Healthy Skepticism Library item: 19536

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Publication type: news

Petersen M.
Growing Opposition to Free Drug Samples
The New York Times 2000 Nov 15
http://www.nytimes.com/2000/11/15/business/growing-opposition-to-free-drug-samples-ultimate-costs-and-safety-are-cited.html

Full text:

Worried about safety and rising drug costs, a small but growing number of hospitals, clinics and other health care organizations across the country are banning free samples of brand name prescription drugs, or limiting what samples their doctors can accept from drug companies.

Doctors have long used free drug samples to let patients try new treatments or to start patients on medications quickly while they are waiting for prescriptions to be filled. But now, doctors, administrators and pharmacists at hospitals in cities including Madison, Wis., and Everett, Wash., say they worry they cannot control the increasing amount of free medicines that are doled out by pharmaceutical representatives.

Health care administrators also assert that the samples are helping to inflate their drug costs because the drug companies tend to give out samples of the newest brand name drugs, which are often the most expensive. The companies rarely give away samples of lower-cost generic drugs. And if the sample medicine works for the patient, the administrators say, physicians will often prescribe the higher-cost drug, even though a generic drug may work just as well.
Even some hospitals that take care of many uninsured patients who could benefit from the free pills are limiting their use of the samples.

Dr. John B. Chessare, chief medical officer at one such hospital, Boston Medical Center, said that his hospital was strongly discouraging its doctors from accepting free drug samples. The drugs that sales representatives hand out, he said, are often those with the highest profit margins.

‘‘They are not bringing us samples of things we need,’‘ Dr. Chessare said. ‘‘They are bringing us things they want us to know about.’‘

Like consumer advertising, the handouts of sample-size medicines are a growing part of drug companies’ marketing budgets. Last year, drug companies gave doctors free pills worth more than $7.2 billion at their retail price, almost 10 percent more than the year before, according to IMS Health, a company that tracks prescription drug information. By comparison, the companies spent $1.8 billion — one-quarter as much — on consumer advertisements. And the value of free samples continues to rise, up another 8.4 percent in the first half of 2000 compared with the comparable period a year earlier.

The actual cost of the free samples to the companies, however, is much less than their retail price because the expense of making the pills — the raw materials and factory costs — is often just 20 percent to 30 percent of their sales price, according to a review of the major drug companies’ annual financial reports.

As the drug companies have increased their handouts of the samples to help increase their sales, the hospitals and clinics say the free medicines have become harder to control.

The doctors and pharmacists say that there is an increased risk that a doctor could give a patient a sample of pills that is later recalled by its manufacturer, and they would have no way of notifying that person. And, unlike prescriptions, where there are two people — a doctor and pharmacist — to serve as safety checks, samples pass directly from doctor to patient.

‘‘This is a fallible system,’‘ said Lee C. Vermeulen, a pharmacist and the director of the Center for Drug Policy at the University of Wisconsin’s hospital and clinics, which banned drug samples in April. ‘‘It has got to end. It is unsafe by design.’‘

Many of the hospitals that are limiting the drug samples also say that they became concerned that they would be cited for not properly controlling the samples by the Joint Commission on Accreditation of Health Care Organizations. The commission does a survey of each hospital every three years and decides whether it meets the group’s standards for accreditation.

Dr. Paul M. Schyve, a senior vice president at the commission, said that the group had increased its emphasis on medication safety in the last two years. As part of that, he said, the commission’s surveyors have been making sure that hospitals properly control drug samples.

Mr. Vermeulen said that the University of Wisconsin banned samples at its hospital and clinics after being cited by the commission for lacking some controls over the sample-size medicines. And, Dr. Chessare said that he believed that many hospitals were responding to the commission’s new focus on samples.

But many doctors have complained bitterly as the clinics’ cabinets of drug samples have been emptied out. They say that they often depend on the samples to help patients who lack insurance coverage and cannot afford the expensive newdrugs. Some doctors say that they believe that their administrators are too focused on the bottom line.

‘‘We’re putting the interest of an H.M.O. ahead of that of patients,’‘ said Dr. Don Bukstein, a Wisconsin pediatric allergist and pulmonologist at Dean Health Systems, a doctor-owned group of clinics and managed care system in Madison.

Two months ago, Dean Health began barring drug sales representatives from visiting its 450 doctors and handing out free samples.

Before then, Dr. Bukstein often used sample-size medications to see if a drug would work for a patient before writing a prescription. He has also used samples of asthma drugs like inhaled steroids, he said, to help teach his patients how to use the drug inhalers.

