From: "Saved by Internet Explorer 11" Subject: Experts Tell Congress How To Cut Drug Prices. We Give You Some Odds. | Kaiser Health News Date: Tue, 12 Dec 2017 13:41:53 -0500 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01D3734E.F85C2CB0" X-MimeOLE: Produced By Microsoft MimeOLE This is a multi-part message in MIME format. ------=_NextPart_000_0000_01D3734E.F85C2CB0 Content-Type: text/html; charset="utf-8" Content-Transfer-Encoding: quoted-printable Content-Location: https://khn.org/news/experts-tell-congress-how-to-cut-drug-prices/ =EF=BB=BF =20 =20 =20 Experts Tell Congress How To Cut Drug Prices. We Give You Some = Odds. |=20 Kaiser Health News =20 =20 =20 =20 = =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =20 =

By Sarah=20 Jane Tribble December=20 12, 2017

The nation=E2=80=99s most influential science advisory group was set = to tell Congress=20 on Tuesday that the U.S. pharmaceutical market is not sustainable and = needs to=20 change.

=E2=80=9CDrugs that are not affordable are of little value and drugs = that do not=20 exist are of no value,=E2=80=9D said Norman Augustine, chair of the = National Academies=20 of Sciences, Engineering and Medicine=E2=80=99s committee on drug = pricing and former CEO=20 of Lockheed Martin Corp.

The report, =E2=80=9CMaking Medicines Affordable: A National = Imperative,=E2=80=9D identifies=20 eight steps to cut drug prices. It also provides a list of specific=20 =E2=80=9Cimplementation actions=E2=80=9D for various federal agencies, = including Congress, the=20 Federal Trade Commission and the U.S. Departments of Justice and Health = and=20 Human Services.

Tuesday=E2=80=99s hearing, which is the third in a series by the = Senate Health,=20 Education, Labor and Pensions Committee, comes as Americans across the = political=20 spectrum say lowering the price of = prescription drugs=20 is a top priority. Yet, while individual states have passed laws for more = transparency=20 and price controls and President Donald Trump has publicly called for = lower drug=20 prices, Congress has stalled.

So, will the committee=E2=80=99s recommendations spur action? Kaiser = Health News=20 takes the political temperature, talks to experts and rates their = chances:

Recommendation No. = 1:=20 Allow the federal government to = negotiate drug=20 prices

3D""

Current law prohibits the U.S. Health and Human Services secretary = from=20 directly negotiating drug prices, and the committee says that=E2=80=99s = ridiculous.

The committee recommends Medicare and other agencies negotiate which = drugs=20 are placed on a list of covered drugs and, when necessary, exclude some = drugs.=20 This is not a new idea.

Some states are already restricting high-priced drugs in Medicaid, = the=20 state-federal insurance program for low-income Americans. But federal = efforts to=20 change Medicare are more complicated.

Just two months ago, top House Democrats introduced another Medicare negotiation = bill. But don=E2=80=99t=20 hold your breath, Trump hasn=E2=80=99t responded to multiple letters = sent from Rep.=20 Elijah Cummings (D-Md.) =E2=80=94 including one after the most recent = bill was=20 introduced in late October. That bill hasn=E2=80=99t moved past the health = subcommittee.

Recommendation No. = 2:=20 Speed approvals of safe and effective = generics=20 and biosimilars

3D""

This recommendation has a strong ally at the Food and Drug=20 Administration.

Commissioner Scott Gottlieb announced a =E2=80=9Cdrug competition action = plan=E2=80=9D in June and=20 followed it up two months ago with a new set of policies aimed at = speeding the=20 drug approval process for complex generics. More changes are expected, = too, as=20 Gottlieb wrote in his blog post: =E2=80=9CIf consumers are priced out of = the drugs they=20 need, that=E2=80=99s a public health concern that FDA should = address.=E2=80=9D

But the pharmaceutical world knows which games to play to keep = competition at=20 bay. The committee specifically recommends the U.S. Department of = Justice and=20 the Federal Trade Commission should watch for anti-competitive tactics, = such as=20 pay-for-delay and extending exclusivity protections. The U.S. Supreme = Court=20 weighed in on pay-for-delay, saying settlements between brand-name = drugmakers and=20 generic rivals warranted antitrust review. The total number of these = deals=20 has fallen in recent years.

