Watch Why One Hospital Restricts Sales Reps

Great topic, Ed. Drug detailing is one of those “slippery slopes” where the reality is actually much worse than the appearance.

Carilion’s initiative does not go nearly far enough. It may well be just "window dressing" to atone for a practice that has been RAMPANT for years. My view is the detail people should not ever make it past the front door. No exceptions!

Perhaps its just coincidental (NOT!!!) but the next video clip titled “Carilion Clinic flu expert says get both seasonal and H1N1 shots” REALLY pulls my chain.

Interesting. 20+ years ago, a lot of drugs were distributed for free because docs were supposedly brand loyal until something else was shown equal or better. The pharma companies went so far overboard in so many ways that this hospital says it is "returning to the tried and true." Wonder how they will get docs to even try new drugs, and what evidence they'll believe.

These restrictions may thwart Pharma, but in device we are IN the ORs every day. We are WALKED in the ORs and surgery suites BY THE PROVIDERS. Ban Pharma if you want, but I can get in Carillion this afternoon if I want.

um, yeah, devices are not pills, but I fail to understand why you're patting yourself on the back. why the "in your face, pharma" attitude?

Does anyone really think that if the pharma/bio companies are refrained from giving samples to physicians or hospitals, the years and years of hard labor and the tremendous expenses to bring the therapy to market, would be requested by the patients out of the blue who wouldn't even know it's available or exists?

Does anyone believe that the doctor has time to read about every new drug? NO!!!!! But a visit by the salesman would garner direct and immediate attention.

Every successful company has to advertise and this is a an excellent source, face to face.

It would be negligent if a doctor just used the old standbys and not know about new advances that may be a lot better.

Conclusion: Let the doctor be informed and suggest the drug if appropriate.

Mr. Experience, in case you are new to this board, you will soon learn the frustration at being assaulted by the conspiracy theorists on this board, who aim their froth at those who even hint at neutrality, let alone a pro-pharma bias. These people remind me of my wife, who, when she was growing up during the Cold War, her father reminded her to check underneath her bed and the closets before going to sleep just in case there were any Communists hiding out.

Just keep your head up. There will certainly be black helicopters coming your way.

Maybe someone who knows more than me can answer this: didn't the jobs and backgrounds and responsibilities of drug reps change considerably over the past decades, to align with new ways of marketing?

Could there not be a revision in what reps actually know and do, that would create a new model for docs to learn about drugs without the excesses and harms that keep being reported?

Elmore, back in the 1970's, Eli Lilly hired mostly pharmacists as reps. They were educated, knowledgeable, and conversant with pharmacology and the doctors. They were the model for the industry; however they were expensive. The industry model changed in the 1980's and 1990's, when the concept of "reach", "frequency" and "share of voice" began to permeate the rep world. Armies of reps were hired based on the concept that hitting the doc over the head with the same messaging 7-10X/week was best. Reps were literally tripping over each other in the offices. There were simply not enough pharmacists to fit the new paradigm, and soon enough even science majors were no longer required.

Thus, the typical rep today has a BA liberal arts degree, or has no college degree but good selling skills; for example one of my former companies hired ex shoe salesmen. The idea is to spoon-feed them enough science to memorize a 2-minute spiel in fron of the doc, and hope to get a signature on a sample drop before the pizza that the rep delivered (which got him/her in the door in the first place) gets cold.

"...would be requested by the patients out of the blue..."

self-medication? I thought doctors prescribed the appropriste drug for a given condition.

Pharmavet: Thanks much for the inside info. Clearly a lot has changed. Do you think there's any chance of returning to the old model, especially if rep access is restricted so that fewer, higher quality interactions are the goal?

Great. They're gunna make them wear puke green.

Pharmavet and Harpy,

When none of the Congress can agree on anything about the Health Care madness,letting a rep. into the doctor's office should be an easy task. At least for now. Tomorrow, Congress could come up with a bill not to give out drug samples. But, I bet they don't. When all else fails, "graft" is cheerfully accepted.

I edit my consent form, and advise others to do the same.

Mr. Experience I've got a bit of Avandia for you, some Baycol should do, a little Vytorin by your side...

