The record is 11 in one day. The drug company representatives come constantly, Dr. Stephen M. Scott says, bearing promotional goods, sample packets and materials touting the superiority of their products to competitors and to cheaper generic drugs.
They take up “at least” a half-hour of each workday, Scott says. And while he and his partner, Dr. Gregory Sadovnikoff, speak dismissively of the sales pitches – they do their own research, and prescribe accordingly – the pharmaceutical reps do score their victories.
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For as many as three in four patients, Scott acknowledges, the doctors provide samples from the cabinet, usually with a prescription for after the samples run out. And so, many patients end up on Zoloft, Lipitor and other pricey drugs.
Now Blue Cross & Blue Shield of Rhode Island is striking back.
Last month, in a partnership with California-based MedVantx Inc., the insurer began installing machines in doctors’ offices to dispense common generic drugs. It’s starting with practices with a heavy prescription volume; among the first half-dozen was Scott and Sadovnikoff’s Atmed Primary Care in Johnston.
The idea, said Daniel P. Curran, pharmacy benefit manager for Blue Cross, is that if doctors have the same access to free generic samples as they do to brand-name samples, they’ll be more likely to write prescriptions for generics, which cost less for patients and Blue Cross.
Take Lipitor, the cholesterol reduction drug: A 30-day supply of 20mg pills costs about $120, Curran said, but some patients don’t need such a strong drug and would do fine with generic lovistatin, which costs about $25 for 30 days’ worth. Or instead of antidepressant Zoloft, which has no generic equivalent yet, a doctor might try a generic version of Prozac or Celexa. Generics cost about 30 percent as much as brand-name drugs, Curran said, so even after paying for the drugs and the MedVantx dispensing fee, Blue Cross saves money. The program is just beginning, but the goal is to install at least 100 statewide, he said.
“The return on investment for us is avoiding the cost of that brand-name prescription,” he said. “And going forward, the member will save each time they fill the prescription by paying a generic co-pay rather than the brand-name co-pay. It’s a win-win for everyone.”
(UnitedHealthcare of New England, Blue Cross’ biggest competitor, feels the same way. It doesn’t have dispensers in doctors’ offices, but it has been providing free generic samples for about three years, spokeswoman Debora M. Spano said.)
About 52 percent of the prescriptions filled by Blue Cross members are now generics, Curran said, up from about 42 percent just five years ago. Among elderly people with limited drug coverage, generics are even more prevalent, accounting for 65 to 70 percent of prescriptions.
Rhode Island law requires pharmacists to offer a generic equivalent to patients when available, Curran said, and although patients have a right to demand the brand-name version, 93 percent in those cases take the generics. To that extent, even if doctors hand out brand-name samples, their patients could still fill their prescriptions with generics – with lisinopril instead of blood pressure drug Zestril, for example.
But the main target for the MedVantx program, Curran said, is the drugs that don’t have generic equivalents but do have generic alternatives in the same class. Drug companies “dispense billions of dollars’ worth of samples” to doctors just to sway them to prescribe their products, Curran said, and this is meant to sway them in the opposite direction.
“It reinforces behavior among the physicians, because they get used to dispensing those samples and they write for that product,” Curran said.
The scope of pharmaceutical companies’ drug sample giveaways is daunting: nearly $16.4 billion worth, nationwide, in 2003, up from $11.9 billion in 2002 and more than three times the $4.9 billion worth distributed just seven years earlier, according to IMS Health.
(For context, total U.S. prescription drug sales in 2003 were $216.4 billion, up from $194 billion in 2002, both including generics.)
In industry circles, few question the purpose of those giveaways – IMS Health, which supplies data to drugmakers, classifies them as “promotional” spending, along with the nearly $4.5 billion spent on other marketing activities targeting doctors’ offices in 2003.
In an interview, however, Wanda Moebius, a spokeswoman for the Pharmaceutical Research and Manufacturers of America (PhRMA), said it’s not all about marketing.
“Primarily, I think, it’s a great way for a physician to see if a medicine fits the needs of a patient before committing to a longer-term prescription,” Moebius said. A doctor can check the dose, look for side effects, and verify the effectiveness of the drug, she noted.
And for many patients, Moebius added, especially the uninsured, free samples also provide a “safety net” when they can’t afford the cost of drugs.
That’s definitely the case at Atmed Primary Care, Scott and Sadovnikoff said.
“Every practice has a certain number of patients who can’t afford medications,” Sadovnikoff said. “We have patients who we basically keep medicated through samples.”
Both doctors and their physician’s assistant, Dian J. Cullion, said they do use samples to test-drive medicines – especially expensive ones – with patients, so someone doesn’t end up paying $35 or $50 for a drug only to discover that it has nasty side effects.
The biggest advantage of having samples on hand, however, the doctors said, is that it encourages patients to start their treatment immediately, especially with antidepressants. “From our perspective, if we don’t put pills in somebody’s hands, the likelihood that they’ll fill the prescription and take the medication is low,” Scott said. “If we give them samples, the compliance rate goes up significantly.”
Given the price differential, both doctors said, they’re happy to prescribe generics when appropriate, and both said they like that unlike many brand-name samples, most MedVantx packages include a full month’s worth of drugs.
Scott said it took him a few days to stop going to the brand-name supply cabinet by default, but the MedVantx system has grown on him quickly.
“I’ve used it four or five times today,” he said. “And I think it’s sort of accelerating as I remember what’s in it. What’s neat, too, is that you can tailor it to your practice.”
