Drug samples can mean fewer generic prescriptions for the uninsured

A study's findings raise questions about whether the benefits of drugmakers' free samples outweigh patients' out-of-pocket costs.

By Kevin B. O’Reilly — Posted Oct. 6, 2008

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Without brand-name drug samples to hand out, physicians are three times more likely to prescribe generic medications for their uninsured patients, according to a study in the September Southern Medical Journal.

The study looked at prescribing habits of 70 doctors at a university-affiliated internal medicine practice in the nine months before and after an office move meant losing access to a secure place to store drug samples.

When doctors had access to samples, they wrote prescriptions for generics 12% of the time for uninsured patients. They ordered generic drugs 30% of the time when no drug samples were available. Uninsured patients' out-of-pocket costs declined after the sample closet was closed, but the drop was not statistically significant.

The study appears to be the first to look at how samples affect doctors' prescribing for uninsured patients. The findings come amid increased scrutiny of many forms of industry-medicine relationships, from drugmakers' funding of medical education and physician speakers to gifts such as pens and notepads.

Because physicians often use drug samples to aid uninsured patients, such samples have not been targeted by lawmakers. But critics say drugmakers use the free medicine to influence physician prescribing behavior, and they argue that doctors should refuse them. More than 90% of physicians accept samples from drug reps.

"Physicians need to ask themselves if drug samples are doing more harm than good," said David P. Miller, MD, lead author of the study and associate professor of internal medicine at Wake Forest University School of Medicine. "While drug samples might save patients money in the short term, they can also influence what physicians prescribe and result in much higher costs later."

Dr. Miller, who does not use samples in his practice, speculated that time-pressed physicians may rush to write brand-name refills, forgetting potential financial repercussions for uninsured patients.

Costly consequences

The new study seems to confirm other findings that samples are associated with greater out-of-pocket costs for patients, experts said. For example, an April study in Medical Care found that patients who got samples paid $66 more for drugs over six months than patients who did not get them.

The lead author of the Medical Care article, G. Caleb Alexander, MD, said higher costs can affect clinical outcomes because more than one in five patients skips medications at some time to save money.

"Samples can provide valuable economic relief to patients, but in some settings they may be penny-wise and pound-foolish," said Dr. Alexander, assistant professor of medicine at the University of Chicago Pritzker School of Medicine.

But he added that it is too early to conclude that a no-samples policy is best, as long as doctors only hand out samples when they offer a clinical advantage over generic alternatives.

Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers of America, said, "Critics overlook key facts when they question how much struggling patients benefit from low-cost or free medicines provided by America's pharmaceutical research companies." He said generics accounted for two-thirds of prescriptions filled last year, and that samples are but one factor among many influencing physicians' prescribing choices.

In a June report, the Assn. of American Medical Colleges said academic medical centers should distribute drugmaker-provided samples through a central system such as a campus pharmacy to reduce industry influence. AMA policy says physicians should not take samples for personal use or for friends or family.

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Sampling effect

A new study looked at the percentage of generic prescriptions written in the nine months before and after a university clinic stopped accepting drug samples in 2001.
Percentage of generic prescriptions written:

Samples present
March-May 14%
June-August 11%
September-November 10%
Samples absent
January-March 20%
April-June 27%
July-September 40%

Source: "The Impact of Drug Samples on Prescribing to the Uninsured," Southern Medical Journal, September (link)

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