This guy is a jerk plain and simple. It just goes along with the same ego that when we were kids he was at the front of the class getting his straight A's in order to go to med school. The same guy was socially dysfunctional, quiet, and very structured. Now that Dr is an adult its time to give everyone payback. Does he ever think what it would be like if the shoe was on the other foot? Give me a break, we are just trying to make a living. I don't have to grovel to these god complex guys. Never have and never will. Just look at the intensity in his eyes! Lighten up dude.

Riv,

You obviously missed the whole thrust. No, the whole story.

You need more rest, then re-read and look for the bull's eye!

Re, altering a consent form without the approval of your employer or the approval of house counsel, you are looking for big problems.

Mr. Experience. I made my post real short. Plain English. Still...how you say...you missed the whole thrust. Try again.

elmore - re a return to the old model of higher quality interactions: for a few years companieshave employed medical science liaison (msl) people whose role is to discuss at a high level the science and medical management around a product's target use. They are not supposed to promote, but to discuss and on occasion, to educate. There often possess Ph.D degrees and are perhaps closer to the model described by pharmavet, although in those days the reps were both qualified and sales people.

I don't think the msl model works for many drugs (general medicine etc) and wouldn't justify the cost, but for more complex areas and conditions - such as cancer - they are quite prominent and I think well accepted.

Some additional thoughts from a veteran rep. who sells hospital pharmaceuticals. 1. Anyone who understand the pharmaceutical business knows that some products are more technical than others. ie: injectible antibiotics are more complex than a cholesterol pill. My knowledge on resistant bacteria is extensively greateer than any generalist, and most specialists treating infections. Pharma has had MSL's that were very useful in the past, but due to more legal concerns have eliminated many of them. 2. Sad, but true, many non-specialist physicians, and some specialists in a product field do not keep up with the clinical data that is published, esp. in their specialized scientific journals. Without a rep., discussing clinical based evidence medicine(which is as much discussed to doc's as a madison avenue slick)these doctors would be sadly uninformed. 3. Most pharma companies that have pill samples have stopped sampling in the hospital environment for several years now. Independant physicians cannot be forced to not accept samples in their private practice offices by any hospital that they may have privledges at. 4. It is not always clinically superior to use older generic products, and in some cases not always cheaper. An example would be generic Omeprezole vs. Protonix. Why? Because Wyeth manufacters both branded Protonix and their own generic(from ESI Lederle). It is the same as the branded. Pharmacies will give the option that is cheaper-generic Protonix(same as branded) or branded Protonix-if the co-pay is less than the generic co-pay. That means patients can receive a 40mg. dose of a branded product for about or less than a 20mg. dose of generic Omeprezole(which needs to be doubled to 40mg. for clinical efficacy). 5. The pharma industry has been given alot of crap in the last several years about how a pen/or pad will influence prescribing habits. Think about it. One pharma rep. was following another giving out 10cent promos. Would it not be fair to say we canceled each other out as soon as one rep. left and a competitor followed. Every industry has a version of promotional incentives. Should we also stop every company from their marketing incentives on products.

Why don't we ask the patients who have benefitted from free samples, to treat their ailment, what they think rather than listen to the doctor pontificate on what he 'thinks' is 'unfortunate'

Since Congress imputted themselves into medicine much greater in the last 3-4 years, the market has changed for Dr.s too. Less reimbursement....most reps are a "wealth" of help to patients who are economicly disadvantaged. Also,consider my grandfather who ran out of coverage last November thanks to the gov't donughnut hole in coverage, he went 2 months without his heart drug thanks to Carilion,sorry sir we have no samples for you anymore due to our new policy,and he ends up in thier hospital in early January.....sounds to me that they made much more $$$$$$ off him due to "policies". Dr. GREED and arrogance and gov't intervention almost killed him. If his Dr's (or any DR.) is prescribing a drug because they had a pizza, pen or just a drug sample from a drug company, they have serious issues with medical practice and don't deserve to be in this profession. Whatever happened to critical thinking by DR's? BTW, don't let any sales people in...let them figure out which EMR, MRI or computer to by without a reps help....afterall, they may be influencing........

Dr. Doom,

Excellent post. A rep's. help and the free samples are really an important part of the medical profession. Yes, a lot of people depend upon samples. Why should a patient not first try the sample, then order the drug if it works? If samples are no longer allowed as a trial, the cost of insurance premiums will go even higher as the patient must first buy the medicine and throw it away if it doesn't work.