To further encourage generic approvals, Congress could include = several=20 proposed bills, such as the so-called CREATES Act, in a final year-end = package,=20 said Chip Davis, president of the generics and biosimilars lobby = Association for=20 Accessible Medicines.

=E2=80=9CPeople are starting to pay more attention=E2=80=9D to = anti-competitive patent=20 tactics, Davis said.

Recommendation No. = 3:=20 Transparency

3D""

The committee takes direct aim at drug prices by saying that Congress = should=20 make manufacturers and insurers disclose drug prices, as well as the = rebates and=20 discounts they negotiate. It also asks that HHS curate and publicly = report the=20 information.

States have taken the lead on price = transparency, with=20 Vermont the first to pass a law, which requires an annual report on up = to 15=20 drugs that cost the state a lot of money and have seen price spikes. In=20 Congress, Sen. Ron Wyden (D-Ore.), introduced a bill in June that would impose=20 price-reporting requirements on some drugs. It now sits in the Senate = Finance=20 Committee. The pharmaceutical industry has fended off most price disclosure = efforts in=20 the past.

Notably, the committee also recommends that nonprofits in the = pharmaceutical=20 sector =E2=80=94 such as patient groups =E2=80=94 disclose all sources = of income in their tax=20 filings. That=E2=80=99s a move that would reveal exactly how much the = pharmaceutical=20 companies are supporting advocacy groups.

Recommendation No.=20 4: Discourage the = pharmaceuticual=20 industry=E2=80=99s direct-to-consumer = advertising

3D""

The U.S. is only one of two developed countries in the world to allow = direct-to-consumer pharmaceutical advertising (the other is New Zealand, = and doctors there have called for a = ban). And=20 U.S. taxpayers support the tax breaks with a deduction that politicians have tried to = eliminate in the=20 past.

Now, the committee recommends Congress eliminate the tax deduction=20 pharmaceutical companies are allowed to take on direct-to-consumer=20 advertising.

This is an idea that should have wide support. Polls show that most = Americans=20 favor banning the ads and federal = lawmakers=20 have tried to change the rules on so-called DTC for years. The American = Medical=20 Association (AMA) called for a ban on = pharmaceutical=20 advertising directly to patients in 2015, saying there were concerns = that the=20 ads were driving up demand for expensive drugs. The FDA provides = guidance for=20 the advertising and, in August, FDA Commissioner Gottlieb said he may reduce the number of risks = manufacturers must=20 reveal when advertising a medicine.

In a sign of just how entrenched the tax break is in D.C. politics, = Sen. Dick=20 Durbin (D- Ill.) introduced a bill last month that = doesn=E2=80=99t=20 eliminate the break but takes a step to rein in the advertising. = Durbin=E2=80=99s bill=20 would require manufacturers to provide the wholesale price of a drug in = their=20 advertisements.

Recommendation No. = 5:=20 Limit what Medicare enrollees pay for=20 drugs

3D""

The committee ticks off a to-do list for Congress when it comes to = what older=20 Americans and those with disabilities are paying for drugs.

Their recommendations include asking Congress to establish limits on = total=20 annual out-of-pocket costs for Medicare Part D enrollees and telling = Congress to=20 make sure the Centers for Medicare & Medicaid Services efforts to = guarantee=20 enrollee cost sharing is based on the real price of the drug as well as = how well=20 the drug works.

Turns out, there is already some limited movement on this one.

Medicare allows negotiations between the corporate insurers and = pharmacy=20 benefit managers who help administer the Part D program. CMS announced = last=20 month that it is exploring how to pass on the=20 behind-the-scenes manufacturer rebates to patients, though it warns = premiums may=20 rise if they make this move.

Recommendation No. = 6:=20 Increasing oversight of a very specific = federal=20 drug discount program

3D""

The committee is stepping into a hot-button political issue by = recommending=20 increased transparency and oversight of a program that Congress created = in=20 1992.

The program, known as 340B, requires pharmaceutical companies to sell = drugs=20 at steep discounts to hospitals and clinics that serve high volumes of=20 low-income patients. Congress held two hearings this year, questioning = who is=20 benefiting from the discounts, and CMS recently announced it was = slashing Medicare=20 reimbursement to some hospitals enrolled in the program.

