Highlights--DowJones: "Use of Samples In Drug Industry Raises Concern"
dowjones.wsj.com
>>>July 19, 2000
By Scott Hensley and Shailagh Murray
Staff Reporters of The Wall Street Journal
Trudy Hargett, operations manager at the Middlesex Health Center in north Baltimore, has an open-door policy -- for pharmaceutical-company salespeople bearing samples of prescription drugs in great demand.
"Am I going to smile big for the Celebrex guy?" asks Ms. Hargett, referring to the Pharmacia Corp. arthritis drug that is among the most popular at the clinic, which caters mainly to low-income patients. "Well, I'm human, and I know what my patients need."
One frequent clinic visitor, Joann Eisenhart, suffers from several ailments, including panic attacks so severe that she sometimes blacks out. For these episodes, Mrs. Eisenhart, who lacks health insurance, relies on free samples of Paxil, the antidepressant from SmithKline Beecham PLC.
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At a time when drug manufacturers are under fire for rising prices and costly marketing campaigns, their growing -- and expensive -- practice of giving away samples has gone largely unnoticed. The companies mainly give away their newer, more profitable drugs, aiming to hook doctors and patients.
Door-to-door salesmen dropping off free brushes or trial-sized soaps for consumers have gone the way of the milkman, but drug companies continue to arm their swelling legions of salespeople with starter doses of everything from antibiotics to antidepressants. Their hope is that physicians will be favorably disposed toward their company in the future and prescribe their newest drugs.
Last year, drug companies gave doctors and nurse practitioners free drugs valued at more than $7.2 billion at retail, a 10% increase over 1998, according to IMS Health, which tracks the industry. At many drug companies, the cost of samples is second only to compensation paid to salespeople in the budget for promoting new drugs, industry insiders say. The companies don't break out spending on samples in their financial reports.
Doctors and drug companies know that once patients begin taking a particular drug they are unlikely to switch to another, such as a cheaper generic version. Samples are "a big expense, but there's a proven return on investment," says Steve Saltz, a former vice president of sales for Roche Holding AG's Hoffman LaRoche Inc. and now a consultant for CommonHealth, a drug-marketing and advertising firm in Parsippany, N.J. "When a person walks out of the doctor's office and they have a sample in hand, that's the most powerful form of marketing there is."
Some critics raise concern about the practice, particularly when the drugs are given to patients without health insurance. It "gives drug companies a sense that they can have greater license to keep prices high, to advertise, to prevent ways to provide real, systemic relief for people -- such as through a Medicare drug benefit," says Ron Pollack, head of Families USA, a health-care advocacy group. Moreover, Mr. Pollack says, relying on samples for needed drugs can harm a patient's health, since the supply can be sporadic.
Frank Clemente, director of Public Citizen's Congress Watch, says he thinks drug companies are trying to win over low-income people -- including millions with Medicaid coverage -- the same way they lure higher-income patients. "Samples reinforce that marketing is the primary focus for these companies at this point in time," he says. "They know they only have a fixed amount of time before a competitor comes along. It's no different from Nike advertising on television."
Drug companies say there are good medical reasons behind the expensive and seemingly anachronistic practice. Even the most thorough clinical testing doesn't guarantee that some drugs will work for a given patient. "Every drug will act differently," says Rose Crane, president of the Bristol-Myers Squibb Co. unit that caters to U.S. primary care doctors. "It's not like any other mass-produced item." A sample lets doctor and patient determine whether a particular drug is worthwhile before an expensive prescription is filled.
Drug companies also know that samples help build brands and can be directly linked to increased prescriptions for the drugs. The pharmaceutical industry heavily distributes freebies for its newest drugs and usually curtails or eliminates them for products about to go off patent.
Companies say that samples are needed most for new drugs so doctors can gain experience with them. But some physicians say the pattern of sampled drugs is more about marketing than medical practice.
"There's a direct correlation between what I see in my sample closet and what I see on TV in direct-to-consumer advertising," says Jaan Sidorov, an internist at Geisinger General Internal Medicine Clinic in Danville, Pa. "Cheap, safe, and effective generic medications are not there."
