Marketing drugs: debating the real cost: concern about close ties between doctors and pharmaceutical firms are prompting new financial disclosure laws and education efforts.

• Author: Brand, Rachel

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Like any sales representative, Leigh Bradshaw cold calls her prospect list, befriends office managers and chats up harried physicians.

Unlike her drug industry competitors, she visits doctors simply to educate them.

"My doctors value what I bring," says Bradshaw. "They know I am trying to share information, not manipulate them in any way."

As one of Pennsylvania's 10 academic detailers, the former nurse helps doctors pre scribe the best, most appropriate treatments, including diet and exercise. Her 30-minute sales pitch relies on Harvard University research about drug efficacy, safety and costs.

It's no secret that pharmaceutical companies flood doctors' offices with peppy, well-groomed drug detailers. They're salespeople who arrive bearing bagels, cookies, clocks and calendars. Medical product companies also pay lavish honorariums to physicians who lecture in favor of brand-name drugs, hire doctors as marketing consultants and pay physicians to attach their names to industry-written articles. Although the pharmaceutical industry does not release figures, published estimates put the cost of physician marketing and distributing free drug samples at about $25 billion. Of that, an estimated $7 billon is spent on one-on-one marketing to doctors.

Nobody disputes that innovative biological products and drugs save lives. Pills and injections save money, too, by keeping patients out of the hospital. But a growing number of legislators and patient advocates say cozy doctor-industry ties push up healthcare costs and threaten patient safety.

"It's hard to defend it with a straight face," says Senator Mark Montigny of Massachusetts. "How do you defend having a physician on your payroll ghostwriting articles and then prescribing your product when the doctor-patient relationship is supposed to be sacred?"

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LIMITING GIFTS

In response, some states are passing laws that require drug companies to report physician payments. Others limit gifts to $25 or $50 a year, and Massachusetts is weighing a complete gift ban. Pennsylvania leads the nation in so-called counter-detailing programs, in which state employees use the drug industry's marketing tactics to promote evidence-based medicine.

Much is at stake. Prescription drugs have been one of the fastest-growing costs in the Medicaid program, climbing each year at double-digit percentages. Total U.S. prescription drug spending has mushroomed fivefold from $40.3 billion in 1990 to $200.7 billion in 2005, according to the Kaiser Family Foundation.

Plus, aggressive marketing can promote risky treatments. After the painkilling drug Vioxx was yanked from the market because of its cardiac side-effects, a literature review found the painkiller worked no better than Tylenol.

The pharmaceutical industry and American Medical Association scoff at the idea that a bauble or snack can influence behavior. They maintain laws limiting physician-industry contact are unnecessary since both groups promote ethics guidelines. The AMA permits physicians to accept gifts that cost less than $100 and help patient care (stethoscopes, not golf bags). Doctors can't get paid to travel to or attend conferences. And both the Office of Inspector General and FDA already regulate pharmaceutical marketing.

"There is no need for the state to get involved in this," says Marjorie Powell, general counsel for the Pharmaceutical Research and Manufacturers Association.

SAFETY CONCERNS

Since 2002, five states and the District of Columbia began forcing drug companies to report how much they pay doctors.

Lawmakers first hoped to uncover drug marketing and advertising costs, according to Maine Representative Sharon Treat, executive director of the National Legislative Association on Prescription Drug Prices.

"In 2002, there was a lot of attention paid to the cost of prescription drugs," says Treat. "The drug companies kept...