription needed to access on-line). To satisfy conspiracy theorists, I should admit up front that the notorious duo of Steffie Woolhandler and David Himmelstein, single-payer advocates and big honchos in Physicians for a National Health Program, are co-authors.

The authors took advantage of the fact that a large, detailed national survey, the Medical Expenditure Panel Survey (MEPS), asks several questions about receiving free samples, and allows those answers to be correlated with information about demographics, income, and insurance status.

The results: more insured than uninsured people received free samples in 2003, the year for which data were available. The poorest patients were less likely to receive samples. The authors note the likely dynamic--being given free samples by a physician usually requires that you were able to get inside the door of a certain type of office. Once you get inside that door, if you lack insurance, you may be more likely to be given a sample than your neighbor who has insurance. Within the confines of the office, that is, the docs may make decisions about distributing samples that are in keeping with an intention to serve the neediest. But whatever shift that produces toward the poor and uninsured getting more samples, is outweighed by the fact that the poor and uninsured usually cannot get inside that door to begin with.

The finding that most samples do not go to the medically indigent is no surprise; previous studies have shown similar findings, without the benefit of a national database. (This study could not detect an effect reported in previous studies, that as many as 1/3 of the samples may walk home with the physicians and office staff.)

The bottom line here seems to be that yet again, when we try to get straight on the various issues at the interface between medicine and the pharmaceutical industyry, we encounter layers and layers of rationalization before we ever get to enlightenment. Studies show that the majority of samples do not go to the indigent. It is not in the interests of the companies to give samples to the indigent. (Samples come out of the marketing budgets. The companies have separate programs to give away drugs for free as charity; how well those programs work is a matter for another post; but there is no benefit to the company in robbing its marketing budget to enhance charitable giveaways. As marketing, samples given to the poor are mostly a flop; you want to focus your marketing efforts on folks who can afford to buy your product.) Yet, as soon as a critic of the industry talks about samples, the industry apologists immediately trot out the canard about all the samples going to the needy.

Cutrona SL, Woolhandler S, Lasser KE, et al. Characteristics of recipients of free prescription drug samples: a nationally representative analysis. Am J Publ Health 98:284-89, 2008.



The response by PhRMA to this study was interesting. For another take, read my blog (jan 3) which addresses this issue.

PhRMA Prefers No 'Second-Guessing' When Discussing Pharmaceutical Sampling

Also, I have my personal opinion of PPArx. (I'm not a fan.)

Neurogirl said...

How many of the truly "poor" do not qualify for Medicaid or other indidgent programs? Very few. And those programs provide free medications to their recipients. Those with no insurance qualify for pharmaceutical company patient assistance programs where, again, they receive medication for free.

I give samples to all types of patients. I give the most samples to Medicare patients in the "donut hole" of their prescription coverage, or insured patients with a large prescription copay.

Our "poor" patients in NW PA manage to find their way to the ER, often by calling an ambulance to transport them for such emergencies as sore throats. A lot of my Medicaid patients lose their insurance because they couldn't be bothered to fill out the yearly renewal forms.

Let's stop perpetuating the myth that the US is a third world country-I have lived in, and practiced medicine in, such places--they would love to have drug samples, along with simple things like bandages and surgical tape.

Anonymous said...

A couple of facts regarding the content of this post:

1. drug samples are the greatest influencer of prescribing habits of doctors, as well as one of the few access material a rep has to gain access to a doctor.

2. While more expensive, these samples, over other meds, such as generics, perhaps if generics were sampled as well, this would allow for greater treatment options for the doctor to consider for his patient instead of the convenience of selecting a branded sample readily available for a partcular diagnosed disease state.

Anonymous said...

Are Drug Reps Really Necessary?

