Monday, September 8, 2008

Are Free Samples Bad for Patients?

While many doctors have transformed their offices into No Drug Rep Zones, many, including myself, still accept free samples of drugs to give to our uninsured patients.

But a steady drumbeat of research is showing that free samples are ultimately more expensive, and may even be unhealthy. The current issue of the Southern Medical Journal reports that free samples actually cost patients more in the long run, because they encourage doctors to prescribe more expensive drugs. Researchers tracked the prescriptions written by 70 doctors in a large internal medicine practice. During the first 9 months of the study, doctors had access to free samples, but halfway through the study period, the medical offices moved to a different building, resulting in the sample closet being closed for 9 months. This provided an ideal accidental experiment for seeing whether samples lead doctors to prescribe more expensive brand name drugs. In fact, during the first 9 months, only 12% of prescriptions were for generic drugs. But during the 9 month sample-free period, prescriptions for cheaper and therapeutically equivalent generics nearly tripled to 30%.

Those who argue that the doctors prescribing brand name drugs were providing more modern and therefore better care would do well to read this study from 2002, which showed that uninsured patients who were given free samples of blood pressure medications had higher blood pressures than patients who did not receive free samples, implying that use of free samples leads to suboptimal treatment.

In fact, the popular notion that samples are given primarily to uninsured patients is untrue, according to an article published recently in the American Journal of Public Health. Researchers analyzed data from a nationally representative sample of 32,681 US residents, and found that the poorest third of respondents were less likely to receive free samples than were those with incomes at 400% of the federal poverty level or higher.

The data are clear. Free samples are simply another marketing tool for drug companies. I guess it's time for me to empty out my sample closet!

12 comments:

John Mack said...

The data shows that physicians are not cognizant -- or caring -- about the out-of-pocket costs of drugs to their patients.

It's fine to dole out free samples of brand drugs to test efficacy on patients -- which is what the drug industry says is the benefit of samples -- but then NOT to prescribe the GENERIC version (if there is one) when the sample runs out is the real problem that this study uncovered.

I invite you and your readers to take my 2-minute survey: Should Free Drug Samples Be Banned? which you find at: http://tinyurl.com/5tc9zo

therapyfirst said...

Free samples access is not a black and white issue. There are patients who come in from inpatient treatment who are on such meds and in the process of accessing insurance, usually via Medical Assistance, so changing their meds is a risky venture if they report stabilization. Then there are patients who had coverage and lost it via a snafu, or worse, the patient responsibly got a job or changed jobs and were screwed for healthy choices. What I will say is a legit issue to limit samples are those who are pathologically dependent and expect samples forever, making no effort to apply for insurance or other options to get meds from a different source. That is ridiculous and unacceptable to me!

An equal player to making prescription access more difficult these days has been this $4 Rx access started by WalMart and copied by Target and KMart. It is now trickling down to the insurers that we should not be writing for any brand name drug because these $4 scripts are there. Well, yeah, some of these patients might be appropriate candidates for such meds, but some aren't. You think insurers insure individuals? If you answer yes to that question, what planet are you on?!

It is an issue of some careful determination who should be offered samples, not discard the access after possibly overdependence on it for years.

Last point, and this will piss off physicians, so disclaimer put out up front: primary care docs are as much if not more egregious of this behavior than psychiatrists. This quick fix mentality to treat so many somatic illnesses with a Rx at moment one has to end! Diabetes, hypertension, headaches, GI problems are just some up front examples that require a psychosocial approach to many first encountered patients and not just "take this and call me in the morning" crap that is endemic in our profession. You all remained silent as managed care gutted our abilities to care; well, step up to the plate and swing like it is the bottom of the ninth and you are the winning run, 'cause that analogy is about where we are!

Sara said...

