PLoS - Following the Script: How Drug Reps Make Friends and Influence Doctors

[Guest guest]

http://tinyurl.com/3taoefj

Following the Script: How Drug Reps Make Friends and Influence Doctors

Article

Metrics

Related Content

Comments: 1

..

e Fugh-Berman*, Shahram Ahari

To add a note, highlight some text. Hide notes

Make a general comment

Citation: Fugh-Berman A, Ahari S (2007) Following the Script: How Drug Reps Make

Friends and Influence Doctors. PLoS Med 4(4): e150.

doi:10.1371/journal.pmed.0040150

Published: April 24, 2007

Copyright: © 2007 Fugh-Berman and Ahari. This is an open-access article

distributed under the terms of the Creative Commons Attribution License, which

permits unrestricted use, distribution, and reproduction in any medium, provided

the original author and source are credited.

Funding: This work was supported by a grant from the Attorney General Prescriber

and Consumer Education Grant Program, created as part of a 2004 settlement

between Warner-Lambert, a division of Pfizer, and the Attorneys General of 50

States and the District of Columbia, to settle allegations that Warner-Lambert

conducted an unlawful marketing campaign for the drug Neurontin (gabapentin)

that violated state consumer protection laws.

Competing interests: Shahram Ahari is a former pharmaceutical sales

representative for Eli Lilly, and the primary findings of this paper summarize

points he made in testimony as a paid expert witness on the defendant's side in

litigation against a New Hampshire law prohibiting the sale of prescription

data. e Fugh-Berman has accepted payment as an expert witness on the

plaintiff's side in litigation regarding menopausal hormone therapy.

Abbreviations: AMA, American Medical Association

* To whom correspondence should be addressed. E-mail:ajf29@...

e Fugh-Berman is an Associate Professor in the Department of Physiology

and Biophysics, town University Medical Center, Washington, District of

Columbia, United States of America. Shahram Ahari is with the School of

Pharmacy, University of California San Francisco, San Francisco, California,

United States of America.

It's my job to figure out what a physician's price is. For some it's dinner at

the finest restaurants, for others it's enough convincing data to let them

prescribe confidently and for others it's my attention and friendship...but at

the most basic level, everything is for sale and everything is an exchange.

—Shahram Ahari

You are absolutely buying love.

— Reidy [1]

In 2000, pharmaceutical companies spent more than 15.7 billion dollars on

promoting prescription drugs in the United States [2]. More than 4.8 billion

dollars was spent on detailing, the one-on-one promotion of drugs to doctors by

pharmaceutical sales representatives, commonly called drug reps. The average

sales force expenditure for pharmaceutical companies is $875 million annually

[3].

Unlike the door-to-door vendors of cosmetics and vacuum cleaners, drug reps do

not sell their product directly to buyers. Consumers pay for prescription drugs,

but physicians control access. Drug reps increase drug sales by influencing

physicians, and they do so with finely titrated doses of friendship. This

article, which grew out of conversations between a former drug rep (SA) and a

physician who researches pharmaceutical marketing (AFB), reveals the strategies

used by reps to manipulate physician prescribing.

Better Than You Know Yourself â Top

During training, I was told, when you're out to dinner with a doctor, “The

physician is eating with a friend. You are eating with a client.â€

—Shahram Ahari

Reps may be genuinely friendly, but they are not genuine friends. Drug reps are

selected for their presentability and outgoing natures, and are trained to be

observant, personable, and helpful. They are also trained to assess physicians'

personalities, practice styles, and preferences, and to relay this information

back to the company. Personal information may be more important than prescribing

preferences. Reps ask for and remember details about a physician's family life,

professional interests, and recreational pursuits. A photo on a desk presents an

opportunity to inquire about family members and memorize whatever tidbits are

offered (including names, birthdays, and interests); these are usually typed

into a database after the encounter. Reps scour a doctor's office for

objects—a tennis racquet, Russian novels, seventies rock music, fashion

magazines, travel mementos, or cultural or religious symbols—that can be used

to establish a personal connection with the doctor.

Good details are dynamic; the best reps tailor their messages constantly

according to their client's reaction. A friendly physician makes the rep's job

easy, because the rep can use the “friendship†to request favors, in the

form of prescriptions. Physicians who view the relationship as a straightforward

goods-for-prescriptions exchange are dealt with in a businesslike manner.

Skeptical doctors who favor evidence over charm are approached respectfully,

supplied with reprints from the medical literature, and wooed as teachers.

