No Free Golf

By Julie Rawe

The American Academy of Family Physicians Foundation ended up bagging its annual golf tournament this year. The event, which would have been held this month in San Diego, used to draw big bucks from drug companies eager to talk shop with doctor-duffers. One year Pfizer served breakfast, Otsuka America brought lunch, Novartis supplied the golf carts, TAP Pharmaceutical stocked the beverage cart and nine other drugmakers each sponsored a hole or two. But these days no one is willing to give or take so much as a logo-stamped golf ball.

That's because pharmaceutical companies are trying to shake their reputation for inveigling their way onto doctors' prescription pads and into patients' wallets. An industry trade group recommended in April that its members stop promoting drugs at golf outings, ski trips, luaus and anything else that goes beyond bringing cold cuts to a sales pitch. And the drugmakers were just a step ahead of regulators. On Oct. 3, the Federal Government published draft guidelines on how drug reps should interact with physicians and hinted at tougher enforcement of anti-kickback laws.

Over the past five years, drug companies have doubled promotional spending, to $19 billion. Half that money goes toward free samples, and nearly a third is spent pitching those pills to physicians at work or after hours. And--surprise!--studies show that doctors who spend more time with drug reps are less likely to prescribe cheaper generic drugs. So whether salesmen chat up physicians over a slice of pizza or during a dinner cruise is drawing the attention of legislators trying to bring down prescription-drug costs, which have risen 30% since 1996--nearly twice the rate of inflation. The industry's sudden call to heal itself comes in the wake of a record $875 million fine that TAP Pharmaceutical agreed to pay last fall to settle charges that it gave kickbacks and lavish gifts to get doctors to prescribe its prostate-cancer drug Lupron.

Among physicians surveyed last year by the Kaiser Family Foundation, 61% said they had received meals, tickets to events or free travel from drug reps. The Pharmaceutical Research and Manufacturers of America (PHRMA) now discourages entertainment outings as well as "dine and dash" or "gas and go" events, where sales reps deliver their 60-second spiel to doctors who line up for free takeout or a tank of gas. The group recommends giving only educational items valued at $100 or less.

"Drug promotion can still continue, but without the bribery," says Dr. Bob Goodman, 43, a New York City internist who in 1999 founded NoFreeLunch.org to raise awareness of the effect that drug promotion has on doctors' prescriptions. Goodman's group has even launched an assault on the ubiquitous ballpoint pens bearing drug logos; doctors are urged to trade in branded pens for ones that say no free lunch. (The old pens go to charity.)

Goodman and other watchdogs are worried because the industry and federal guidelines are only voluntary. "There's no penalty if you ignore them," says Ben St. John, spokesman for the inspector general of the Health and Human Services Department.

That's not the case in Vermont, where Medicaid spending on prescription drugs jumped from $40 million in 1998 to $115 million last year. There, according to a new law, a drug company can be fined $10,000 for every physician's gift in excess of $25 that it fails to report to a state registry. Massachusetts, Maine, New York and Wisconsin are considering similar legislation. "Doctors don't want their names in public as taking money or tickets or whatnot from drug companies," says Vermont Governor Howard Dean, who is an M.D.

As a smattering of hospitals and clinics create drug-rep-free zones, PHRMA spokesman Jeff Trewhitt points out that doctors who shun salesmen also forgo the free samples, which are often used to treat indigent patients. Nevertheless, physicians are relying less on sales pitches and turning instead to unbiased sources like the biweekly nonprofit Medical Letter medletter.com to get the lowdown on new drugs. The crusade is also making inroads among a new generation of doctors who haven't yet experienced drug-company largesse. The American Medical Student Association is trying to ward off drug reps who try to cozy up to future doctors long before they can write prescriptions. Instead of chowing down on a free sales-pitch sandwich, students--who are usually buried in debt and years away from making a salary--are being asked to brown-bag it. A tall order, but it beats the hospital cafeteria.