updated 3/2/2008 3:19:50 PM ET 2008-03-02T20:19:50

Leigh Bradshaw could be mistaken for a drug-company sales rep as she pulls out charts and leaflets to tell Dr. Ernest Josef about the costs and benefits of various cholesterol-lowering drugs.

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But notably absent during her visit to his family practice is the swag typical of a pharmaceutical marketing arsenal — the free pill samples, the logo-emblazoned pads and pens, the free lunch for doctor and staff.

That's because Bradshaw, a registered nurse, isn't trying to pitch a product for a drug manufacturer. She works for Pennsylvania taxpayers.

In a David vs. Goliath battle, Pennsylvania is among a handful of states trying — with modest results at best — to counter the pharmaceutical industry's multibillion-dollar marketing and cut costs for prescription-aid programs for senior citizens, who are bombarded with "ask your doctor" advertising.

"The more times they see it on TV, they feel that implies it is a better drug, which might not necessarily be the case," Josef said.

Josef, who is 45 and has been practicing medicine for 16 years, said he had already begun prescribing more generic cholesterol drugs in response to patient cost concerns, but that Bradshaw's presentation gave him more information to back up his recommendations.

State officials here say they are trying to ensure that patients get the most effective treatment. But driving the outreach is an effort to hold down expenses — in some cases by steering doctors to generics, in others by showing how lifestyle changes can sometimes be preferable to medication.

Pennsylvania is not the first state to try what is known as an "unsales" strategy, but its program, begun in late 2005, is considered the most extensive. The state spends $1 million a year on its "unsales" force — 11 consultants, including some former pharmaceutical salespeople, assigned to the 28 counties with the highest concentrations of seniors enrolled in discount drug programs.

West Virginia ran a similar program in two cities from 2003 to 2005. Vermont has a program focusing on rural medical practices and South Carolina began one last fall, focusing on mental-health prescriptions.

Reps point out cost savings
In visits with doctors, Pennsylvania's consultants share findings such as:

  • The cost of a 20-milligram daily dose of various cholesterol drugs can range from 13 cents for generics to $4.53 for one of the more expensive brand names.
  • A 30-day supply of some popular brand-name heartburn drugs can cost anywhere from $111 to $124, compared with just $1 to $2 for an equivalent supply of over-the-counter antacids.

With generic drugs already accounting for two-thirds of all prescriptions, the pharmaceutical industry's main trade group questions the value of the "unsales" programs.

The group said care could suffer if steering patients to generics is the primary objective — which the programs deny. It also maintained that state consultants are not held to the same strict standards as drug company reps in their presentations.

"A less expensive treatment may be more costly in the long run if it is not the best therapy for the patient," Ken Johnson, spokesman for The Pharmaceutical Research and Manufacturers of America, said in a written statement to The Associated Press.

Bradshaw said generics are not pushed "unless the generic is the better choice," noting there are cases where brand-name products are deemed the most effective.

An uphill battle, at best
States are clearly outgunned.

The industry spends more than $7 billion a year on direct marketing to doctors and employs about 90,000 salespeople — one for every five doctors, according to the Prescription Project, a campaign funded by The Pew Charitable Trusts to challenge pharmaceutical marketing practices.

Still, Pennsylvania reports some slight cost-control success in its assistance programs, which last year enrolled 360,000 people 65 and older and cost the state $325 million, up more than 30 percent in the last decade.

For patients of nearly 300 participating doctors, average monthly spending on some pain relievers dropped from $400 to $340 per doctor within six months after a state consultant visit, a preliminary analysis found.

Another analysis found that the program saved Pennsylvania about $572,000 a year alone on heartburn drugs.

In both instances, the state took into consideration other factors influencing doctors' prescriptions — such as publicity about dangerous side effects and a strong push for generic drugs by insurance companies, said Thomas Snedden, director of Pennsylvania's prescription drug discount programs. The evaluations included control groups of doctors who either did not participate in the program or practiced in counties where it is not offered.

To develop Pennsylvania's program, state officials consulted with Dr. Jerry Avorn, a Harvard Medical School professor who pioneered the practice in the late 1970s.

He determined that the best way to combat industry marketing was to try to beat them at their own game — by using the industry's basic tools to tell medical professionals about a broader base of medical research in a more engaging style than the pedantic lectures he endured as a medical-school student.

But states have found it hard to staff their programs, let alone measure the results.

West Virginia used pharmacists to educate doctors but because it could not pay enough, the state had difficulty recruiting enough consultants to expand beyond Morgantown and Charleston, said S. Suresh Madhavan, a professor at West Virginia University's pharmacy school, which collaborated on the initiative.

Vermont relies on a two-person staff and a $50,000 annual budget which leaves little room for extensive evaluation, said Amanda Pinckney, a co-director of the program. The state is now considering partnering with Maine and New Hampshire.

In her recent visit with Josef, Bradshaw presented data compiled by Harvard researchers, including a cholesterol chart showing when lifestyle changes should be pursued as opposed to medication, and a price comparison of various brand-name and generic drugs.

Doc appreciates the information
Josef said he was initially skeptical about the value of an "unsales" pitch but now appreciates getting a broader view of research into various classes of drugs.

"It makes me feel more comfortable that I have some data to back up that the generic drugs are just as efficacious," he said. "It saves me time from having to do a lot of the research."

He said patients do not put up much resistance to switching once he can assure them a generic is just as effective.

The state uses data it keeps on the number of prescriptions doctors write for certain drugs covered by the prescription-discount programs to identify potential participants, and passes it along to the consultants so they can set up visits, Snedden said.

Participation in the program is voluntary, and doctors can earn continuing medical education credits from Harvard for doing so.

"I think the physicians are very receptive to these calls, in large measure because it is the state calling," Snedden said. "Physicians have a good deal of respect for the (prescription drug-assistance) program."

To no one's surprise, Bradshaw said she often runs into drug industry reps when she's out in the field.

She said they are relieved when she tells them she works for the state, and not a competitor.

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