RX for Change: Confronting the health care crisis in Kansas

Dec. 6, 2005

By Chris Green

Harris News Service

Some visitors who regularly appear at Hutchinson Clinic cardiologist Michael Hagley's office - as well the offices of other health care providers across Kansas - aren't patients.

A couple days each week, representatives from pharmaceutical companies visit with Hagley to promote a new drug or a new use for an older drug.

Often described as "detail" people, drug representatives work as the industry's sales force, although it is the doctors who prescribe the medications that patients ultimately purchase.

When visiting, the marketers also provide free samples of new offerings that Hagley can distribute to patients. Sometimes they'll even come bearing gifts of notepads, pens and other common items emblazoned with their company's logo or the name of the drug.

With health care professionals, like Hagley, juggling hectic schedules, pharmaceutical representatives help providers learn about the latest drug treatments and trends in the industry during face-to-face meetings in doctors' office or at conferences.

As a result, the sales reps play a significant role in their industry's multibillion-dollar promotional campaigns for prescription drugs.

But some critics, such as former New England Journal of Medicine editor Marcia Angell, claim that drug companies' marketing efforts, including the use of representatives, help drive up prescription drug costs.

Others express concern about the impact sales pitches have on the prescribing decisions of doctors - and how much patients spend on their prescriptions.

Jerry Menikoff, a bio-ethicist and associate professor of law, ethics and medicine at the University of Kansas, said having drug representatives inform doctors about new medications could be problematic because of their interest in selling the drug.

"It has its pluses and minuses," Menikoff said of the drug rep system. "Many of the people who study it these days would say it has more pluses than minuses."

Visits from drug company representatives tend to be everyday occurrences in doctors' offices across the state.

Salina physician Rob Freelove, associate director of the Smoky Hills Family Medicine Residency Program, said his clinic daily receives visits from two to five pharmaceutical representatives.

Those visits generally are brief and the interactions take place away from areas where representatives could interact with patients or patient information, Freelove said.

Sometimes salespeople give more in-depth presentations to doctors over lunch or sponsor continuing education conferences, he said.

But gone are the days when marketers could do just about anything they wanted to in promoting sales for a prescription drug.

"There are, in my mind, appropriate restrictions in place," Freelove said.

Scott Lassman, assistant general counsel for the Pharmaceutical Research and Manufacturers of America, which represents drug makers and biotechnology companies, said drug salespeople generally follow a voluntary code of ethics. It directs that meetings with doctors be informative in nature.

Under the guidelines, sales reps can offer only promotional or "reminder" items to doctors that primarily benefit patients or have a use in the practice and have a value of $100 or less. Meals can be provided, but only during informational presentations in an appropriate setting and without guests or doctors' spouses.

Gifts for the personal benefit of doctors, such as golf balls with the drug company's logo, sporting event tickets and cash or cash equivalent gifts, should not be offered, according to the code.

"The real purpose of the code is to get the focus away from the peripherals and back on the information," Lassman said.

However, drug industry spending on marketing activities remains a controversial topic.

According to a recent industry analysis, drug companies spent $25.3 billion on promotional activities in 2003. Of that, more than $16 billon came in the form of free drug samples distributed to office-based physicians, a PhRMA report noted.

About $3.3 billon of promotional spending was for direct-to-consumer advertising, with a remaining $5.7 billion spent on office and hospital promotion and journal advertising. In comparison, industry estimates place research and development expenses for pharmaceutical companies at $33 billion.

However, in a recent book, "The Truth About Drug Companies: How They Deceive Us and What to Do About It," Angell argues that some of the nation's biggest drug makers spend more than twice as much on marketing and administration than they do on research.

She also claims that some drugs being marketed aren't more effective than less expensive ones on the market.

Menikoff said it's possible for doctors' prescription practices to be subconsciously influenced by the amount of money companies pour into marketing efforts, even if they're just hearing informational presentations or receiving token gifts.

The power of suggestion possibly could prompt doctors to prescribe newer, more expensive drugs that they're more familiar with over cheaper, older alternatives that might be as or more effective, Menikoff said.

"Maybe we should be thinking about some way to get information to physicians in a less biased way," he said.

But drug industry spokesman Jeff Trewhitt said it's unclear how much the sales pitches affect doctors.

"We have not conclusively pinned down how successful pharmaceutical representatives are," Trewhitt said. "They are the best source of information but they are not the only source."

Freelove said he finds the information provided by drug representatives helpful but takes "most of what they say with a grain of salt."

Because most of his patients pay for their own medication, Hagley said he has to be sensitive to what his patients can afford.

In some instances, patients who initially save money using the promotional free samples could end up paying more in the long run when they're finally forced to purchase the newer, more expensive drug themselves.

"You have to remember," Hagley said, "that who you have the obligation to is the patient."