Healthy Skepticism Library item: 19537

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Publication type: news

Page L
More Clinics Ban Drug Samples, Citing Cost, Safety Concerns
American Medical News 2000 Oct 16
http://www.ama-assn.org/amednews/2000/10/16/bil11016.htm

Full text:

When the University of Wisconsin Hospital and Clinics in Madison decided to withhold most free drug samples from its 800 doctors, it was like “asking physicians to hand in their stethoscopes,” said Lee C. Vermeulen, RPh, director of UW’s Center for Drug Policy.

Vermeulen, who helped plan the ban, said the new policy addresses security concerns about keeping samples in physicians’ offices, promotes more appropriate prescription patterns and — just as important — should help keep the skyrocketing cost of prescriptions in check.

UW is one of a small but growing number of clinics that is taking drug samples out of physicians’ hands or restricting doctors’ access to salespeople who hand out billions of dollars’ worth of samples each year.

The new policies are backed by studies showing that liberal distribution of samples may influence doctors to prescribe these drugs when they are no longer free.

In a study published in the July Journal of General Internal Medicine, nine out of 10 physicians said they would dispense samples that differed from their drug of choice. In the same study, 27% of physicians said they would dispense samples of new anti-hypertensives, even though many of them know that experts still prefer unsampled diuretics or beta blockers.

Vermeulen and others say sampled drugs can be less appropriate and 100 times more expensive than equivalent unsampled drugs. And higher drug expenses — particularly for newly released drugs — accounted for one-third to one half of the increase in insurers’ claims expenses this year, according to the Health Research and Education Trust.

Drug company representatives hand out samples “by the bagful rather than by the handful,” said Don Logan, MD, chief medical officer for Dean Health Systems, which runs the second-largest practice in Madison after UW.

IMS Health, a drug research firm in Plymouth Meeting, Pa., reports that drug companies handed out 766 million samples in the past year, or an average of 1,500 for each practicing physician. That amounts to several billions of dollars in free drugs across the country and an estimated $10 million to $12 million at Dean alone.

In July, Dean barred drug representatives who hand out samples from visiting 300 doctors at its facilities in the Madison area. These physicians still can order samples by mail from drugmakers that will cooperate, but the flow has been greatly reduced.

Meanwhile, UW banned free samples for all but a few labels in April. Instead, UW replaced some popular samples with paper vouchers for drugs in the same therapeutic category. Patients can redeem the vouchers at pharmacies at no cost.

UW asked drug companies to supply and pay for the vouchers, but only two have done so. So in July, the university began distributing its own vouchers for 15 generic drugs that are equivalent to the sampled drugs, at an estimated cost of tens of thousands of dollars a year for UW.

So far, the university has distributed thousands of mostly generic vouchers but no more than 75 have been redeemed, Vermeulen said.
Physicians object

Few Madison doctors would comment publicly about the new policies, but Don Bukstein, MD, pediatric allergist and pulmonologist at Dean, said the reaction had been generally negative.

“Most physicians — the vast majority — don’t like it that they don’t have samples to give their patients,” he said.

Doctors also say free samples help forge a bond with patients, are often given to those who can’t afford prescriptions and eliminate a trip to the pharmacy.

Pat Donohue, a spokesman for drugmaker Bristol-Myers Squibb, said samples usually represent the best therapies available and improve compliance because one-fifth to one-third of all prescriptions are not filled.

Doctors add that drug representatives help educate them on use of new drugs, thus ensuring dissemination of important breakthroughs.

But Al Fisk, MD, medical director at the 175-doctor Everett (Wash.) Clinic, which banned drug reps two years ago, said older brand names and generics that are not sampled were often “the most demonstrated to prolong life” and that the effectiveness of many samples “is not clear yet.”

Critics of samples also worry about the security of keeping them in doctors’ offices and the dangers of distributing them without a prescription, risking drug interactions with other drugs patients might be taking.

The University of Washington Medical Center in Seattle reported that an audit a few years ago found that only 10% of the drugs that were removed from its sample closets were properly documented.

Some states like Wisconsin require labeling of samples, and federal law requires documentation of distribution at all doctors’ offices. Dean officials said a more tightened version of the federal law goes into effect in December. But both the state and federal laws are said to be laxly enforced, and the only effective regulator seems to be the Joint Commission on Accreditation of Healthcare Organizations, which oversees hospitals.

The Joint Commission reports that one of the top 10 abuses of its standards is lax documentation of drug samples in hospital-based practices. Indeed, the immediate cause for the University of Wisconsin’s ban on samples was the expectation that the Joint Commission would issue a citation for poor record-keeping of its samples, which in fact occurred this summer.
Off to a slow start

Compliance issues aside, UW officials said a key reason for banning samples was the assumption that they induce doctors to prescribe higher-cost drugs. Most practices do not have to foot the bill for drug costs, but both the university and Dean operate health plans that cover drugs, and the Everett clinic assumes insurance risk for some of its patients’ drugs.

Dr. Fisk said that after Everett imposed its 1998 limit on drug reps, drug costs for the clinic’s patients fell by 10% in 1999 while the same costs at other practices in the area rose 15%.

Although UW’s voucher program is off to a slow start, Vermeulen said the university still expects to save up to $1.2 million in lower drug costs for its insurers, including UW’s own Unity Health Plans. He is asking all the plans to underwrite the $123,000 cost of the voucher program, but none of them — even Unity — is willing to do so.

But doctors who think free samples are out of control are committed to limits even if insurers won’t back them.

“There is no free lunch,” said UW internist Juanita Halls, MD. “More and more large groups will go to this.”