Hospitals are fighting back, filing a lawsuit over the reimbursement = cut. The=20 committee, echoing concerns from House Republicans, recommends making = sure the=20 program helps =E2=80=9Caid vulnerable populations.=E2=80=9D

Recommendation No. = 7:=20 Revise the Orphan Drug Act =

3D""

The committee wants to make sure the 1983 Orphan Drug Act helps = patients with=20 rare diseases.

The law, intended to spur development of medicines for rare diseases, = provides financial incentives for drugmakers such as seven years of = market=20 exclusivity for drugs that treat a specific condition that affects fewer = than=20 200,000 people.

The program has been under fire this year after Kaiser Health News, = whose=20 investigation is cited by the committee, reported that approved drugs = often=20 gamed this system and won blockbuster sales for more common diseases. = The=20 Government Accountability Office has begun an investigation into the = program=20 after receiving a request from top Republican senators and FDA=E2=80=99s = announced =E2=80=9Cmodernization=E2=80=9D plan for = the agency this=20 summer.

The committee=E2=80=99s requests include limiting the number of = exclusivity periods a=20 drug can receive and making sure drugs that win the financial incentives = really=20 do treat rare disease. Finally, the committee says HHS should = =E2=80=9Cobtain favorable=20 concessions on launch prices, annual price increases,=E2=80=9D and = more.

Recommendation No. = 8:=20 Make sure doctors prescribe drugs for = the right=20 reasons

3D""

Medical practices, hospitals and doctors should = =E2=80=9Csubstantially=E2=80=9D tighten=20 restrictions on office visits by pharma employees, and the acceptance of = free=20 samples, the committee recommends.

This isn=E2=80=99t the first time the national group has recommended = controlling drug=20 samples and visits. In 2009, the then Institute of Medicine said doctors and medical schools = should stop=20 taking free drug samples. It may have worked =E2=80=94 to some extent. A = study this year=20 found that academic medical centers that limited visits saw changes in prescribing = patterns.

Now, the National Academies committee says doctors in private = practice should=20 also stop taking free samples and welcoming pharmaceutical visits. The = AMA,=20 which is the nation=E2=80=99s largest membership group of doctors, = supports physicians=20 using samples on a voluntary basis, particularly for uninsured = patients.

KHN=E2=80=99s coverage of these topics is = supported by Laura and John Arnold = Foundation=20 and John A. Hartford=20 Foundation

Experts Tell Congress How To Cut Drug Prices. We Give You Some = Odds.