Here's a free sample story that might get some of your reader's attention. In 2001 a young 12 year old boy ran away from home because his mother who had abandoned the family when he was much younger came back briefly and seemed headed for a reconciliation with his Dad. Suddenly she left again and,upon leaving, said she never wanted to see her son again. After he was picked up from his failed attempt to run away he was put on Paxil. Later he was sent to live with his grandparents and when the Paxil ran out they took him to a local doctor because he wasn't feeling too good. The doc felt sorry for them and said, "Since you don't have health insurance why don't you take some of this free Zoloft I have here in my office -- it's the same as Paxil. He gave it to them in a brown paper bag with instructions scribbled on the outside, so here we have a 12 year old boy in withdrawal because his Paxil ran out and being put on Zoloft without very clear instructions on dosing to his grandparents who were elderly. A few days later this young boy killed his beloved grandparents with a birdshot gun and set their house on fire. He's in prison now for 30 years. So yes, I think free samples are, as you say, "unhealthy."

CL Psych said...

Shocking! Samples are just a marketing tool? You mean that Big Pharma was not just making kind, charitable donations for the sake of improving patient welfare? Who knew they were capable of such trickery?

OK, I can keep straight face no longer. Nice reportage. This falls in line with every bit of information I've seen about drug samples. Very good post.

Mike M. said...

Alright Dr. C., you have presented yourself with the challenge, now will you follow through? It is time for you to get rid of your closet full of "novel" stereoisomers and active metabolites.

James M. La Rossa Jr. said...

DC, TF & Dr. Mack all make important contributions here. Two quick comments: John, in my experience, once a pharmaceutical goes generic, the branded samples generally slow considerably as the field reps move on to other branded drugs. Secondly, I moved from NY to CA. + two years ago and was w/out insurance for a transitional period. My California doc kept me supplied with samples until my new policy kicked-in, which saved me thousands of dollars. I also know of a few psychopharmacologists who "park," or stockpile, drugs for indigent patients. Your retort will be that the good of the many outweighs the good of the few and you are right. But in the spirit of full disclosure, I have to admit that -- for a short time -- I was happy to be one of the few. Regards, j.

Stephany said...
This comment has been removed by the author.
Gina Pera said...

Oh good lord, the association-causation confusion is rife in all these studies and presumed conclusions.

For example:
"...would do well to read this study from 2002, which showed that uninsured patients who were given free samples of blood pressure medications had higher blood pressures than patients who did not receive free samples, implying that use of free samples leads to suboptimal treatment."

Here's a little news flash from the real world, folks: I know uninsured patients, and by and large, people who are uninsured are often chronically under/unemployed, not thinking of consequences, or in other ways suffering from undiagnosed/untreated neurocognitive disorders. These are the people who are least likely to be compliant with ANY treatment, including lifestyle changes.

The very notion that you, Daniel, would jump to the conclusion you did is just beyond the pale.

Studies must be read in context -- and without an agenda. People's lives depend upon it. Real people. Not statistics.

Gina Pera said...

The do-gooders here who think you are saving patients from free samples should get out into the real world more often. MANY people cannot afford the "meds roulette" that comes with trying to find the right medication/dosage that works for them or their loved ones. They NEED these samples in order to try a medication and see if it's worth spending scarce resources for -- or hassling their insurance companies about.

Once again, this blog gives insurance companies a free pass and hammers pharma and docs. Don't you see how predictable -- and simplistic -- this is? Not to mention missing the forest for the trees?

therapyfirst said...

While I am a bit wary to say this, I do agree with Gina Pera's last posting. It is beyond imagination how much health care insurers have intruded into the patient-physician relationship, and now they tell us not only what we can prescribe, but how many tablets we can write each month.

This is not an exaggeration or embellishment on my part: recently I had a patient who I increased the Lexapro to 15mg a day from 10mg, and the insurer refused the Rx saying the patient can only access 30 tablets a month. They go on to tell me in the fax rejection that there are only 3 strength tablets to access--5/10/20mg. So I reply with how does she get 15mg in 30 tablets? No response. Then, and this is both priceless and obscene, they send me a three page form asking me to sign to be the patient's representative in this authorization process, a document that as written makes me the patient's representative generically, not just with this matter. I just sent it back blank and told them to fill the RX as written or risk impeding with medically necessary treatment. I gave the patient samples of lexapro to hold her over until someone at her insurance co returns to reality.

