A policy recently approved by the Advisory Board of the Medical Faculty will eliminate drug company handouts, including free samples of medication, and will more tightly regulate the Hospital's association with the pharmaceutical and medical device industries.
On March 25, the board approved the industry interaction policy that prohibits the acceptance of gifts from pharmaceutical and medical device companies, effective July 1 of this year, as well as the acceptance of free pharmaceutical samples, effective July 1, 2010. The new policy also restricts the access of marketing representatives to non-patient care areas only.
The policy will apply to the faculty, students and volunteers of all Johns Hopkins Medicine (JHM) member associations, including the hospital, the School of Medicine and Bayview Medical Center. Other JHM institutions may adopt their own standards so long as they are as stringent or more so than those adopted by the hospital.
Last year, Hopkins Hospital received a "D" grade on the PharmFree Scorecard, a measure of conflict of interest policies at academic medical centers. According to Julie Gottlieb, assistant dean of Policy Coordination at the School of Medicine and one of the authors of the policy, there was discussion about developing this policy even before the scorecard was released, though it was one factor in its approval.
"Over time, biomedical and pharmaceutical companies have increased the marketing components of their relationships with our institution," Gottlieb said.
"This is troubling because we want to have a good scientific exchange with industry, but it is difficult for physicians to make independent decisions about clinical care, teaching and purchasing if there is marketing influence in their facilities."
IMS Health, an expert on the pharmaceutical market, estimated that the amount spent on drug-promotional activities in 2006 totaled $12 billion. This number includes the costs of pens, notepads and other promotional items, as well as the costs of sample drugs provided to physicians and the costs associated with distributing these items.
"Though most of us [physicians] like to think that we aren't influenced by [promotional items] on an individual level, the literature seems to indicate that it does influence us," Lenny Feldman, assistant professor in the Department of Internal Medicine and Pediatrics, said.
Gottlieb explained that many other academic institutions are developing similar policies, including the medical schools at the University of Pennsylvania, Stanford, Yale and Vanderbilt.
"There is a general feeling that we want to reorient our relationships with industry so they are not about marketing but about progress in medical care," Gottlieb said.
According to a former pharmaceutical representative in the Baltimore area, who preferred to remain anonymous, marketing representatives were always trained and required to be ethical and professional in their dealings with physicians.
"We never indicated that just because a physician went out to dinner with us, he was obligated to prescribe our drugs," she said. "Almost every other sales job in the world relies on client interactions over meals to further business relations."
With regard to the elimination of promotional items such as pens and notepads, the former representative felt like the policy was an insult to physicians.
"Doctors are selling themselves short as professionals if they think pens and pads will influence their judgment," she said.
The former representative explained that more than influencing the judgment of physicians, the role of promotional items was to appease physicians' secretaries and receptionists. In the pharmaceutical industry, the people in these office positions are known as "gatekeepers," because they grant representatives access to the physicians.
"When you make the gatekeepers happy, they let you see the doctors," she said. "Now that these items like pens are taken away, the salesperson will have to rely on their interpersonal skills to gain access, as obvious as that sounds."
According to Feldman, most physicians in the hospital receive very few promotional gifts from pharmaceutical companies, the majority of which are pens with the names of drugs.
"I prefer to use pens that don't have a drug company's name on them," Feldman said. "It's mostly for appearances sake, and to make sure that patients don't perceive any bias based on the name of the medication [on the pen]."
The policy change that is expected to make the biggest impact in the hospital setting is the elimination of free drug samples.
"The ban on pharmaceutical samples is being phased in over the next year," Gottlieb said. "This will allow those clinics that have been relying on them to make arrangements for alternatives for their patients."
According to Stephen Sisson, doctor and associate professor of Medicine at Hopkins Hospital, the goal of physicians is not to be influenced by the options in the sample cabinet.
"Typically, those drugs are the more expensive ones because pharmaceutical companies are trying to market those primarily." Sisson said.
"Drug companies expect us to provide samples to patients who can afford to buy the drug once they see that the therapy works," Feldman said. "But most of us use them for patients who cannot afford medications in any other way."
Both Sisson and Feldman expressed that they are put in a difficult situation when they run out of samples for patients who cannot afford them.
"Samples were often sporadic since companies often changed the marketing representatives they sent and their marketing strategy," Sisson said. "We couldn't always rely on having samples."
Feldman explained that the magnitude of the impact will depend on the setting that a physician works in and how accessible medications are to his or her patients.
"For a long time, there were very few options for patients who could not afford medications, as most medications tended to be prohibitively expensive," Feldman said.
In 2006 Wal-Mart introduced its $4 prescription drug program, which offers approximately 95 percent of the prescriptions that are written for the majority of drug therapies.
"Since the advent of the Wal-Mart $4 list, the number of medications that you can buy at a very reasonable price has gone up," Feldman said. "But this doesn't mean everyone has access. It's often difficult for patients in cities like Baltimore to get to pharmacies with a $4 list."
Although access to affordable drugs is not as much of a problem as it used to be, the former pharmaceutical representative said that the impact of eliminating drug samples will be huge in the academic setting of Hopkins Hospital.
"There are so many indigent patients being cared for [at Hopkins Hospital] because of its inner city setting," she said. "We know it's a secret that samples are used primarily for patients that cannot afford drug therapy. If they don't have access to samples, their small health issue could turn into an urgent issue and land them back in the emergency room."
In addition to the impact on the drugs that physicians can offer to patients with financial needs, the former representative said that prohibiting free drug samples will force pharmaceutical companies to adapt their marketing strategies.
"Representatives that are good at selling will figure out how to bring value to an interaction with a doctor without the crutch of providing samples," she said. "Bad reps will quickly be highlighted and won't be able to make it in the business."
Exceptions to the hospital's policy include drug or medical device samples that are necessary for patient education, as well as the acceptance of medical or scientific books, as long as they do not carry the name of a pharmaceutical or medical device company.