One of the main functions of pharmaceutical representatives is to provide free samples to doctor’s offices presently instead of authentic persuasion, and these samples in themselves cost billions to the pharmaceutical industry. Yet arguably, samples are the most influential tool in influencing the prescribing habit of a health care provider. Let me be clear on that point: Its samples, not a representative, who may be the top influencer of prescribing habits.
Yet considering that drug promotion cost overall is approaching 20 billion a year, combined with about 5 billion spent on drug reps themselves, what if there is another way for doctors to get free drug samples, which is what they desire for their patients to initiate various treatment regimens? What if prescribers could with great elation avoid drug reps entirely?
There is, actually, a way to do this, but it is limited. With some select, smaller pharma companies, doctors have the ability to order samples by printing order forms on line for certain medications through certain web sites associated with the manufacturers of these samples. Some examples are such medications that can be ordered in this way are keflex, extendryl, and allerx. Possibly several more can or are available to prescribers in this way. Others, however, cannot be acquired by this method.
So in some situations, a doctor can go on line, print off a sample order form, fax it into a designated fax number after completion of the form, and the samples are shipped directly to the doctor’s office with some products thanks to their manufacturers who provide this avenue. There is no review of the doctor’s prescribing habits. No embellishments from reps actually sounds pretty good.
Usually, this system is available for those smaller companies with very small sales forces to compensate for what may be vacant territories, but can be applied to any pharmaceutical company who, upon discretion, could implement such a system.
Now, why is this not done more often? Apparently, it is legal to obtain samples in this manner. If samples are the number one influencer of prescribing habits, why spend all the money on reps to deliver samples personally? It’s worth exploring, possibly, since the drug rep profession has evolved into those who become UPS in a nice suit.
Think of the money that could be saved if more pharma companies offered samples to doctors in this manner. Furthermore, additional benefits with this ideal system are that there is no interruption of the doctor’s practice. And again, there is no risk of bias presented to the doctor by a rep, as they would avoid contact with reps if they order samples through this way- to have the samples directly to be shipped to their office.
When samples are shipped to doctors’ offices in this manner, prescribing information of the particular med is included with the samples shipped. Doctors can order and utilize samples according to their discretion, and would be free of interference from the marketing elements of pharmaceutical corporations. Patients benefit when this occurs.
Considering the high costs associated with the pharmaceutical industry, having samples shipped directly to doctor’s offices should be utilized more than it is presently- regardless of the size of the pharmaceutical company.
Something to think about as one ponders cost savings regarding this issue.

“The new source of power is not money in the hands of a few but information in the hands of many.”
---- John Naisbitt

Dan Abshear

Anonymous said...

You Have Now Been Sampled (Drug Reps, Part 2)

