I was thrilled to read that drug-giant GlaxoSmithKline has decided to stop paying doctors to promote its drugs and to stop rewarding its sales representatives based on how many prescriptions doctors write for their products. The public disclosure of drug company payments to doctors mandated by the Physician Payment Sunshine Act and record-breaking $3 billion fines levied against Glaxo by the Department of Justice for unlawful promotion practices has certainly contributed to their change of mind. But whatever the reasons may be, they are certainly welcome and long overdue.
Just a couple of weeks ago, I saw a licensed practical nurse (LPN) in my community health clinic for the first time. She had lost her insurance when she was laid off and couldn’t continue to see her previous doctor. She had a number of medical problems including high cholesterol, but she admitted to me that she hadn’t been taking her cholesterol medicine for many months. Here’s why.
Her previous doctor chose to start her on Crestor® (rosuvastatin, AstraZeneca) by giving her a couple of weeks of free samples that he had in his medicine closet. I’m sure he thought he was doing her a favor by giving her the samples. But when the samples ran out, she discovered to her horror that a 30-day supply would cost her over $200. She simply couldn’t afford that and felt too embarrassed to tell her doctor. She just stopped taking it.
If my patient’s previous doctor had instead started her on a generic statin like lovastatin, she could have purchased a 30-day supply for $4 or a 3-month supply for $9.99 at several pharmacies. There was no reason medically to start her on Crestor when a low-cost generic statin would have sufficed. Indeed, one of the “Top 5” recommendations to internists included in the National Physicians Alliance’s Good Stewardship project (now called Choosing Wisely ) is to use one of the many low-cost generic statins whenever you start treatment for high cholesterol. I switched her to lovastatin.
This case illustrates why drug samples are generally a bad thing. Most of the time, a low-cost generic would work just as well. Once started on an expensive brand-name drug, patients—especially well-insured patients—are likely to stay on it. That’s the marketing strategy that drug companies use when plying doctors with free samples. The result is higher sales and higher profits for the drug companies and higher premiums and taxes for the rest of us. And sometimes it results in patients, like my nurse, who find themselves unable to afford their medicines.
Yet doctors covet the free samples. The main reason that many doctors continue to see drug sales representatives is to obtain the free samples (and maybe a free lunch, to boot). Most doctors may sincerely believe that being able to give free samples to patients is helping the patients (and, rarely, this actually might be true if the patient is very low income and no low-cost generic is available). But most of the time, the samples go to patients who have insurance and who don’t really need a small supply of free samples.
But starting a patient on a free drug sample can make patients and doctors alike less inclined to switch to a different drug. So samples are also a way that pharmaceutical sales representatives can get the doctors they are visiting to write more prescriptions for their products. This, in turn, can increase the sales persons’ own income. That’s why Glaxo’s agreement to untie the compensation it pays its sales reps from the number of prescriptions written by doctors for its products is a good thing.
Eliminating samples and other promotions that undermine good patient care would be even better, but Glaxo’s action is a step in the right direction. And it is a response to widespread efforts to reform marketing relationships with physicians, including strong policies at a growing number of medical schools and teaching hospitals, such as bans on samples and drug rep visits. (See last week’s post.)
Stephen R. Smith, M.D., M.P.H., Community Catalyst physician consultant