Drug reps used to pop in and out of doctors' offices, toting their trademark suitcases, pens, mugs and free lunches.
With only the receptionist as a gatekeeper, they would quickly get in to see doctors and within minutes leave behind invitations to junkets and samples of the latest medications.
Providence Health System in Portland, Ore., this fall became the latest to restrict when, what, where and how drug "detailers" can promote their wares. The policy was adopted by Providence in September after being piloted for a year. During that trial run, only approved samples were put in the sample closet, and the number of prescriptions for those products skyrocketed, Providence officials say. Approved samples, officials say, include those that are proven to be cost effective or the best drug for the condition, regardless of cost.
The new policy, they say, was adopted because of concerns about the increasing liability of having myriad samples around the office and the time physicians were spending with pharmaceutical matters (See October, page 76).
Drug reps are limited to once-a-week, invitation-only lunches. Each week, one drug company is invited to detail only the drugs that are approved by the pharmaceutical committee, a group comprised of physicians, pharmacists and others.
"We worry about their bias in detailing," says Jacquelyn Hunt, the lead clinical pharmacy specialist for the Providence Medical Group. Physicians don't need to be detailed on all products, she says.
Only preapproved samples can be left in the sample closet, Hunt says. Notes are tacked on some sample boxes, reminding providers that generics are available. However, providers aren't prohibited from prescribing any medication they deem necessary.
Representatives from several major pharmaceutical companies and from the industry's trade association either didn't return phone calls seeking comment or declined to comment.
Kaiser Permanente Northwest Division's policy is stricter than that of Providence: Drug reps who get approval to detail must sign in at the pharmacy where the samples will be distributed. Kaiser has told drug reps that they can't promote or sample nonformulary drugs or approach physicians. Doctors must approach the reps.
"I think that we really discourage sampling. Period," says Jim Norris, M.D., formulary chair and practicing internist for Kaiser. Kaiser found that when drug reps dropped off samples, physicians wrote prescriptions for those medications within a few hours, he says.
A Michigan state law that went into effect in March 1998 tightened the reins on drug sampling. A provider who gives patients samples must record the lot number as well as the reason for giving the sample.
Henry Ford Health System in Detroit took it one step further: Doctors have to earn the right to keep samples on hand by complying with formulary rules and those regarding pharmaceutical reps. Other samples are distributed through the pharmacies, says Barbara Zarowitz, director of ambulatory clinical pharmacy for Henry Ford.
Henry Ford Health Clinic established the policy about 2 1/2 years ago, Zarowitz says. "Rather than allowing the drug companies to manage us, we bring the drug rep in and market according to our guidelines," she says.
Reps promoting drugs not included in the formulary are not allowed to peddle their products, she says. "We've really allowed for a cooperative partnership for those with whom we feel there's added value and closed out those for whom there isn't clear added value."
The policy has rankled some and led some pharmaceutical reps to resort to extraordinary measures to get doctors' attention. One even faked illness and went to the emergency department in hopes of catching a few minutes of the doctors' time, Zarowitz says. She declined to name which companies were involved.
"They'll do anything to make a sale," she says. "Drug companies have a tremendous budget to spend on physicians. . . . A lot of money is floated to influence the prescribing decision."
Physicians generally don't appreciate having their day interrupted by sales people, says William Conway, M.D., chief medical officer at Henry Ford Medical Group.
"I believe that sophisticated physicians get their prescribing information from journals and not from sample medications," he says.
Yank Coble, M.D., clinical professor of medicine at the University of Florida, notes that some medical organizations work with drug manufacturers to give samples to patients who can't afford medications.