While the pharmaceutical industry’s image and reputation has suffered, and has been complicated with their declining profits due to a few reasons, these companies still apparently insist on keeping most of their gift- givers on board. Known presently as simply drug reps today, this job has become a vocation void of a sense of accomplishment, which will be described below.
So they may be named at times in different ways, these promoters will be referred to as drug reps, which number close to 100,000 in the U.S. presently, it is believed. The cost to the pharmaceutical industry of these employees is around 5 billion dollars a year. Income for each rep grosses close to or above 100,000 grand a year on average, along with great benefits and a company car, as well as stock options as they gladly work from their homes.
The main function these days of drug reps, I believe, is primarily to offer doctors various types of inducements of a certain value. The drug sampling of doctors may be considered an inducement, and a rather valuable one for the drug rep, as many believe that these samples are what ultimately influence the doctor’s prescribing habits over anything else, including statements from drug reps. This may be why the drug industry spends around 20 billion every year on samples.
While historically drug reps have used their persuasive abilities to influence the prescribing habits of doctors in an honest and ethical manner. However presently, most health care providers now simply refuse to speak with them, or have banned all drug reps permanently from their practices for a number of reasons, including the recommendations from their colleagues. It is possible that this may be due to the following reasons:
1. The doctors lose money. Doctors are normally busy, so their time is valuable. As a drug rep, you are a waste of their time. Yet they will accept your samples still. The credibility you possibly have as a rep is not considered anymore to be present in your vocation due to various controversies associated with the pharmaceutical industry, it is speculated.
2. Most drug reps in the U.S. are hired for their looks and their personality. As a result, many are somewhat ignorant in regards to anything that is clinically relevant to a medical practice, so doctors seem to know this and have responded in such ways. Most drug reps have college degrees that do not correlate with their profession as a drug rep, which is to say that the clinical training of drug reps is limited. In fact, many consider this of such a serious nature that an Act is presently being considered called the SafeRx Act that would certify pharmaceutical reps, and this would be mandatory. One main reason would be to ensure personal accountability for their tactics and statements, I believe, which may improve the quality and safety of their function in the medical community.
3. Many drug reps, it is believed, are void of any ethical considerations due to ignorance of what they are coerced to do or say to prescribers by their employer, and this allows them to embellish the benefits of their promoted products at times in addition to offering inducements to doctors. This is usually due to the rep being unaware of the consequences of their actions at times, yet at other times what reps say is with premeditated intent for potential financial gain for such a drug rep. Worse yet, due to pressure to keep their high-paying jobs, they always are anxious to please their superiors, who require them to offer various types of inducements to physicians that are designated targets of a particular drug company. Such tactics are especially true with the larger drug companies. These reps are in fact coerced to spend these individual promotional budgets assigned to them by their employer. While legally risky, the drug companies continue to dispense to their reps these large budgets reps have been forced to be responsible for dispensing, and are required to spend these budgets. In fact, so much emphasis is placed on this promotional spending, there seems to be an association between the money a rep spends and the progression that occurs with their career working for their pharmaceutical employer. Disclosure laws are being considered presently to mandate the release of all funds dispensed from pharmaceutical companies, which is to say to allow others to see where their money goes and who it goes to, as it is presently very secretive, overall. It is not unusual for a big drug rep to spend 50 thousand dollars a year for clinic lunches alone. In addition, drug reps hire doctors as speakers for certain disease states, and they find many other ways to spend this money they are required to spend.
4. Another issue is what is referred to as data mining. The American Medical Association sells this prescribing data on individual doctors to pharmaceutical companies, which allows them to track the scripts a doctor writes, and the data is free of the patient names. Yet the names the products prescribed are well illustrated and available to the drug reps. This allows reps to tailor their tactical approach with any given doctor, if they see the doctor at all during an office visit. Worse yet, doctors who greatly support the promoted products determined by this data allow reps to reward those doctors who favor the rep’s products that they promote, and this could be considered a form of quid pro quo. Laws are being considered presently to prevent this practice of allowing reps to have this data. Doctors are opposed to the data the reps have as well about them for privacy and deceptive reasons, so they say.
5. Overall, reps can be best described as far as their function goes with their profession is to, whenever possible, manipulate doctors with remuneration or other forms of inducements, as they also continue to sample such doctors along with others their promoted meds. Also, frequent lunches are in fact bought often for doctors’ offices and their staff as a method of access, primarily, as stated earlier with the money reps spend earlier for this type of function. Essentially, because of the income and benefits the drug reps receive that they would likely not be able to obtain with any other job, they are compelled to do such unethical if not illegal tactics mentioned earlier that they perhaps normally would not do in another setting. Usually these drug reps rarely refuse to implement such tactics encouraged to them by their employers.
6. Samples keep the prescriber from selecting what may be their preferred choice of med due to cost savings from samples left with a medical office by a drug rep. In addition, doctors are now being paid by prescription providers, which are called pharmacy benefit managers (PBMs) that are typically owned by a managed care company to have a doctor switch their patients to generic substitutes, if they exist, and this is often not disclosed to such patients. Apparently, these PBM companies are doing this in response to the activities of the branded drug companies, as they continue pay doctors often for various reasons, which are questionable in themselves.
It is likely that most drug reps are good and intelligent people who unfortunately are coerced to do things that may be considered corruptive to others in order to maintain their employment, ultimately. It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps that exists, with their encouragement, which forces the reps to do the wrong thing for the medical community, possibly. Clearly, greed has replaced ethics with this element of the health care system, which is the pharmaceutical industry, as illustrated with what occurs within these companies. However, reversing this misguided focus of drug companies is not impossible if the right action is taken for the benefit of public health. Likely, if there are no drug reps, there is no one to employ such tactics mentioned earlier. Because authentically educating doctors does not appear to be the reason for their vocation. This is far from being the responsibility of a pharmaceutical sales representative.

“What you don’t do can be a destructive force.” --- Eleanor Roosevelt

Dan Abshear