I'm all for samples.

The very large academic medical center up the street from me banned detailers, trinkets, and samples some years ago. I am not aware of any patient complaints.

Every study of which I'm aware suggests that samples are correlated with an increase in drug expenditures--ultimately, both for individual pts and in general--(which, of course, includes insurance expenditures). Does Mr. E. have data which suggest otherwise?

Justice,

No, I have no such animal, nor reason to explore the matter.

BUT, I do know from my own personal experience, my family and many, many friends and acquaintances, that samples have helped them to get on the right path and at no expense, while saving unnecessary costs.

I just don't think every corner of every life adventure should have or need studies. By the way, studies also cost money. (See your concluding paragraph.)

DeviceDude,

you are an idiot. The caps, the attitude; you are the rep that nurses, techs, and physicians laugh about when you're not there. From one device "dude" to another; you are expendable. You are a convenience, and you are not required in the OR. So, please, lose the loser attitude.

If you really wanted to be in the OR doing something, you would have become a physician.

Yikes. Did I say something that would compromise "every life adventure"?

If the link works, MSNBC references a study in the pice below. My experience is that the link sometimes work. Sometimes it doesn't. So there's at least a bit of adventure there.

While samples obviously help some folks, they are also given without the usual screen on what other drugs a pt. may be taking, and--often enough--without the doc checking for a possible drug allergy (as usually happens at the pharmacy). There also may or may not be a PI included. So there's adventure there, too, as my pal with a sulfa allergy can vouch when he got a Celebrex sample. The peeling skin was definitely memorable.

http://www.msnbc.msn.com/id/23783105/

Samples are free so they are good. Let's look at matters on a micro, rather than macro level. Yes, of course samples may become so necessary that the practitioner decides tha nothing else can substitute. But really, there are always options aren't there?

Point is in this crummy economy, when people in all walks of life are losing jobs, pensions, hope and the rest of it, having samples to offer cannot be a bad thing.

O.K. so on this site we are all pretty cool and sophisticated and so probbaly wouldn't use something which might save us a couple of dollars/quid/whatever. Coupons, let's say. Or use a saving from restaurant.com (no plug but it exists) that might offer a 50% reduction on a check.

Of course we would! So why would we resist samples which are free at the time, and arguably not as expensive on the macro level to the system, which I assume is the basis of some of the studies to which JiM refers.

With all studies - as we know - there are always counter arguments. Why not this? Let people (who need it) benefit from free access to medicines that help them now, and address the broader issues objectively in parallel.

Christopher--Always a pleasure. Actually, what is surprising about the study linked is that the numbers are counter-intuitive on the micro level.

But there are obviously folks who both benefit and really need samples. There are suggestions in the piece about ways pharma could respond to that without samples being "the price" of seeing the rep.

But...what are the odds?

That said, I guess there are lots of samples in the world--"the first month is free," "your interest rate is X% [until...]]", "free checking," "happy hour," etc. Some folks certainly benefit.

And some folks get taken for the ride...

OK, and then I'll shut up.

Being the unadventurous guy I am, I sometimes read marketing guides for sales rep. Some of them emphasize hitting "inner city" [viz., black] docs particular hard with samples. Their "gratitude" for having them to give to poor and uninsured pts will be reciprocated by their writing the brand at every opportunity for folks who have insurance. And it will all pay off in the end.

Viva Zyprexa!

I've been on all sides of the industry over the past 20+ years. Riv, I was even the CV market reserach analyst when Baycol was under development - and BTW there were concerns among the sharper medical staff folks even back then relating to the link between potency and toxicity. I remember what the industry used to be like, and how it changed. (One of the reasons I left for medical school) Nevertheless, I've found myself using my prior knowledge and training to provide pharmacy benefit design consulting services.

I've got to say that more than usual, there are a lot of unchecked assumptions in this set of comments. Ed's story must have found some play on CafePharma.

Free is almost never free, and not always good(on a micro or macro level) - This is especially true if the person handing out the sample (which is often not the MD) has an incomplete (like 30 second sound bite deep) knowledge of what the medication does and might do, who is an appropriate candidate, what are the contraindications and possible interactions, and what allergies, or other treatments/foods/beverages you, the recipient, might be subjected to at the same time.