By Sarah=20 Jane Tribble December=20 12,=20 2017

<h1>Experts Tell Congress How =
To Cut Drug Prices. We Give You Some Odds.</h1>=0A=
	Sarah Jane Tribble, Kaiser Health =
News=0A=
=0A=
The nation=E2=80=99s most influential science advisory group =
was set to tell Congress on Tuesday that the U.S. pharmaceutical market =
is not sustainable and needs to change.=0A=
=E2=80=9CDrugs that are not affordable are of little value and =
drugs that do not exist are of no value,=E2=80=9D said Norman Augustine, =
chair of the National Academies of Sciences, Engineering and =
Medicine=E2=80=99s committee on drug pricing and former CEO of Lockheed =
Martin Corp.=0A=
The report, =E2=80=9CMaking Medicines Affordable: A National =
Imperative,=E2=80=9D identifies eight steps to cut drug prices. It also =
provides a list of specific =E2=80=9Cimplementation actions=E2=80=9D for =
various federal agencies, including Congress, the Federal Trade =
Commission and the U.S. Departments of Justice and Health and Human =
Services.=0A=
Tuesday=E2=80=99s hearing, which is the third in a series by =
the Senate Health, Education, Labor and Pensions Committee, comes as =
Americans across the political spectrum <a =
href=3D"https://www.kff.org/report-section/kaiser-health-tracking-poll-la=
te-april-2017-the-future-of-the-aca-and-health-care-the-budget-rx-drugs/"=
>say lowering the price of prescription drugs</a> is a top =
priority. Yet, while individual <a =
href=3D"https://www.washingtonpost.com/national/health-science/absent-fed=
eral-action-states-take-the-lead-on-curbing-drug-costs/2017/09/29/1d34682=
8-a4d1-11e7-ade1-76d061d56efa_story.html?utm_term=3D.4b78303ec839">sta=
tes have passed laws</a> for more transparency and price controls =
and President Donald Trump has publicly called for lower drug prices, =
Congress has stalled.=0A=
So, will the committee=E2=80=99s recommendations spur action? =
Kaiser Health News takes the political temperature, talks to experts and =
rates their chances:=0A=
Recommendation No. 1: Allow the federal government to negotiate =
drug prices=0A=
=0A=
Current law prohibits the U.S. Health and Human Services =
secretary from directly negotiating drug prices, and the committee says =
that=E2=80=99s ridiculous.=0A=
The committee recommends Medicare and other agencies negotiate =
which drugs are placed on a list of covered drugs and, when necessary, =
exclude some drugs. This is not a new idea.=0A=
Some states are already restricting high-priced drugs in =
Medicaid, the state-federal insurance program for low-income Americans. =
But federal efforts to change Medicare are more complicated.=0A=
Just two months ago, top House Democrats introduced <a =
href=3D"https://democrats-oversight.house.gov/news/press-releases/top-dem=
s-introduce-bill-to-allow-hhs-to-negotiate-lower-drug-prices-for-medicare=
">another Medicare negotiation bill</a>. But don=E2=80=99t hold =
your breath, Trump hasn=E2=80=99t responded to multiple letters sent =
from Rep. Elijah Cummings (D-Md.) =E2=80=94 including one after the most =
recent bill was introduced in late October. That bill hasn=E2=80=99t =
moved past <a =
href=3D"https://www.congress.gov/bill/115th-congress/house-bill/4138/all-=
info">the health subcommittee</a>.=0A=
=0A=
Recommendation No. 2: Speed approvals of safe and effective =
generics and biosimilars=0A=
=0A=
This recommendation has a strong ally at the Food and Drug =
Administration.=0A=
Commissioner Scott Gottlieb announced a =E2=80=9C<a =
href=3D"https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm564=
725.htm">drug competition action plan</a>=E2=80=9D in June and =
followed it up two months ago with <a =
href=3D"https://blogs.fda.gov/fdavoice/index.php/2017/10/reducing-the-hur=
dles-for-complex-generic-drug-development/">a new set of =
policies</a> aimed at speeding the drug approval process for =
complex generics. More changes are expected, too, as Gottlieb wrote in =
his blog post: =E2=80=9CIf consumers are priced out of the drugs they =
need, that=E2=80=99s a public health concern that FDA should =
address.=E2=80=9D=0A=
But the pharmaceutical world knows which games to play to keep =
competition at bay. The committee specifically recommends the U.S. =
Department of Justice and the Federal Trade Commission should watch for =
anti-competitive tactics, such as pay-for-delay and extending =
exclusivity protections. The U.S. Supreme Court weighed in on =
pay-for-delay, saying <a =
href=3D"https://www.statnews.com/pharmalot/2016/11/07/supreme-court-pay-d=
elay-glaxo-teva/">settlements between brand-name drugmakers and =
generic rivals</a> warranted antitrust review. The total number of =
these deals <a =
