Every "free" sample comes with a price.
Dermatologists who accept free tubes and bottles of brand-name drugs are likelier to prescribe expensive medications for acne than doctors who are prohibited from taking samples, a study reports Wednesday.
The difference isn't chump change. When patients see a dermatologist who gets and gives free samples, the average cost of medicines prescribed is $465 per office visit. That cost drops to about $200 when patients see a doctor who can't hand out freebies, a team at Stanford University found.
The findings, published in the current issue of JAMA Dermatology, adds to the growing evidence that free handouts may influence doctors' prescribing habits — and the type of medications people request.
"When a doctor gives a sample to a patient, it's a very strong endorsement of a drug," says Georgetown University's Dr. Adriane Fugh-Berman, who wasn't involved in the study.
"Patients think the physician has chosen this sample because it's the best drug for them," she says. "They don't realize that the doctor might have chosen it because a drug rep gave him samples and it was what he had around the office."
Once doctors have given a free trial pack, it's hard for them to prescribe a different generic drug, Fugh-Berman adds. "That would look really inconsistent."
So some physicians — in all specialties — end up prescribing an expensive branded drug when a cheaper alternate is available, she says.
That connection between freebies and costlier drugs is exactly what Stanford University's Alfred Lane and his colleagues found among dermatologists.
The team analyzed the prescribing habits of 3,500 dermatologists in private practices across the country. They then compared that data with prescribing patterns at Stanford's clinics, where doctors aren't allowed to take samples from drug companies.
The difference was stark. Doctors in private practices, where samples are common, recommended brand-name medications nearly 80 percent of the time. At the academic clinic, only 17 percent of drugs were name brands.
"Physicians don't realize the effect free samples have," Lane tells Shots.
Dermatology may be especially effected, he says, because handing out samples is common in the specialty.
About 18 percent of all drugs prescribed in dermatology in 2010 started with free samples, Lane and his team found. But only 4 percent of medications in all other specialties started with freebies.
Not long ago, Lane was actually a fan of such samples. Then in 2004 Stanford University and many academic clinics started prohibiting doctors from accepting them. "We fought the change," he says. "We thought it would have a negative impact on our practice."
But the result was the opposite. "Now I'm absolutely delighted that we're not using samples," Lane says."When I look at the cost difference [to patients], I'm glad I'm not writing more expensive medications."
The quality of care at his clinic has changed in a good way, he thinks. But he worries that some people think better of doctors who offer samples.
"[Doctors] think patients want them," Lane says. "When we stopped giving them, patients started complaining right a way."
One recent study found that more than a third of doctors surveyed say they sometimes prescribe a brand-name drug because a patient requests it, even when there's a generic available.
Of course, all samples aren't bad. They can be a big help for patients who lack insurance or are on tight budgets. And some of the name-brand drugs come in a time-released formulation, which may be more convenient for some people.
But often, it's up to the patient to ensure their drug bill isn't getting an extra, unwanted bump.
"Patients need to be aware that by receiving samples or branded drugs, they may be paying more for something that isn't documented to be any better than a generic," Lane says.
Yael Mizrachi, a 33-year-old Israeli woman, has been to many matchmakers.
"Too many," she says, rolling her wide dark eyes and tossing her shoulder-length hair.
Matchmakers are the traditional way to find a mate in the ultra-Orthodox Jewish community to which Mizrachi belongs. But she is not entirely traditional.
"I identify myself as a modern ultra-Orthodox," Mizrachi says.
Mizrachi is part of a growing number of ultra-Orthodox Jews in Israel who are seeking job skills, getting higher education or joining the military. And those changes are shaking up the community's established customs for finding a spouse.
On a practical level, to Mizrachi, being "modern ultra-Orthodox" means she wears long sleeves and long skirts, but also drives — something unmarried women in her community normally do not do.
She won't attend mixed parties, but bucked tradition by getting undergraduate and master's degrees in social work. Most ultra-Orthodox women in Israel only finish religious high school.
Mizrachi's parents, who became ultra-Orthodox as adults, supported her college education, she says, but others did not.