Congress is no more nor less involved in health care than they have been probably since Nixon was president. The FDA is much worse for the wear in that time, but the "government takeover of healthcare" happened long ago. The least regulated area of medicine these days may be cosmetic dermatology, but even these folks weht state subsidized medical schools, completed government-funded residency programs, must answer to state medical boards, use FDA approved medicines and devices and buy their malpractice insurance (unless they are stupid - not typically a characteristic of anyone clever enough to focus on cosmetic dermatology as a career/lifestyle choice).

Newer is almost never better - Though certainly it is considerably more expensive over the long term.

It is neither negligence nor malpractice to prescibe time-tested and true medications. In fact, typically this is the most desirable outcome if that treatment is supported by treatment guidelines and a substanital body of clinical evidence. It is malpractice for a doctor to give someone a sample of a medicine they should not take (whether or not they suffer an ill-effect). It is negligent for a doctor to prescribe or sample a medication which they do not thoroughly understand.

Doom, I'm sorry that your grandfather was hospitalized. I lost both of my grandfathers not long after finished medical school. I miss their wisdom.

BUT, that he experienced a gap in his government provided social benefits is unrelated to the availability of samples. The donut hole didn't "cause" him to stop his medication, the high cost of the branded product he had been given (possibly originally as a course of samples?) caused it to be more expensive than he or his family (including you) was willing to pay for. Weird isn't it, to think that a medicine is so good and necessary that you will only use it if it is free or if you are only required to pay a fraction of the price.

The actual cost of making the pill your grandfather was treated with was likely a fraction of a penny, but that would not be what you would be charged. Despite the prevalent complaints about the encroachment of socialism, few seem willing to actually pay the costs of their or their family's healthcare. Unlimited healthcare is a great idea, but it does not come for free - you just may not be aware of the many ways you are paying for it.

MrE would be wise to consider caution when jumping in to unknown waters (with the samples he is "all for"). JiM (typically the voice of reason AND experience) is quite correct that use of samples increases the costs of healthcare. I learned long ago that the early adopters were always the ones getting burned. I never want to be in such a desperate state that the only option left for me is a "new" drug. If it hasn't been around for 5-7 years, and been shown to offer some long-term benefit, I really don't want to use it.

It is also strange that MrE and Pharmarep both seem to endorse that the rep is vital to maintian a physician's competent practice. Yet, I did not need assistance from a cadre of drug reps while mastering the material in medical school or residency. For that matter, I don't know any other colleagues who did either. I know that despite the nod and wink to fair balance in any discussion, the rep can only offer the "official" bullet point on only the "approved for promotion" studies. The rep is there to sell not educate.

PhRMA sales reps can not provide a complete and comprehensive education on all aspects of a medication no matter how much time they spend with current literature, nor how superior their experience than the physicians the meet (who must focus their attention on more than one thing). This is simply true because (as can be seen in other posts on this very sight) manufacturers work feverishly to control "messaging" and suppress negative news. Why shouldn't they? This is a capitalist/profit driven system (with government oversight to protect "intellectual property," ensure proper manufacturing procedures, etc).

It was nice that Glaxo put together their sample pack for new consumers of Lamictal- as it requires gradual introduction. The cost of that drug is crazy expensive. I was silly enough to fill the prescription right away only to have that med land me in the ER with an allergic reaction before I got through the samples. I would be happy to sell what I bought back to them and use the several hundred dollars to help recoup some of my losses. This is a very valuable sample kit: http://www.lamictal.com/epilepsy/patients/about_lamictal/free_sample_kits.html

Alternately, a friend was getting samples of Lyrica for awhile. When the samples stopped her insurance wouldn't cover it. So you might want to look at your insurer's formulary before you start with a new drug.

