Pharmaceutical companies have slashed their sales rep force by about 30% from a high of 105,000 five years ago, according to industry figures. And as the number of detailers has fallen, so, too, has another hallmark of pharmaceutical marketing: drug samples.
Drugmaker spending on the samples that drug reps leave behind in physician offices has gone down by 25% since 2007, said Cegedim Strategic Data, a global pharmaceutical market-research firm that surveys a rotating panel of 2,300 U.S. physicians to generate its industrywide estimates. In 2007, drugmakers spent nearly $8.4 billion on samples. That figure fell to about $6.3 billion in 2011, the most recent data available.
The number of detailer visits that included samples has dropped even faster, decreasing 35% from 116 million in 2007 to 76 million in 2011, CSD said.
Some doctors are noticing the difference.
"Just last week, I asked my assistant, 'Do we have this drug?' and she said no. We're also out of five other things that we commonly use," said Tanya Kormeili, MD, a dermatologist in Santa Monica, Calif. "I left a message for all the reps, and I haven't heard back. This is something that is more recent -- we actually have to call them to come in and bring in samples. They come in, and it's five little boxes. We used to get massive amounts of creams to the point where they'd go bad."
Samples are especially important for patients trying a new dermatological treatment to see how effective or well-tolerated it is, said Dr. Kormeili, who has a solo practice but splits overhead costs with two other dermatologists. She has turned to prescribing generics for patients who have trouble affording brand products and otherwise would have been given samples. But generics can have their downsides, she said.
"Some of the generic antibiotics, for example, are harsh on the stomach, and you have to take them twice a day," Dr. Kormeili said. "The branded products are slow-release, so you don't have to remember to take them twice a day. And in dermatology, some of the creams make all the difference. The older ones are more irritating to the skin, and patients may only use them two or three times a week when they should be using them every day."
Drugmakers' decision to scale back their sales forces is the principal reason why sampling has declined, said Jerry Maynor, director of marketing and business development for CSD's U.S. division.
"If we're seeing a decline in samples at this point, today one of the major drivers is the drop in the overall number of sales calls being delivered," he said.
23% of physicians refuse to see drug reps.
The reduction in sales force is due in part to drugmaker consolidation and the need to cut costs, pharmaceutical industry experts said. In 2011, the world's best-selling drug, Pfizer's Lipitor (atorvastatin), went off patent. So, too, did the Eli Lilly antipsychotic Zyprexa (olanzaprine). In 2012, patents expire for the clot-buster Plavix (clopidogrel), made by Bristol-Myers Squibb and Sanofi-Aventis, AstraZeneca's anti-psychotic Seroquel (quetiapine), and Takeda's diabetes drug Actos (pioglitazone). With fewer big-name brands to bring in big profits, drugmakers feel less need for sales reps and samples to promote them.
Also driving the move away from sales reps -- and, consequently, samples -- is that detailers find it harder than ever to visit physicians who are pressed for time or find little value in drug-rep visits.
About a quarter of doctors refuse to see drug reps, according to SK&A, a division of CSD that regularly tracks detailers' access to 680,000 physicians by conducting phone surveys with nearly 240,000 clinics. Nearly half of physicians will see reps only by appointment, said the firm's October 2010 report. The remainder of physicians have no restrictions on seeing detailers.
As for samples, 23% of physicians refuse to take them, said an August 2011 SK&A report. The rest of the surveyed doctors accepted samples, although their likelihood of doing so varied by specialty.
The bigger the practice, the less likely it is to accept samples, the company said. Three-quarters of practices with three to five physicians took samples, compared with 54% of groups with 10 to 19 doctors.
Nearly two-thirds of medical schools have significant restrictions on access to or distribution of samples, such as barring doctors from accepting them directly from reps, according to the American Medical Student Assn. PharmFree Scorecard released in March. The number of schools with the most restrictive samples policy rose from 12 in 2008 to 31 in 2012, said Lee Shapley, director of the scorecard.
Many drugmakers are giving physicians the option to order samples electronically, using services offered by companies such as Physicians Interactive and the mobile drug-reference tool Epocrates. Electronic sampling was not included in the CSD data, which were released in January in a private client newsletter. Experts say electronic sampling is growing but remains uncommon. Only 5% of doctors want to receive samples by mail only, SK&A says.
Going "sample free"
Sentara Medical Group, owned by the Norfolk, Va.-based Sentara Healthcare integrated health system, is an example of a large physician group that is saying no to samples. The policy, which Sentara dubbed "sample free," takes effect April 1. It was formulated in late 2011, principally in response to concerns about compliance with Joint Commission rules that govern sample dispensing in physician practices.
"We haven't always done as good a job as we should in monitoring and tracking and keeping close tabs on the inventory of samples that we have," said David Maizel, MD, president of Sentara Medical Group, which employs nearly 400 doctors. "For us to really be in compliance requires a significant administrative effort. For instance, if we got a recall notice from a manufacturer, we'd have to be able to identify the affected samples by lot number, expiration date and so on. We don't have anything other than a manual process for that now."
23% of doctors refuse to take drug samples.
A larger physician group such as Sentara would make a more inviting target for regulatory enforcement, Dr. Maizel said. The medical group also limits detailer visits to times outside patient-care hours, such as before or after clinics open or during lunch. Sentara works with local pharmacies to give patients access to manufacturer vouchers or co-pay coupon cards, and clinics help eligible patients sign up for pharmaceutical assistance programs.
Physician practices face potential medical liability for sloppy management of their sample closets, said Alyce C. Katayama, a health lawyer in the Milwaukee office of Quarles & Brady LLP. She said clinics should make one person responsible for keeping the sample closet organized to prevent dispensing errors, dispose of expired medications and comply with manufacturer recalls. Katayama noted that under the Patient Protection and Affordable Care Act, drugmakers as of April 1 must report to the Dept. of Health and Human Services all the samples they distribute, with the name, address, professional designation and signature of the requesting prescriber.
Whether physicians find fewer samples available for the asking or work in a setting where they are restricted, practicing without the free drugs on hand can pose a challenge.
"It's a change for some patients," said Michael G. Charles, MD, a Sentara family physician in Virginia Beach, Va. "I've tried not to make my patients very sample-dependent. You have to look for something that's affordable for them one way or another. ... Not having that easy solution to go and grab something, it makes you think twice before prescribing a new medicine nowadays."