Editorial What Is the Impact of Free Drug Samples on Patients? La Vonne A. Downey, PhD W hat is the impact of free prescription drug samples upon the US healthcare system? Is this a timely and important question to ask? According to studies using the US Medical Expenditure Survey (MEPS), 12% of Americans have received at least one free sample of a prescription drug. The value of these drug samples has increased from $4.9 billion in 1996 to $16.4 billion in 2004. During these same years, spending for prescription drugs has risen 15% and now accounts for 10% of total healthcare costs. 1 It is unquestioned that the gains for the drug companies from this increase in spending for prescriptions surpass the threefold increase in the value of free samples. The drug companies’ motivation for providing these free samples raises certain questions: are the free samples meant to create and/or increase the market for these drugs? Are the providers, when they dispense the samples provided to them, being used as mini-marketing machines for the drug compa- nies? Many providers believe that the answer to these ques- tions is “no.” They see the availability of drug samples as a way to give free medication to patients with limited incomes. If the answer to these questions, however, is “yes,” there should be a measurable impact on the providers’ prescribing habits and on patients’ drug purchases. Numerous studies, including the one published in this edition of the SMJ, show a much more complex interaction among free samples, providers and patients. This study found that physicians, if brand name samples were no longer avail- able, were three times more likely to prescribe generic drugs for their uninsured patients. With or without the availability of samples, Medicaid patients would typically be prescribed generics. 2 Cutrona et al 3 found that a higher percentage of patients with uninterrupted health insurance received free samples compared to those who were uninsured for part of the year. Lurk et al 1 showed that removal of drug samples served to increase patients’ out-of-pocket drug costs. These results make it appear that some providers are using the availability of drug samples to address an array of patient prescription needs, e.g., free samples can provide drugs for those patients unable to afford to fill their prescriptions. The number of such patients, according to a national study by the Center for Studying Health System Change, equals 14 million American adults. Providers are also not prevented from giving free samples to patients who have health insur- ance. According to the same study, these insured patients could be part of the 15% of those with chronic conditions who do not fill at least one prescription a month due to cost. 4 No easy answer exists to the question of whether or not these are good uses of drug samples. A positive aspect: pro- viders, as these studies show, are sensitive to their patients’ out-of-pocket drug costs and that these costs affect the utili- zation of prescribed drug therapies. A negative aspect: the provider’s behavior is influenced by a free drug sample pro- vided with the intent to increase drug company profits, i.e., drug samples are given for the newest, most profitable drugs, not necessarily for the ones needed most by the provider’s uninsured or underinsured patients. Additionally, these free drug samples might not be the most effective drug therapies for these patients. The provider is constrained by market forces in conflict with patient needs. The free drug sample dilemma is a symptom of the long- term influence of the pharmaceutical industry on medical practice and, in turn, on patient care. A pharmaceutical com- pany wants access to a market for its drugs and the provider’s office is the gateway to this market. The problem comes about due to a clash of differing values. Pharmaceutical com- panies are in the business of making profits; the more copy- right protected drugs they sell, the more profits increase. These companies reach out to providers in numerous ways, including providing free samples, in order to build or expand the market for those drugs. Providers are paid for care to their patients, but only for direct patient care and/or patient services. They are not re- imbursed for learning about new drugs on the market and on the ways these drugs could impact their patients. In order to obtain this information, they rely in part on those pharma- ceutical representatives whose mission is profit. Many in healthcare feel the solution is to constrain the pharmaceutical companies’ influence. A more comprehen- From the School of Policy Studies, Roosevelt University, Chicago, IL. Reprint requests to La Vonne Downey, PhD, School of Policy Studies, Roosevelt University, 430 Michigan Ave, Chicago, IL 60605. Email: ldowney@roosevelt.edu Accepted May 20, 2008. Copyright © 2008 by The Southern Medical Association 0038-4348/02000/10100-0879 La Vonne A. Downey, PhD Southern Medical Journal • Volume 101, Number 9, September 2008 879