Dr. Helm,

When hospital treating physicians do not even know what is the latest information on resistant bacteria(both in the community and hospita environment), you bet your ass that the clinical data I discuss and leave behind to them is excessively greater than what they would uncover on their own(because they are not reviewing the clinical data themselves). They do not even keep up with the therapeutic guidelines on medicines. Would one expect anything else, since even you, are aware that doctors do not take the time to inform themselves about a medicines side effects, etc. from a PI. Doctors are the ones keeping reps. from providing consistantly solid informtion about a product because they force them into 30 second soundbites, unless the rep. would like to provide lunch for the office to get more time with the doctor. Then, of course, the pharma industry is blamed for providing meals that would influence a prescribers habits. The pharma industry cannot win the battle. Also, I have called on physicians for years now, and one is able, over a long period of time, to slowing provide good, accurate, clinical data to physicians, I am not a primary care rep., so my job as a hospital rep. selling IV antibiotics requires more discussion surrounding guidelines, protocols, and clinical data. I am amazed that most physicians outside of Infectious Diseases, are neglegently not keeping themselves informed when it comes to the disease state that I cover. Doctors have the responsibility to keep up in their field of work, just like experts in other industries are expected to do. In any other field, one would welcome the additional information provided, if not anything but to supplement their own knowledge base, instead of bashing them all the time. By the way, I have seen many patients who are economically challenged use samples as a primary source of their medicine that doctors are happy to provide them. Thankfully, the small price samples play in the overall cost of medicines is often quite helpfull to the patients who are receiving them for free.

oh, M Helm, your post was so thorough and sensible I'm not even going to take my usual poke at the bombasts and blowhards.

but there is that guy on the corner downtown who has also offered me free samples of his wares...

Justice,

I say this with no malice intended but re your 2-25-10, 12:07am, message, where do you find this stuff? (Not those sales rep guides?) Black, white, brown or yellow! Talk about "micro"! I say jokingly, you may place in the top 1/8% of nit pickers. Try Sarah Palin's new book. It's more entertaining.

Plenty of malice, Mr. E. Look in the mirror.

When I read that particular nit, I was reminded about the Rezulin-related memo about how easy it was to get Hispanics to "try anything."

The fact that some number of marketeers--not only in pharma--bank (literally) on racism and poverty to ply their trade is, for me, a nit worth picking.

Harpy,

I'm sorry that happened to you, but no one needed to tell YOU that free samples are not so good as they may seem! Your example is a great illustration of how the person offering a free sample may overestimate the value.

I plan to incorporate your illustration into my discussions on sampling. It will be very hard to give proper attribution.

Thanks for the laugh and the compliment.

I say this somewhat tongue-in cheek, but maybe we could reduce need for sampling by going back to the good old days, when drug companies were allowed to print prescription pads. Although they couldn't put the name of the drug on the Rx pad, what they did was to put a velcro sticker on the bottom of the pad. The other end of the velcro was attached to a large paperweight with the name of the drug of choice emblazoned on it. Thus when the doc detached the Rx pad from the paperweight, the name of the drug would be looking back at him. Now how is that for a novel idea?

JaT,

Initial titration packaging is a good idea, particularly when there is a significant risk that the medication will not be tolerated or effective. Nothing stopped GSK from making these commercially available rather than only as samples. Since the company establishes the price, they could set it at such a point that the cost would be signficantly less than the monthly cost for the medication when titrated.

Alternatively they could have started out with a voucher program providing the cost of the first month for free.

Your neurologist could have also taken a little more time to explain the risk that the medication might have, and provided you with a prescription which permitted you to fill a one week supply at a time. That would have taken more time, but in retrospect wouldn't that have been helpful to you?

The newer anticonvulsants have been shamefully expensive. The reason is not the costs of research and development or production, it is because this is the price the market would bear. Seizures are bad, and people will pay a lot of money to avoid them. Anticonvulsants have inelastic demand; therefore, if you have a patent on one - even if it is not that great - you can go ahead and plan your villa on the French Riveria, and buy that co-op with the Central Park view.

Sampling of anticonvulsants is a particularly sketchy area. The signficant interactions many have with one another and other drugs make it all the more important that before one is started (or added) a thorough check of the known and potential interactions is essential. That is best done by a pharmacist who knows exactly what the patient is taking, and has immediate access to computerized algorithms that routinely check this.

You are absolutely correct about the formulary coverage issue (which could also be dealt with if initial trial vouchers were redeemable at a pharmacy).

Samples in doctor's office closets may have been there for some time. They also likely travelled in a rep's trunk. Certainly between warehouse and rep storage unit they spent some time in a panel van or similar commercial delivery truck. Not all reps have climate controlled storage units, so some portion of the samples docs give out have likely been cooked.