‘‘I’ve had a lot of patient complaints,’‘ Dr. Bukstein said. ‘‘The difficulty of not having samples in my area is a major problem.’‘

And Dr. Finley W. Brown Jr., a doctor with his own family practice in Chicago, said that he could not understand why clinics and health care groups were deciding to ban both the free drug samples and sales representatives from their offices. Dr. Brown said that 10 to 20 drug salespeople, most of them handing out free samples, visited his office each week.

‘‘It doesn’t sound quite right that some clinics are not letting their doctors see the detail men,’‘ Dr. Brown said. ‘‘It is as if a doctor cannot be trusted to make a judgment.’‘

For their part, the drug companies say that the free samples play an essential role in the health care system.

‘‘They allow doctors to learn about the benefits of new drugs recently introduced to the market,’‘ said Dr. Bert A. Spilker, senior vice president for scientific and regulatory affairs at the Pharmaceutical Research and Manufacturers of America, the industry’s trade group, ‘‘and they allow patients to evaluate a drug’s benefit before spending the money on a full prescription.

‘‘At the same time, it is entirely up to doctors to determine whether it’s appropriate to use drug samples,’‘ Dr. Spilker continued. ‘‘Doctors make decisions that are best for their individual patients’ needs.’‘

A spokesman for Pfizer said that companies did not often provide samples of generic drugs because physicians already understand how the older drugs work.

There have been no definitive studies of whether drug samples influence doctors to write prescriptions for those sample medicines. But at one large clinic in Washington State drug costs have declined since it banned samples, even as the costs rose for other medical centers in the area. The Everett Clinic in Everett banned drug samples and barred drug representatives from visiting its 185 doctors in 1998. Dr. Al Fisk, the clinic’s medical director, said that the clinic had been worried about its rising drug costs and about trying to comply with the state laws governing the free samples.

Instead of relying on visits from sales representatives, Dr. Fisk said that the clinic’s doctors now got their information on drugs from a clinical pharmacist who was hired to provide more balanced information about new drugs.

‘‘I have been troubled by the fact that the major source of information that physicians use to educate themselves is from drug representatives,’‘ Dr. Fisk said. Often that information is ‘‘one sided,’‘ he said, and includes descriptions of the drugs’ benefits, while omitting their drawbacks.

The Everett Clinic’s drug costs declined 10 percent in 1999, Dr. Fisk said, after it banned the samples and took some other measures to control pharmaceutical expenses, including encouraging patients to split pills into smaller dosages. Drug costs at other health care organizations in Washington State rose about 15 percent last year, he said.

In Pittsburgh, Highmark Blue Cross and Blue Shield, a health insurer, said it was planning to begin giving doctors samples of generic drugs early next year so that they would have more samples to choose from than just the new brand name drugs. The insurer is working with Merck-Medco, a pharmacy benefit manager owned by Merck, to provide the generic drug samples.

Ann Smith, a spokeswoman for Merck-Medco, said that the company was working on programs that would make more generic drug samples available and increase the use of generic drugs. ‘‘It’s a huge opportunity for us to drive down the cost of health care,’‘ she said.

Dr. Donald C. Logan, chief medical officer at Dean Health in Wisconsin, said that the group decided to bar sales representatives from visiting its doctors in July, after its drug costs soared by 25 percent last year.

‘‘We were finding that the pharmaceutical reps were beginning to cause doctors to prescribe certain drugs,’‘ he said, ‘‘even though there were equally effective but less expensive medicines available.’‘

Dr. Logan said that some sales representatives, knowing the importance of having samples easily accessible to doctors, were even reorganizing the clinics’ cabinets of sample-size medicines so that the pills made by their respective companies were in a more prominent position.

While the sales representatives are no longer allowed to visit Dean’s doctors, Dr. Logan said, the physicians can still use mail order to get most pill samples from the drug companies if they feel the medicines are beneficial.

Some doctors have tried to find ways around the bans on samples. At the University of Wisconsin, a month after the cupboards in its 90 clinics were emptied of samples, senior medical managers discovered that some doctors were still accepting the sample-size medicines from sales representatives, Mr. Vermeulen said.

The physicians wanted to keep supplying their needy patients with free samples of the expensive drugs, he said, and some doctors were found to be storing drug samples in their private offices, automobile trunks and homes.

To give the doctors and patients a replacement for the samples, he said, the university now provides doctors with vouchers that patients can use for a free prescription of a range of medicines, which are mostly generic drugs.

Mr. Vermeulen said that some doctors had become upset at meetings where he discussed the sample ban.

‘‘If they would have had anything to throw at me,’‘ he said, ‘‘they would have.’‘