25 August 2004

Health systems cutting costs by closing door on drug reps
But banning brand samples meets with some resistance

Employees at Affinity Health System conducted a controversial sort of spring cleaning this year.

The company, based in northeast Wisconsin, cleared its clinics of clocks, calendars and other freebies dished out by drug companies. The goal: to strip away promotional items that encourage doctors to prescribe pricey brand-name drugs.

Drug salespeople also may no longer buy lunch for office staff as a way to finagle more time to pitch their products, says Michael Madden, Affinity's medical director for primary care.

And Affinity is developing a policy to dramatically cut back on free drug samples. Consumers who refill prescriptions for brand-name pills may spend hundreds of dollars more than if they started off with cheaper generics, Madden says.

With prescription drugs driving up the cost of medical care, Affinity is among a small but growing number of health care systems that are turning their clinics into commercial-free zones.

Such changes have been unpopular with drug reps, who say they're just trying to help doctors stay up-to-date on the latest medical information, as well as some physicians, who often reserve samples for patients who can't afford prescription drugs. Some health companies have tried to soften the blow of banning samples by hiring specialists to help poor patients enroll in discount-drug programs.

California-based Kaiser Permanente pioneered such reforms more than a decade ago. In the past year and a half, a number of health systems have followed its example:

·Minnesota's HealthPartners has reduced sample use by nearly 90% in the past seven months.

·Seattle's Group Health Cooperative and Pennsylvania's Geisinger Health System have banned samples and allow drug representatives by appointment only.

·The University of Michigan Health System employs pharmacists to track doctors' prescribing patterns and sometimes suggests more cost-effective treatments.

·New York state's Excellus BlueCross BlueShield uses pharmacy consultants to update doctors on new drugs so health professionals don't have to rely on industry representatives.

Even doctors who still see drug reps say they are spending less time with them. Five years ago, doctors often spent 15 to 20 minutes with a sales rep, according to Accenture, which analyzes the drug industry. Typical sales calls today last just 90 seconds.

Health systems that own both medical offices and insurance plans have a strong incentive to check drug costs. Many health providers also say they want to avoid the hassle and potential safety hazards involved in storing samples.

Though some doctors say they have stopped meeting with drug reps to avoid the appearance of impropriety, others say they're simply too busy. Before the Madison, Wis.-based Dean Health System changed its policy in 2000, sales reps in the office outnumbered doctors 2 to 1, says Don Waldrop, who helped write the new rules. Today salespeople are welcome only at formal educational conferences.

Some health care systems have seen dramatic results. Drug costs declined 10% after the Seattle-area Everett Clinic banned sales reps and samples in 1998, even as costs rose 15% at competing practices, medical director Al Fisk says.

The University of Wisconsin Hospital and Clinics offers patients vouchers for free generics in place of samples. Lee Vermeulen, director of the school's Center for Drug Policy, estimates that every $1,000 spent on generics saves the health care system -- including patients, insurers, employers and others -- $1 million a year.

The University of Wisconsin and other clinics in Madison also have developed a common disciplinary database. Drug representatives with three violations -- for offenses such as giving out food or loitering outside doctors' lounges -- may lose their hospital access across the city for six months, Vermeulen says.

Even critics note that the drug industry has eliminated many of its former excesses. In 2002, the American Medical Association and the Pharmaceutical Research and Manufacturers of America released updated ethical guidelines on gifts. While textbooks are acceptable, golf outings and lavish junkets are not.

Some doctors complain that reformers are going too far. Drugmakers note that samples also let patients try medications -- to make sure that they don't cause allergic reactions or side effects -- before paying for a larger supply.

Christine Kirby, a spokeswoman for Aventis, says her company opposes policies that limit interactions between drug reps and doctors. "We believe that access to relevant scientific and educational information leads to optimal patient care," she says.

Some wonder whether the drug industry really needs so many sales reps. Nationwide, the number has quadrupled in the past decade to more than 90,000. The industry spent $22 billion last year marketing to doctors, including samples with a retail value of more than $16 billion, according to IMS Health, which analyzes the pharmaceutical field.

Doctors such as John Billi of the University of Michigan Medical School say that restrictions on drug marketing actually ease the pressure on manufacturers. "If one pharmaceutical company does it, they all have to do it," says Billi, associate dean for clinical affairs. "We feel like we're helping them by calling off the arms race."

By Liz Szabo
USA TODAY

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