href=3D"http://www.raps.org/Regulatory-Focus/News/2017/11/01/28806/Pay-fo=
r-Delay-Deals-FTC-Notes-Continued-Decline-Since-SCOTUS-Ruling/">has =
fallen in recent years</a>.=0A=
To further encourage generic approvals, Congress could include =
several proposed bills, such as the so-called <a =
href=3D"https://www.leahy.senate.gov/imo/media/doc/CREATES%20Act%20-%20Pr=
ess%20Background%20Materials%20updated%204.24.17.pdf">CREATES =
Act</a>, in a final year-end package, said Chip Davis, president =
of the generics and biosimilars lobby Association for Accessible =
Medicines.=0A=
=E2=80=9CPeople are starting to pay more attention=E2=80=9D to =
anti-competitive patent tactics, Davis said.=0A=
Recommendation No. 3: Transparency=0A=
=0A=
The committee takes direct aim at drug prices by saying that =
Congress should make manufacturers and insurers disclose drug prices, as =
well as the rebates and discounts they negotiate. It also asks that HHS =
curate and publicly report the information.=0A=
States have <a =
href=3D"https://public.tableau.com/views/HowStatesAreTacklingSkyrocketing=
DrugPrices_0/SkyrocketingDrugPrices?:embed=3Dy&:toolbar=3Dno&:dis=
play_count=3Dno&:showVizHome=3Dno#1">taken the lead on price =
transparency,</a> with Vermont the first to pass a law, which =
requires an annual report on up to 15 drugs that cost the state a lot of =
money and have seen price spikes. In Congress, Sen. Ron Wyden (D-Ore.), =
introduced <a =
href=3D"https://www.congress.gov/bill/115th-congress/senate-bill/1348?q=3D=
%7B%22search%22%3A%5B%22S+1348%22%5D%7D&r=3D1">a bill</a> =
in June that would impose price-reporting requirements on some drugs. It =
now sits in the Senate Finance Committee. The pharmaceutical industry =
has <a =
href=3D"http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline=
/2016/03/07/high-drug-prices-prompt-demands-for-transparency">fended =
off</a> most price disclosure efforts in the past.=0A=
Notably, the committee also recommends that nonprofits in the =
pharmaceutical sector =E2=80=94 such as patient groups =E2=80=94 =
disclose all sources of income in their tax filings. That=E2=80=99s a =
move that would reveal exactly how much the pharmaceutical companies are =
supporting advocacy groups.=0A=
Recommendation No. 4:  Discourage the pharmaceuticual =
industry=E2=80=99s direct-to-consumer advertising =0A=
=0A=
The U.S. is only one of two developed countries in the world to =
allow direct-to-consumer pharmaceutical advertising (the other is New =
Zealand, and <a =
href=3D"https://www.fiercepharma.com/marketing/doctors-new-zealand-only-o=
ther-country-allows-dtc-advertising-hate-it-too">doctors there have =
called for a ban</a>). And U.S. taxpayers support the tax breaks =
with a deduction that <a =
href=3D"https://www.franken.senate.gov/?p=3Dpress_release&id=3D3384"&=
gt;politicians have tried to eliminate</a> in the past.=0A=
Now, the committee recommends Congress eliminate the tax =
deduction pharmaceutical companies are allowed to take on =
direct-to-consumer advertising.=0A=
This is an idea that should have wide support. Polls show that =
most Americans <a =
href=3D"https://cdn1.sph.harvard.edu/wp-content/uploads/sites/94/2016/05/=
STAT-Harvard-Poll-May-2016-FDA-Regulation.pdf">favor banning the =
ads</a> and federal lawmakers have tried to change the rules on =
so-called DTC for years. The American Medical Association =
(AMA) <a =
href=3D"https://www.ama-assn.org/content/ama-calls-ban-direct-consumer-ad=
vertising-prescription-drugs-and-medical-devices">called for a =
ban</a> on pharmaceutical advertising directly to patients in =
2015, saying there were concerns that the ads were driving up demand for =
expensive drugs. The FDA provides guidance for the advertising and, in =
August, FDA Commissioner Gottlieb said he may <a =
href=3D"https://www.fda.gov/NewsEvents/Newsroom/FDAInBrief/ucm572267.htm"=
>reduce the number</a> of risks manufacturers must reveal when =
advertising a medicine.=0A=
In a sign of just how entrenched the tax break is in D.C. =
politics, Sen. Dick Durbin (D- Ill.) <a =
href=3D"https://www.durbin.senate.gov/newsroom/press-releases/durbin-new-=
legislation-will-require-disclosure-of-drug-prices-in-advertising">int=
roduced a bill</a> last month that doesn=E2=80=99t eliminate the =
break but takes a step to rein in the advertising. Durbin=E2=80=99s bill =
would require manufacturers to provide the wholesale price of a drug in =
their advertisements.=0A=
Recommendation No. 5: Limit what Medicare enrollees pay for =
drugs=0A=
=0A=
The committee ticks off a to-do list for Congress when it comes =
to what older Americans and those with disabilities are paying for =