"My 12th-grade teacher tried hard to convince me to stick with the classic path," she says. "But that didn't happen."
Looking For A Spouse Who Will 'Earn A Living'
Much of the changes among ultra-Orthodox come from political and social pressure from other parts of Israeli society. Traditionally, ultra-Orthodox men have been able to avoid serving in the military or getting a job by engaging in intense religious study. Their families then often rely on government support or wives with limited education for income.
Still, skilled Torah students have long been seen as the best husband an ultra-Orthodox woman can catch. Not for Mizrachi.
"The matchmakers were always trying to set me up with somebody who studies the Bible all day. I don't want that," she says. "I want somebody who can also earn a living."
You might think college would be a good place to meet that somebody. Except college programs designed especially for ultra-Orthodox students, including the programs Mizrachi chose, are strictly sex-segregated.
Enter a new dating service, especially designed to serve ultra-Orthodox just like her.
It's called "Shidducation" — rooted in the Yiddish (and Hebrew) word for matchmaker, but ending with a modern lilt. The founder, 26-year-old Eli Postavsky, studies law at a college where men and women take classes on different days of the week.
"We talked about this need for a long time," he says. "The men and women here have no way to make connections, although they'd probably find a good match."
So Postavsky pitched it to the school director. Rabbi Yehezkel Fogel had already seen the need.
"Being an academic school, we did not have anything to do with matchmaking of course," Fogel says. "But one day I got a call from someone who said, 'You have women students. I have a son. So if you have something to offer ...' "
Online Survey Meets Old-School Matchmaker
The dating service starts digitally, but it's nothing like online dating in the rest of the world. Students at the dozen or so ultra-Orthodox campuses in Israel are eligible.
They periodically get an email with a link to an online form. Questions include the usual name and age, plus number of siblings and if those siblings are married, parents' occupations and what style of religious dress the person wears, including what head covering would be expected after marriage. Photos, please.
Then it's back to tradition. A matchmaker reads all the forms, calls up each student and sets to work.
In this start-up, the matchmaker happens to be the founder's mom. Tubi Postavsky doesn't follow the custom of meeting participants — or parents — in person. But she digs into their soul on the phone.
"I have had conversations of over an hour. I'm trying to open them up and learn what they need," she says.
The key difference between traditional ultra-Orthodox matchmaking and this service is that here people are valued for having experiences outside the often closed ultra-Orthodox communities. Founder Eli Postavsky says he saw matchmakers who didn't really know how to treat him without the familiar pedigree of religious study.
"College and working was not something accepted," he says.
Rabbi Fogel interrupts him.
"What he means is, he wasn't offered girls that would really fit for him," he says. "Because he was not a regular boy, he was offered second-rate girls."
Fogel says helping students find good mates may help convince skeptical ultra-Orthodox that education can respect tradition.
"If they have enough faith that we have good students here, who could be considered good potential matches for their children, that is very important," he says. "We are not against the community, we are part of the community."
'Something That Came From Heaven'
One marriage, another engagement and scores of dates have happened so far through Shidducation's services. About 400 students have signed up since it began late last December. There's no up-front fee, but if you find a spouse, a traditional matchmaking fee of perhaps a thousand dollars would be expected.
Natanel Schlesinger, 24, married a woman four months after they met through the service. They go to different schools and lived two hours apart, so may never have met otherwise.
"I think this is something that came from heaven," he smiles. "It's not something I'd usually do, but there was this email about it, and I thought I'd have be a better chance to meet someone suitable here than any other place."
Yael Mizrachi, the 33-year-old woman with two degrees, has met several men through the matchmaking service; no sparks yet. She is certain she wants a husband, plenty of kids and a career. But she is well past traditional marrying age in her community.
"Maybe that makes me less desirable in the classic ultra-Orthodox view," she says. "But I believe that whatever God has decided for me is what I'll get.
Billionaire Michael Bloomberg's plan to invest $50 million in what he describes as a mom-driven grass-roots effort to support pro-gun-safety candidates grabbed headlines Wednesday, and energized gun control activists.
The commitment, the former New York City mayor says, aims to beat back the profound political influence of the National Rifle Association in 15 targeted states — to "make them afraid of us," he told NBC's Today show.
