There Is No Free Lunch – Really


How will the Sunshine Act affect your relationship with pharma?

Fam Pract Manag. 2013 Sep-Oct;20(5):5.

I used to eat them. The free drug lunches. I'd feel vaguely guilty about it, but I'd rationalize it away. I was actually doing this as a service to my office staff and patients. I did it for my staff because they loved the free lunches and for my patients because I figured it was the quid pro quo I had to give the drug reps to keep providing those useful drug samples to my patients who were financially strapped. And besides, the food was tasty.

A number of years ago my partners and I put a stop to it. The three of us talked – my partner who had always refused to talk to drug reps for moral reasons, my partner who married a drug rep, and I. We already felt morally superior. After all, we had limited our drug lunches to just one per week. We had a six-month waiting list of drug reps that wanted to woo us. We knew of offices that had daily free lunches provided by reps. At least we were restrained!

Why did we stop accepting free lunches? We felt that we should stop kidding ourselves. We all agreed that brand-name drug prices were out of control. We noted that an outsized portion of brand-name drug costs were due to marketing and felt that by accepting the largess of pharma, we were helping to drive up the cost of those drugs for our patients. We also tired of hearing about me-too drugs that add no new therapeutic value and tired of hearing marketing over unbiased research.

Our staff was disappointed. We compensated somewhat by providing them two free meals per month at staff meetings. The drug reps were disappointed too, but they kept bringing us samples. Our drug closet still overflows.

It's heretical I know, but I think the Sunshine Act (see the article on page 8) is a good thing. It forces us to confront our complicated and sometimes overly complicit relationship with the pharmaceutical industry. What are our limits? Where should we draw the line?

We rationalize things. The reps bring us information about new drugs. That's useful! But their information is marketing, biased views of data meant more to sell than to enlighten. It's expensive, but if you really want to know best practices regarding pharmaceuticals, you can buy the Medical Letter or The Prescriber's Letter.

The reps are delightful people. They regularly deliver free stuff with a smile. It's easy to forget that they are monitoring your prescribing behavior and work with one goal in mind – to get you to prescribe their very expensive medication. You know this, yet believe yourself incorruptible. You aren't going to prescribe a medication just because that nice drug rep brought you a free lunch. You can't be bought that cheaply – or for any price! You are outsmarting the drug reps and prescribing as you please.

But the research shows otherwise.1 Physicians tend to increase the prescribing of the drug in question after those drug lunches, drug dinners, and free samples. Pharma is not foolish. They monitor their returns on every sale.

And what about those free samples? They help your patients, right? Well, sometimes. You can start that drug regimen when your patient is without insurance and continue it when he or she gets insurance. But if a less expensive and therapeutically equivalent medication was also available, after a couple of years you may have cost your patient more in second- or third-tier copays by prescribing the brand-name drug they initially got for free. And you certainly will have helped raise the cost of health care.

So why do I keep supplying samples? Maybe it's because I enjoy the gratitude I get from my patients for providing them. Patients like free stuff too. But am I really doing them a favor? I'll have to think about that.

Kenneth G. Adler, MD, MMM, Medical Editor


1. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283(3):373–380.


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