Are Drug Reps Bad for Patient Care?
Claiming that pharmaceutical representatives induce physicians to prescribe drugs that are harmful to patient pocketbooks or have little medicinal value, regulators, medical school administrations, and other bureaucrats have pressed for limits on physician contacts with pharmaceutical representatives. They have sought to limit pharmaceutical companies’ communications and advertising and barred people who work for pharmaceutical companies from positions on advisory committees.
Yet a new paper finds that limiting physician access to pharmaceutical representatives “can have the unintended effect of reducing appropriate responses to negative information about drugs just as much as responses to positive information about innovative drugs.
The authors looked at how prescribing behavior varied in response to three cases of new information across areas that varied from low drug representative access to physicians to high drug representative access. The first case was the introduction of sitagliptin, a new drug to treat type 2 diabetes with fewer side effects. The second was the response to a negative clinical trial finding on the results from simvastatin/ezetimbe, a combination drug used to lower low-density lipoprotein cholesterol. The third was the discovery that rosiglitazone, used to treat type 2 diabetes, increased the risk of heart failure.
The results suggested that physicians in the lowest access category were slowest in their adoption of the new sitagliptin therapy. They were also four times slower to reduce their use of rosiglitazone than physicians in the next category. Physicians facing high managed care control were slower to adapt. Specialists adapted more rapidly than primary care physicians.
The authors conclude that “[p]olicies that promote physician ignorance of new medical information resulting from access limits runs [sic] counter to protecting patient health.”
In what might be one of the best counters to the frequent assumption that physicians blindly follow drug company marketing, the authors point out that pharmaceutical representatives aid in lowering the cost of information for a group of highly sophisticated consumers. “Physicians make multiple complex clinical decisions daily for their patients where medical information is costly and time consuming to acquire,” they write. “Optimal health decisions for patients are the result of physicians weighing the value and relevance of medical and marketing information from a variety of channels on top of their own training and experiential knowledge. Limits placed on the flow of relevant medical information from any channel will affect physician decision-making unless that physician can easily replace that lost information through another channel. Drug sales representatives provide timely and convenient regulated clinical information used by physicians, nurses and office staff.”
Physicians knowing all the facts about a drug are good, but the marketing techniques are really to be questioned. You don’t need to fly a doctor to the Bahamas in order to tell him that a new drug will help his patients.
One important use of the reps and sampling is that physicians get some experience with new drugs and treatments. This enhances patient care and keeps physicians up to date. We can distinguish between the truly innovative and another me too drug. If no experience, then we will not innovate and acceptance of new treatments will be even longer. Of course, the feds want us holey dependent on the feds for information and just following the guidelines that anyone can.
Good point, Alex. Really, doctors just need to be ethical about this. Human nature is a factor here, and offers from pharmacuetical reps can be very enticing, but ultimately it is up to doctors to know what’s best and right for their patients.
Bureaucracy should get out of it.
Drug reps are evil.
I think it would be overbearing for government to intervene further in this area.
Critics often accuse drug makers of spending more on marketing than research & development. Few people realize that half of pharmaceutical companies’ marketing budgets are spent on providing free samples to patients.
Free sample have an important place in primary are. If your doctor lets you try a drug before you have to buy it, that’s a beneficial arrangement. The problem is that doctors don’t always have time (or the incentive) to explain a free sample is but one option; other drugs exist to treat most conditions. Patients should always ask about their options — including generic drugs, over-the-counter drugs, non-drug alternatives and brand-name drugs, for which there might be a free sample.
Good points, Devon. It’s up to patients to ask more questions. But doctors need to be more inviting to those questions.
Good point, Mike. Drug reps play a valuable role that ought to lead toward better patient care.
Doctors, though, need to keep them honest and reject those drugs that need to be rejected.
There is no perfect way to ensure optimal dissemination of this information.
Plus, when we criticize the way pharmaceutical firms sell to doctors, let’s not also forget that the physicians have a professional monopoly on getting the drug to the end user – the patient.
An interesting question that we don’t think enough about, IMHO, is the FDA’s role in deciding over-the-counter (OTC) versus prescription (Rx) drugs. The FDA gained this power via the Durham-Humphrey Amendment of 1951 – not that long ago in the scheme of things.
Although pharmaceutical firms are able to advertise directly to the public (in the U.S.), they are not allowed to sell directly to the public. So, innovation in distribution is very limited. Outside the pharmaceutical industry, entire industries have been disrupted to a lower cost base by innovation in distribution. Think, for example of the role of Staples and Office Depot in reducing the cost of office supplies. Or Dell selling personal computers via telephone instead of stores.
Although drug firms can influence the FDA, they cannot make the decision. When Lipitor’s patent expired, Pfizer lobbied the FDA to switch it to OTC status, but failed. This keeps the medicine expensive, because you have to pay a doctor to prescribe, plus take more time out of your busy day to refill the prescription.
Even worse, because Obamacare removes OTC medicines from eligibility for HSAs and similar arrangements, there are reports of patients making doctors’ appointments in order to get OTC drugs via prescription. What a waste of money!
I see two ways to reform this. One, give states the power to decide which drugs are OTC versus Rx. Then measure the differences in costs and patient outcomes in different jurisdictions.
Even, better, how about allowing the owner of the intellectual property to decide whether the drug should be Rx versus OTC? Coupled with responsible product-liability laws, drug firms would make the trade-off between greater liability for OTC drugs and lesser liability for Rx drugs (because of the “learned intermediary” doctrine). Also, of course, they would make their decisions based on actual patient demand, not political or bureaucratic incentives, as the FDA does.
John Graham makes a good point about the regulation of over-the-counter (OTC) drugs. Nearly a decade ago, Wellpoint petitioned the FDA to switch then-prescription Claritin to OTC status. Wellpoint believed there was enough evidence to show that Claritin was safe enough to self-medicate. About this time, I was prescribed Claritin and discovered my cost was going to be about $1,000 annually. We can assume Wellpoint was tired paying for a widely-used drug that had no reason to be restricted to prescription-only status. Schering-Plough, the maker of Claritin, opposed the switch (presumably) because it could earn far more revenue when the drug was restricted to pharmacies and prescribed only by physicians (and largely paid for by insurers and health plans). This was the first time a petition to switch an FDA-approved drug was initiated by an entity other than the owner of the drug. Sources inside the FDA reportedly were uncomfortable with the idea of a non-owner petition for an Rx-to-OTC switch. The reason partly had to do with that if all the Rx drugs safe enough for self-medication were switched without the owners’ approval, the revenue for developing new drugs would be lowered and fewer drugs might be brought to market. Apparently, patients paying out of pocket for drugs are tougher customers that patients who can depend on their health plan to reimburse the cost of drugs. This is especially telling considering how inefficient Rx-only drug distribution is compared to retail drug distribution.
Yes.
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