The burgeoning sales forces at drug companies mean that there is at least one drug salesperson for every 10 U.S. doctors. Doctors, busier than ever, are often reluctant to spare time for salespeople. Thus, samples have become even more important as sales tools. A key factor: Food and Drug Administration regulations require that doctors sign for samples, giving salespeople a precious minute or two of face-to-face time to make their pitches.
"The sample is necessary to gain access to the office," CommonHealth's Mr. Saltz declares. "Without it, the doctors don't even want to see you more often than not."
There's little doubt that most doctors like the freebies and the salutary effect they have on the doctor-patient relationship. "There's something about the doctor walking into the room with a sample," Dr. Sidorov says. "Not only has the doctor come up with the answer but he's got the pills for you."
And sometimes there are medical advantages, such as an immediate start to therapy for patients in urgent need, such as children with ear infections.
"We've done tons of research" on samples, says Bristol-Myers' Ms. Crane, and they're "the most valuable thing that the doctor can give a patient." Indeed, many doctors depend on samples to help their poorer patients get medicine they might not otherwise be able to afford.
Some doctors say railing against the hard sell is futile.
"You can bemoan the situation or try to work with it," says Jeffrey Mason, an endocrinologist and medical director at ProMed HealthCare Network, a 550-doctor practice based in Upland, Calif. He has a keen interest in samples because ProMed shares the financial risk for drugs prescribed under some of the contracts it has with health insurers. Dr. Mason goes to bat for salespeople bearing drugs on the practice's recommended list, sometimes providing letters of introduction to help them gain access to hard-to-reach physicians.
"I'm happy when doctors have samples of the products we want to use," Dr. Mason says, and he encourages the "underdogs" among drug makers who promote cost-effective medicines. For instance, for the past year ProMed has worked with Forest Laboratories Inc., maker of Celexa, a low-cost antidepressant that competes with Prozac, made by Eli Lilly & Co. With other companies, Dr. Mason tries to reach "gentlemen's agreements" that their reps will leave only samples of drugs that the practice finds cost-effective.
Abbott Laboratories Inc., for instance, agreed to provide samples of erythromycin, a time-honored, low-cost antibiotic, along with the samples of Biaxin, a more expensive antibiotic that Dr. Mason's group prefers to use only if others fail.
Sensitive to the impact of rising brand-name prescription-drug prices, some insur ers are paying for samples of generic drugs to be distributed to physicians. Highmark Blue Cross and Blue Shield, a Pittsburgh-based health insurer, is working with pharmacy benefits manager Merck-Medco, a unit of Merck & Co., on a sample counterattack featuring generic blood pressure, gastrointestinal and anti-infective drugs.
Set to start late this year or early in 2001, the generic samples will "provide some counterbalance to the brand sampling that's out there," says Patrick Kerrish, Highmark's vice president of pharmacy and medical affairs.
Even for drug companies, the special packaging of samples and the logistical costs of providing samples make the practice expensive. Each salesperson becomes a "walking warehouse," and the Food and Drug Administration is phasing in new regulations that require drug companies to keep better track of the samples their representatives leave behind.
The heavy cost of samples drives drug companies to periodically rethink their approaches. For example, some companies have experimented with vouchers or coupons to be redeemed for trial portions of drugs at pharmacies.
MedManage Systems Inc., of Bothell, Wash., for one, offers vouchers that doctors can give to patients for redemption at local pharmacies. Vouchers track the drugs a patient is taking and cut the regulatory paperwork for companies and doctors who dispense samples.
Manufacturers spend billions each year on samples, yet "there isn't enough information on what goes on," says Zachary Hector, MedManage's CEO, who formerly ran a small Northwest PBM, Evergreen Health Management Inc. Vouchers, he says, provide a paper trail that shows which sampled products result in prescriptions.
MedManage is now launching pilot projects with vouchers from eight manufacturers, including Novartis AG. But Mr. Hector concedes that drug companies have been slower to respond than he expected.<<< |