Physicians who refuse to see reps are detailed by proxy; their staff is dined

and flattered in hopes that they will act as emissaries for a rep's messages.

(See Table 1 for specific tactics used to manipulate physicians.)



Table 1. Tactics for Manipulating Physicians

doi:10.1371/journal.pmed.0040150.t101

..



Table 1. Continued

doi:10.1371/journal.pmed.0040150.t102

..

Gifts create both expectation and obligation. “The importance of developing

loyalty through gifting cannot be overstated,†writes Oldani, an

anthropologist and former drug rep [26]. Pharmaceutical gifting, however,

involves carefully calibrated generosity. Many prescribers receive pens,

notepads, and coffee mugs, all items kept close at hand, ensuring that a

targeted drug's name stays uppermost in a physician's subconscious mind. High

prescribers receive higher-end presents, for example, silk ties or golf bags. As

Oldani states, “The essence of pharmaceutical gifting…is ‘bribes that

aren't considered bribes’†[1].

Reps also recruit and audition “thought leaders†(physicians respected by

their peers) to groom for the speaking circuit. Physicians invited and paid by a

rep to speak to their peers may express their gratitude in increased

prescriptions (see Table 1). Anything that improves the relationship between the

rep and the client usually leads to improved market share.

Script Tracking â Top

An official job description for a pharmaceutical sales rep would read: Provide

health-care professionals with product information, answer their questions on

the use of products, and deliver product samples. An unofficial, and more

accurate, description would have been: Change the prescribing habits of

physicians.

— Reidy [4]

Pharmaceutical companies monitor the return on investment of detailing—and all

promotional efforts—by prescription tracking. Information distribution

companies, also called health information organizations (including IMS Health,

Dendrite, Verispan, and Wolters Kluwer), purchase prescription records from

pharmacies. The majority of pharmacies sell these records; IMS Health, the

largest information distribution company, procures records on about 70% of

prescriptions filled in community pharmacies. Patient names are not included,

and physicians may be identified only by state license number, Drug Enforcement

Administration number, or a pharmacy-specific identifier [5]. Data that identify

physicians only by numbers are linked to physician names through licensing

agreements with the American Medical Association (AMA), which maintains the

Physician Masterfile, a database containing demographic information on all US.

physicians (living or dead, member or non-member, licensed or non-licensed). In

2005, database product sales, including an unknown amount from licensing

Masterfile information, provided more than $44 million to the AMA [5].

Pharmaceutical companies are the primary customers for prescribing data, which

are used both to identify “high-prescribers†and to track the effects of

promotion. Physicians are ranked on a scale from one to ten based on how many

prescriptions they write. Reps lavish high-prescribers with attention, gifts,

and unrestricted “educational†grants (Table 1). Cardiologists and other

specialists write relatively few prescriptions, but are targeted because

specialist prescriptions are perpetuated for years by primary care physicians,

thus affecting market share.

Reps use prescribing data to see how many of a physician's patients receive

specific drugs, how many prescriptions the physician writes for targeted and

competing drugs, and how a physician's prescribing habits change over time. One

training guide states that an “individual market share report for each

physician…pinpoints a prescriber's current habits†and is “used to

identify which products are currently in favor with the physician in order to

develop a strategy to change those prescriptions into Merck prescriptionsâ€

[6].

A Pharmaceutical Executive article states, “A physician's prescribing value is

a function of the opportunity to prescribe, plus his or her attitude toward

prescribing, along with outside influences. By building these multiple

dimensions into physicians' profiles, it is possible to understand the ‘why’

behind the ‘what’ and ‘how’ of their behavior.†[7] To this end, some

companies combine data sources. For example, Medical Marketing Service

“enhances the AMA Masterfile with non-AMA data from a variety of sources to

not only include demographic selections, but also behavioral and psychographic

selections that help you to better target your perfect prospects†[8].

The goal of this demographic slicing and dicing is to identify physicians who

are most susceptible to marketing efforts. One industry article suggests

categorizing physicians as “hidden gemsâ€: “Initially considered ‘low

value’ because they are low prescribers, these physicians can change their

prescribing habits after targeted, effective marketing.†“Growers†are

“Physicians who are early adopters of a brand. Pharmaceutical companies employ

retention strategies to continue to reinforce their growth behavior.â€

Physicians are considered “low value†“due to low category share and

prescribing level†[9].