So, if I listen to the extreme that all samples are evil, I deny the patient access to meds? Or, as I wrote above in the earlier posting, the issue is gray.

How many docs would have just doubled the dose to avoid the matter and risked side effects by going to 20mg from 10? My guess--at least 2/3 of them.

That's a sad indictment of care these days. Do what is convenient, not what is standard of care.

I see this posting getting mentioned elsewhere, Dr C. Congrats.

Gina Pera said...

As for this portion of Daniel's post:
"The current issue of the Southern Medical Journal reports that free samples actually cost patients more in the long run, because they encourage doctors to prescribe more expensive drugs."

That sounds like a real pinhead of study. Has it ever occurred to the study's investigators (not seeing the study, we're at a disadvantage) that the doc might be prescribing a new medication because the old ones haven't worked for the patient or because the old ones have horrible side effect profiles?

For example, there's not one new medication for ADHD that hasn't proved a vast improvement over the previous generations, typically lasting longer (and thereby avoiding the rollercoaster ups and downs) and causing fewer side effects.

I feel for people who are stuck with the 2-4 hour meds, knowing they typically won't be taking them for long. And woe to those who are stuck with generic stimulants.

Anonymous said...

Are Drug Reps Really Necessary?

One of the main functions of pharmaceutical representatives is to provide free samples to doctors’ offices instead of what has historically been their vocation: implementing authentic and ethical persuasion via presentations. Yet presently, samples are a priority and delivering them is the primary function for drug reps, 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 the healthcare provider. Let me be clear on that point: it’s samples, not a representative, as the true catalyst of establishing the prescribing habits of a prescriber.
Yet considering that drug promotion cost, overall, is approaching $20 billion a year, which includes the approximately $5 billion spent on drug reps themselves, what if there is another way for doctors to get free drug samples? What if prescribers could, with great elation, avoid drug reps entirely, yet still receive drug samples for their patients?
There is actually a way to do this, but it is a limited process.
With some select, smaller pharmaceutical companies, doctors have the ability to order samples by printing order forms obtained on certain drug company sites on the internet for medications associated with the manufacturers. Examples of such branded medications that can or have 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, yet this method may be the most preferable both from a business and efficiency point of view. Customer satisfaction would clearly be elevated.
So in some situations, a doctor can go online, 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. There is no review of the doctor’s prescribing habits nor are there any possible embellishments from reps. And that appears desirable to many health care providers, yet most drug companies apparently place unneeded value on the impact potential of a sales rep of their company to a level of some sort of delusion based on metrics that are possibly categorized as types of fantasies with the copious amounts of drug reps today.
Now, why is this not done more often? Apparently, it is legal. If samples are the number one influencer of prescribing habits, why spend all the money on drug reps to deliver samples personally, as this is essentially their primary duty?
It’s worth exploring, possibly, since the drug rep profession has evolved essentially into those who become a specialized delivery person, dressed in a nice suit, one could say. In other words, and in my opinion as a drug rep, most doctors will not and prefer not to dialogue with you during your visit to their medical clinic.
Think of the money that could be saved if more pharma companies offered samples to doctors in this manner. Furthermore, there is no interruption of the doctor’s practice. And again, there is no risk of bias presented to the doctor.
Doctors again would be able to order and utilize samples according to their discretion, and would be free of interference from the marketing elements of various pharmaceutical corporations. Patients benefit when this occurs, likely. For example, health care providers would be free of possible embellishments and exaggerations voiced by reps on their promoted meds. Inducements would not be offered or accepted. Reciprocity would not be so insisted upon with the absence of drug reps, possibly. In fact, doctors may write more scripts for shipped samples than delivered samples because their discretion is free from interference they have experienced to some degree, and doctors are or would be possibly thankful for this.
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, perhaps. And the pharmaceutical companies would save quite a bit of money as well without a sales force that may likely not be needed after all. Drug prices may improve.
Something to think about as one ponders cost savings regarding this issue, and improving the efficiency of patient care and treatment.

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