drugs.=0A=
Their recommendations include asking Congress to establish =
limits on total annual out-of-pocket costs for Medicare Part D enrollees =
and telling Congress to make sure the Centers for Medicare & =
Medicaid Services efforts to guarantee enrollee cost sharing is based on =
the real price of the drug as well as how well the drug works.=0A=
Turns out, there is already some limited movement on this =
one.=0A=
Medicare allows negotiations between the corporate insurers and =
pharmacy benefit managers who help administer the Part D program. CMS =
announced last month that it is <a =
href=3D"https://khn.org/news/medicare-seeks-comment-on-ways-to-cut-costs-=
of-part-d-drugs/">exploring how</a> to pass on the =
behind-the-scenes manufacturer rebates to patients, though it warns =
premiums may rise if they make this move.=0A=
Recommendation No. 6: Increasing oversight of a very specific =
federal drug discount program =0A=
=0A=
The committee is stepping into <a =
href=3D"https://www.washingtonpost.com/national/health-science/heated-and=
-deep-pocketed-battle-erupts-over-340b-drug-discount-program/2017/11/28/1=
033521e-d425-11e7-9ad9-ca0619edfa05_story.html?utm_term=3D.6645a5b1c2c3"&=
gt;a hot-button political issue</a> by recommending increased =
transparency and oversight of a program that Congress created in =
1992.=0A=
The program, known as 340B, requires pharmaceutical companies =
to sell drugs at steep discounts to hospitals and clinics that serve =
high volumes of low-income patients. Congress held two hearings this =
year, questioning who is benefiting from the discounts, and =
CMS <a =
href=3D"https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/=
2017-Press-releases-items/2017-11-01-2.html">recently =
announced</a> it was slashing Medicare reimbursement to some =
hospitals enrolled in the program.=0A=
Hospitals are fighting back, filing a lawsuit over the =
reimbursement cut. The committee, echoing concerns from House =
Republicans, recommends making sure the program helps =E2=80=9Caid =
vulnerable populations.=E2=80=9D=0A=
Recommendation No. 7: Revise the Orphan Drug Act =0A=
=0A=
The committee wants to make sure the 1983 Orphan Drug Act helps =
patients with rare diseases.=0A=
The law, intended to spur development of medicines for rare =
diseases, provides financial incentives for drugmakers such as seven =
years of market exclusivity for drugs that treat a specific condition =
that affects fewer than 200,000 people.=0A=
The program has been under fire this year after Kaiser Health =
News, whose investigation is cited by the committee, reported that =
approved drugs often gamed this system and won blockbuster sales for =
more common diseases. The Government Accountability Office has begun an =
investigation into the program after receiving a request from top =
Republican senators and FDA=E2=80=99s announced =E2=80=9C<a =
href=3D"https://blogs.fda.gov/fdavoice/index.php/2017/09/fda-is-advancing=
-the-goals-of-the-orphan-drug-act/">modernization</a>=E2=80=9D =
plan for the agency this summer.=0A=
The committee=E2=80=99s requests include limiting the number of =
exclusivity periods a drug can receive and making sure drugs that win =
the financial incentives really do treat rare disease. Finally, the =
committee says HHS should =E2=80=9Cobtain favorable concessions on =
launch prices, annual price increases,=E2=80=9D and more.=0A=
Recommendation No. 8: Make sure doctors prescribe drugs for the =
right reasons=0A=
=0A=
Medical practices, hospitals and doctors should =
=E2=80=9Csubstantially=E2=80=9D tighten restrictions on office visits by =
pharma employees, and the acceptance of free samples, the committee =
recommends.=0A=
This isn=E2=80=99t the first time the national group has =
recommended controlling drug samples and visits. In 2009, the then =
Institute of Medicine <a =
href=3D"http://www.nytimes.com/2009/04/29/health/policy/29drug.html">s=
aid doctors</a> and medical schools should stop taking free drug =
samples. It may have worked =E2=80=94 to some extent. A study this year =
found that academic medical centers that limited visits <a =
href=3D"https://jamanetwork.com/journals/jama/fullarticle/2623607">saw=
 changes</a> in prescribing patterns.=0A=
Now, the National Academies committee says doctors in private =
practice should also stop taking free samples and welcoming =
pharmaceutical visits. The AMA, which is the nation=E2=80=99s largest =
membership group of doctors, supports physicians using samples on a =
voluntary basis, particularly for uninsured patients.=0A=

=20

=20 =20 =20 =20 =20 =20 =20

=20 =20 =20 =20

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