He is a physician in central Connecticut who has asked that his name not be published. He feels that if he were identified, he'd be tarred and feathered by his white-coat colleagues. That's because he refuses to let drug company representatives - so-called "drug detailers" - or their free drug samples into his office.
"The patient is getting the free sample of only the most expensive drug of the drug type that the doctor is giving out that day," the doctor said. The patient is typically flattered by the gift, he said, and when he or she needs to start buying the drug, the insured patient often will pay a high co-payment to stay on the name-brand drug that was the free handout, even if a lower-cost prescription would work just as well.
"The doctor is the guy who decides what [drug] he will order," he added. "The only reason he chooses the Cadillac over the Volkswagen is because the Cadillac is within easy reach."
The doctor, a board-certified internist, is one of a growing minority of doctors who are turning their backs on samples and other drug-company swag in the name of integrity. Dr. Bob Goodman in New York created a website in 1999 that functions as the Internet flagship of this movement: www.nofreelunch.org.
Goodman, on staff at New York Presbyterian Hospital-Columbia University Medical Center, said that several hundred have taken the pledge on his website, through which doctors promise to "accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my practice, teaching, and/or research."
Beyond these defectors is a much wider discussion about drug samples and whether they're used as bait to lure consumers to overspend for their treatment, or whether they are a boon to low-income consumers and an educational tool for doctors. Experts say that the research on the topic is inconclusive.
"You could debate it either way," said Craig Coleman, assistant professor of pharmacy practice at the University of Connecticut School Of Pharmacy. Coleman runs a program at Hartford Hospital that helps needy people apply for patient-assistance programs offered by drug companies. Low-income patients who don't qualify for government programs apply for a three-month supply of free drugs. The industry provided nearly 18 million free prescriptions to about 5.5 million Americans in 2003.
Coleman said that it takes the drug companies awhile to evaluate the applications, and that free samples can fill the gap. In addition, he said that for patients with short-term problems, such as urinary tract infections, free samples of antibiotics might be all that is needed.
But the distribution of free samples is not primarily charitable. Drug firms don't reveal the costs of the drugs they give to physicians, hospitals and clinics, but the street value of the samples they distributed in the year that ended last September was roughly $15.5 billion, according to IMS Health, which provides data and strategic consulting to the pharmaceutical and health care industries. Add to that about $7.8 billion on other "professional" promotional activities - such as ads in medical journals - in the same period. (This total does not include billions spent on direct-to-consumer advertising.)
The freebies are an important foot in the door, according to IMS data, which show that only a fifth of drug representatives get to meet with doctors face to face, while 65 percent just drop off samples and the remainder are turned away. But Koen H. Pauwels, assistant professor of business administration at Dartmouth University's Tuck School of Business, said that the return on investment for samples is the lowest of any of the drug industry's marketing tools.
Dr. Kevin Schulman, a professor at both the Duke University School of Medicine and Duke's Fuqua School of Business, said that for better or worse, samples have an impact. "It is part of a promotional strategy to increase sales," he said. "We wouldn't be having sampling if people didn't think that it led to [prescription] writing and changing physician behavior."
The question is whether consumers - especially those with chronic illnesses who are on long-term drug therapy - are benefiting from the practice or merely getting hooked on costly prescriptions.
The drug industry sees the practice as largely educational.
"It gives doctors early hands-on experience with new medicines to determine whether those medicines fit into their medical practices, and they get that experience with no obligation to continuing using the drug," said Jeff Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America, which represents major, brand-name drug makers. "If a decision is made that the drug does not fit the medical practice, they simply don't have to buy it."
Schulman notes that, ideally, doctors and patients should be sitting down and discussing the best therapeutic options. In that case, samples would be irrelevant. "If it's not the best therapeutic option, but the one in the cabinet, that would not be the optimum outcome for the patient," he said.
It's this last scenario that's happening far too often, said Larry D. Sasich, a pharmacist and research analyst at Public Citizen, the Washington-based consumer advocacy and education organization.
"There is no such thing as a free sample," he said, "because, in the long run, it could waste a patient's money and it could add additional costs to the health care system by encouraging prescribing of more expensive drugs that may very well be no better, or less safe, than drugs we already have."
As an example, he cited Pfizer's drug for high blood pressure, Norvasc, the fourth most-prescribed drug in the United States in 2004. It's not the ideal first drug for most newly diagnosed patients, Sasich said. Most guidelines recommend the use of an older drug, hydrochlorothiazide, that is available as a generic. Sasich said that Norvasc costs $60 to $70 a month, while a month's supply of 25 mg hydrochlorothiazide costs about $12 a month.
"You're saving $600 or $700 a year on that, and you're actually getting a better drug," he said. "But because the doctor has a sample of the name-brand drug - and because companies don't sample generics - doctors give patients what is not the best drug, just because it's free."
However, a patient's managed-care health network might prevent him or her from staying on a name-brand drug once the sample is gone. Nearly three-quarters of Americans with employer-sponsored health coverage have a prescription benefit that includes a formulary, and many government programs also have formularies. This is a list of "preferred" drugs as established by the managed-care plan or its pharmacy-benefit contractor. Ideally, the patient pays the lowest co-payment for the most suitable, lowest-price drug - often a generic, if available.
If the doctor insists on the name-brand drug, the patient will typically pay much more. Sasich said that managed-care formularies vary in their effectiveness as consumer watchdogs.
Patricia M. Danzon, a professor of health care systems and insurance and risk management at the Wharton School of the University of Pennsylvania, said that it is difficult to evaluate the impact of one marketing strategy - such as free samples - apart from other practices, including advertisements in medical journals and direct-to-consumer advertising. Drug marketing is a costly effort, she said, and it's largely about protecting market share, so all of the drug companies feel that they must play.
"The really tough question is, if all of the companies were to cut back on [drug rep visits] and sampling, would anyone be the worse off?"
Danzon and others might soon get a chance to find out. Earlier this month, news reports suggested that Pfizer plans to announce cuts in its workforce. Analysts predicted that many of the cuts would come in its global sales force. Some observers predict an industrywide cutback.
On the other hand, a cutback in promotional spending by Pfizer could simply bring it in line with other drug companies. Pfizer spent more than $1 billion on promotional efforts in 2004, making it the biggest spender among drug makers, according to IMS Health figures. The No. 2 spender, Glaxo- SmithKline, paid out $745 million for promotion in 2004. Pfizer declined to comment on the reports of possible layoffs.Copyright © 2014, Los Angeles Times