JiM - one last comment about samples (from me at least). Your exchange with Mr Ed notwithstanding, I'm not sure that the race/minority issue is appropriate or relevant here. Poverty and limited access to care goes beyond color and race, although I admit there are obvious disparities.

I have no doubt that many people in inner cities need any help that is available. If that means that some docs can assist by offering samples, I'm OK with that. If that leads to prescribing of higher priced drugs to those with insurance (no proof of this) and that adds to the next level of cost, then maybe that cost is spread across a greater population that can afford it. I'm OK with that too.

Maybe I'm a socialist??? But hey, my office is in the center of one of NE USA's largest but least glamorous cities. I see huge disparity between the residents and those in other parts of the state, and of course that includes access to care and medicine. In a previous life I spent time working in in Africa, the Middle East and Latin America where I visited clinics that helped very, very poor people. And today I could walk a half mile from my office and see others living in the US of A with healthcare options that are almost similar yet undoubtedly better, but not a hundred times better.

If offering samples to docs in these centers means that some get drugs which otherwise would be off limits, and if the price is an increase in branded, 'newer' prescriptions, well maybe that's something that is worth paying for. And of course some pharma companies have introduced schemes to help those people gain improved access to those medications. Again, I think a positive step.

As you say, always a pleasure and just one more tax payer's opinion.

Thanks for the thoughts and more of your own story, Christopher.

Shall we cut to the bottom line? Yes! Most insurance carriers don't care what's available, as long as it's generic. So, high retail drugs that have generic equivalents,(those generics)are [first] in line. No ifs, ands or buts.

When I tried to get on an expensive drug, I went through hoops to get Enbrel. I had to try every generic (even though not the same as Enbrel) beforehand. So samples, I vote for permanent position in the world of medicine. If I had paid for all this fooling around, the costs would be outta sight.

OK, I do see the point. To get even partial coverage of Lipitor--still a helluva lot cheaper than Enbrel--my insurance requires trying (and failing) generic simva and even (friggin) zetia.

You're right, of course, M Helm, MD.

The titration pack could certainly be by prescription. As for the neuro writing, and me filling, the prescription:

I was in a really precarious situation and just wanted (needed) to be stable on SOMETHING again- and I put too much hope in the product. No idea what his motivation was.

You are so right about planning the villa. Even if you wanted to switch to the generic later- it would mean titrating again. I don't much care what FDA thinks about exchangability. Not many people are going to sign up for that. It makes me wonder if a generic maker provides a similar package for new consumers.

What is wrong with you people? I have always been successful in getting branded Dilantin/phenytoin.

Oh yeah- that didn't work out so well.

nvm

;)

M Helm, perhaps you missed this posting by Pharma Giles on another thread. It says it all, really, and will illustrate your point and amuse.

cheers!

OMG, Harpy. Your link to Pharma Giles posting is priceless! Certainly, one to be archived...a national treasure. Yes, it is a bit edgey, but like you say, "it says it all".

Mr. Experience, I understand your situation with Enbrel. If we're talking rheumatoid arthritis for example, some insurance plans require that you do an initial 12 week trial of generic methotrexate, and if you fail that course you can get the biologic. Their reasoning is that approximately 25% of patients will improve on MTX alone. Given that MTX runs about $600 per year, and the biologics run about $20,000 per year, the companies can save a considerable amount of money using this stepped approach.

Justice and Pharmavet,

I am happy to see that my explanation was accepted. That's all I was trying to point out.

Thanks !

Drug samples on way out of many doctors’ offices By SHANNON MORTLAND Cleveland Business May 14, 2007

[excerpt]

Doctors at the Cleveland Clinic, MetroHealth Medical Center and University Hospitals cite numerous reasons for no longer providing the free samples, which have been a staple in doctors’ offices for years.

---

read why here: http://www.crainscleveland.com/apps/pbcs.dll/article?AID=/20070514/SUB/70511027/1003&Profile=1003

Let's see my cousin is an ortho surg who do you think he wants to see in the hosp the pharma rep or the Device rep in on a surgical case. I know as an ex drug rep being in the hospital with some dumb detail piece in one hand(for the 10 second message) and a tablet to get a sig was beyond moronic.