"This is what the American public wants," Bloomberg said, referring to his group's intended focus on gun-purchase background checks.
Polls show that Bloomberg, 72, is correct — Americans overwhelmingly support background checks for all gun purchases.
But Bloomberg and his ally in this new initiative, Moms Demand Action for Gun Sense in America, have so far fallen short of overpowering the NRA, and Bloomberg's critics have argued his efforts aren't worth the money.
Just a year ago, in the aftermath of the mass shooting at Newtown's Sandy Hook Elementary School that left 20 children and six adults dead, the Democratic-controlled U.S. Senate failed to pass bipartisan gun safety legislation that included expanded background checks. Bloomberg spent millions supporting the legislation, including paying for tough television advertisements.
Since Newtown, a dozen state legislatures have passed stricter gun safety laws, but twice as many have loosened restrictions. Two Colorado legislators who supported that state's new gun control legislation were removed from office in a recall election viewed as a proxy war between the NRA and Bloomberg. (A third legislator facing recall resigned.)
And in the dozen-plus years that have passed since hundreds of thousands of gun safety activists participated in the Million Mom March on Washington in 2000, that momcentric effort has largely fizzled.
What suggests that Bloomberg, whose Mayors Against Illegal Guns has joined with Moms Demand Action to form the new group, will see a better result?
"Politically, this looks very similar to the past, when there is an impulse for change that falters," says Robert Spitzer, who has written extensively on gun politics, including the 2012 Encyclopedia of Gun Policy and Gun Rights.
The difference now, Spitzer says, is that "there are substantial, high-visibility, well-funded groups that didn't exist previously." Those groups include Bloomberg's and the political action committee created by former Rep. Gabrielle Giffords, D-Ariz., and her husband. Giffords was seriously injured in early 2011 in a mass shooting that killed six people.
Her PAC, Americans for Responsible Solutions, reported raising $2.5 million the first three months of this year, has $7.7 million on hand, and has raised $14.5 million since its creation last year.
Bloomberg insisted Wednesday that he's not undertaking a "battle of dollars" with the NRA, which in the 2012 campaign cycle spent about $20 million. But the claim seemed more than a bit disingenuous.
"That's real money," Spitzer says of Bloomberg's financial commitment and the Giffords' successful PAC.
Jennifer Coffey, national spokeswoman for the pro-gun-rights Second Amendment Sisters organization, says she sees Bloomberg's investment as a waste of money.
"I think he has a very unhealthy fascination with firearms, and how this inanimate object is a threat to everyone in the world," she says. "He lives in a state where people are in food lines with not enough to eat, who are jobless — why doesn't he focus on them? Or on criminals running through his streets, destroying homes, families, businesses?"
Coffey says her major concern with gun-purchase background checks is proposals that would put mental health records into a national database. She predicts that first responders who have sought counseling because of job stresses would be targeted, as would those who have been treated for depression.
"Mental illness is not a crime," Coffey says.
At the California-based Law Center to Prevent Gun Violence, however, Executive Director Robyn Thomas hailed the mayor's investment — and his potential future contributions — as something that will give state legislators courage to pursue gun safety efforts.
"One of the challenges in getting smart laws even considered has been the NRA's money and influence in the political arena," she said. "This investment and this commitment neutralizes some of that.
"Unlike the Million Mom March, having really organized, effective grass-roots efforts in conjunction with the money — that combination has the potential to be incredibly effective."
The grass-roots appeal to women remains a powerful tool, though, political scientist Spitzer says. The focus on women — and mothers in particular — makes demographic sense, he says. Gun control is one of those gender gap issues: Not only do a higher percentage of women support expanding gun safety laws but women also are more likely to believe that gun crime is worse than statistics show.
"In many ways, this is about emotion," Shannon Watts, founder of Moms Demand Action, said on Today. "We're going to go out and educate moms and women and Americans."
The message, she said: "Gun violence prevention, gun violence prevention, gun violence prevention."
With that mantra, plus money, can Bloomberg be a gun law game changer?
"The jury's out," Spitzer says.