Friday, April 25, 2008

No Such Thing as a Free....

.... Medication Sample?

In the Empowered Patient column on CNN's website, Elizabeth Cohen wrote, "In a University of Chicago study published this month, those receiving [medication] samples spent $166 in the six months before they obtained free medicine, $244 when they received the samples, and $212 in the six months after that." Since "free samples aren't always so free when you look at it long-term," Cohen lists five steps to take when a physician offers a sample. These include asking "your doctor how long you'll be taking the drug," finding out "if there's a cheaper alternative" to the drug offered, requesting that "your pharmacist to call your doctor" to "suggest cheaper alternatives," doing "your own price shopping," and keeping in mind that physicians "are often hesitant to change a prescription."

Dr. Adair then goes on to note that his physician "was being nice to me, or he thought he was." "Doctors think they're helping people by giving free samples, but we don't think through the long-term consequences."

Food for thought for physicians and patients. But, let's look into this one. The primary study is in April's Medical Care--and an article by Dr. G. Caleb Alexander. For those interested, the link is here. (A pleasant surprise was noted, by the way, seeing one of my colleagues as co-author, Dr. J. Zhang, right here in Richmond.) I was pleased to see that the study included an analysis to try to differentiate the possible confounding variable of samples being due to increased health demand. (i.e. a sicker patient needs a more expensive medication). This is a difficult variable, and was dealt with fairly logically; although the authors do note that there can still be confounding data skewing to explain the cost difference. They also do note some possible selection bias. I think this is perhaps likely in explaining the difference in sample usage being lower in those with less income, on Medicaid, etc. Commonly, lower income patients and Medicaid recipients are in facilities, insurance structures, or community-based programs which do not encourage samples. For example, one living in a group home, or in a community health center, which is not designed to process samples, and prefers (or demands) prescriptions only.
All-in-all, a this represents a fairly well designed study, that does not portend to be anything beyond a starting point for consideration and further research (naturally!). Of course, there will be media-savvy (or hungry) types that will immediately use this data for the purpose of bad-mouthing the insurance companies and perhaps demanding that doctors further distance themselves from this evil industry by no longer accepting samples: In an posting in 2005, Dr David Pisetsky at Duke University ( forum editor) presents the perils of seeing drug reps and accepting free samples. He suggests that it may be time to "pull up the welcome mat, close the door to my office, and put up a 'No Solicitors' sign."

"Does free mean free?" the headlines read. Well, of course it does--(unless the doc is charging in the parking lot or selling samples to the local pharmacy, in which case may a warm HMO await them in hell). No study will ever show a positive cost analysis of identical prescriptions being given vs. samples (e.g. a sample given of Lipitor vs. a prescription).

I am curious though to the possible rationale for studies like this. Is to promote the usage of generic medications? Perhaps more restrictive formularies? Or, is this a not-so-indirect attack on the pharmaceutical industry, or health care providers? (I didn't know we were just "often hesitant to change prescriptions!")

So, what can we learn from this study? First, that there is a possibility that when medication samples are given to patients, there is a possibility of being a greater long-term cost to those patients (or their insurance companies). Second, that the current studies do not provide sufficient data to condemn the practice of giving samples by physicians. and Third, it would make logical sense for patients and physicians to dialogue regarding samples, and treatment options, and that certainly should help not only the patient's decision-making, but maybe their wallet as well.


Erudite Redneck said...

On yer Third: Yes, absolutely. But some people don't have the ability to even dialog with the hired hands at the Jiffy Lube.

Some of 'em will buy every service the guy with the clipboard says they need (or, take all the free drugs the doctor provides) because, well, he is the authority; and some will resolutely refuse any service they didn't come for that day (decline to take free drugs, or, in my case, be talked into a prescription but then never start taking the scrip) because, well, he's just a guy with a clipboard.

In both cases, the power differential causes the patient -- ah, I mean, the car customer -- to possibly fail to act in his best interest.

What about them? Rhetorical question. ... Surely there is a way for everyday people to be able to avail themselves of on-the-spot advice from a third-party source without a dog in the hunt. ...

I'm thinking an answer might be in an as-yet unthought-of fusion of a nonprofit cooperative, live-time online communication and a cell phone or some other hand-held device -- with the conscientious clinic or doctor's office providing the use of such devices as a community service.

And I just pulled alla that right out of my hind end.

Doc said...

For sure there is a power differential for all patients, even so when I go to another physician, I am at the mercy of their expertise.
It is one of the reasons why physicians need to continue (or start) being taught the idea of a dialog--which should be initiated by the physician.
Most everyday people can ask their doctor these questions, and should be educated to do so. I don't think intelligence has much to do with it. Communication skills and socialization may. Intimidation to the "power differential" likely also plays a role. For those people I would encourage safety in numbers. Bring a friend, spouce, sibling, parent, or whatever.
Perhaps you may have hit upon an enterprising solution: I may need to look to become a professional interpreter and advocate: Sort of a "Dial-A-Doc!" Thanks for the idea!

Erudite Redneck said...

"Dialog a Doc" -- that way, it looks like yer being clever with words, and not that yer just pre-text message! :-) ...