In an interview with Pharmaceutical Representative, Fred Marshall, president of

Quantum Learning, explained, “… One type might be called ‘the spreader’

who uses a little bit of everybody's product. The second type might be a

‘loyalist’, who's very loyal to one particular product and uses it for most

patient types. Another physician might be a ‘niche’ physician, who reserves

our product only for a very narrowly defined patient type. And the idea in

physician segmentation would be to have a different messaging strategy for each

of those physician segments †[10].

In Pharmaceutical Executive, Ron Brand of IMS Consulting writes “…integrated

segmentation analyzes individual prescribing behaviors, demographics, and

psychographics (attitudes, beliefs, and values) to fine-tune sales targets. For

a particular product, for example, one segment might consist of price-sensitive

physicians, another might include doctors loyal to a given manufacturers brand,

and a third may include those unfriendly towards reps†[11].

In recent years, physicians have become aware of—and dismayed by—script

tracking. In July 2006, the AMA launched the Prescribing Data Restriction

Program (see http://www.ama-assn.org/ama/pub/category /12054.html), which allows

physicians the opportunity to withhold most prescribing information from reps

and their supervisors (anyone above that level, however, has full access to all

data). According to an article in Pharmaceutical Executive, “Reps and direct

managers can view the physician's prescribing volume quantiled at the

therapeutic class level†and can still view aggregated or segmented data

including “categories into which the prescriber falls, such as an

early-adopter of drugs, for example….†[12]. The pharmaceutical industry

supports the Prescribing Data Restriction Program, which is seen as a less

onerous alternative to, for example, state legislation passed in New Hampshire

forbidding the sale of prescription data to commercial entities [13].

The Value of Samples â Top

The purpose of supplying drug samples is to gain entry into doctors' offices,

and to habituate physicians to prescribing targeted drugs. Physicians appreciate

samples, which can be used to start therapy immediately, test tolerance to a new

drug, or reduce the total cost of a prescription. Even physicians who refuse to

see drug reps usually want samples (these docs are denigrated as

“sample-grabbersâ€). Patients like samples too; it's nice to get a little

present from the doctor. Samples also double as unacknowledged gifts to

physicians and their staff. The convenience of an in-house pharmacy increases

loyalty to both the reps and the drugs they represent.

Some physicians use samples to provide drugs to indigent patients [14,15]. Using

samples for an entire course of treatment is anathema to pharmaceutical

companies because this “cannibalizes†sales. Among the aims of one industry

sample-tracking program are to “reallocate samples to high-opportunity

prescribers most receptive to sampling as a promotional vehicle†and

“identify prescribers who were oversampled and take corrective action

immediately†[16].

Studies consistently show that samples influence prescribing choices [14,15,17].

Reps provide samples only of the most promoted, usually most expensive, drugs,

and patients given a sample for part of a course of treatment almost always

receive a prescription for the same drug.

Funding Friendship â Top

While it's the doctors' job to treat patients and not to justify their actions,

it's my job to constantly sway the doctors. It's a job I'm paid and trained to

do. Doctors are neither trained nor paid to negotiate. Most of the time they

don't even realize that's what they're doing…

—Shahram Ahari

Drug costs now account for 10.7% of health-care expenditures in the US [18]. In

2004, spending for prescription drugs was $188.5 billion, almost five times as

much as what was spent in 1990 [19]. Between 1995 and 2005, the number of drug

reps in the US increased from 38,000 to 100,000 [20], about one for every six

physicians. The actual ratio is close to one drug rep per 2.5 targeted doctors

[21], because not all physicians practice, and not all practicing physicians are

detailed. Low-prescribers are ignored by drug reps.

Physicians view drug information provided by reps as a convenient, if not

entirely reliable, educational service. An industry survey found that more than

half of “high-prescribing†doctors cited drug reps as their main source of

information about new drugs [22]. In another study, three quarters of 2,608

practicing physicians found information provided by reps “very useful†(15%)

or “somewhat useful†(59%) [23]. However, only 9% agreed that the

information was “very accurateâ€; 72% thought the information was “somewhat

accurateâ€; and 14% said that it was “not very†or “not at allâ€

accurate.

Whether or not physicians believe in the accuracy of information provided,

detailing is extremely effective at changing prescribing behavior, which is why

it is worth its substantial expense. The average annual income for a drug rep is

$81,700, which includes $62,400 in base salary plus $19,300 in bonuses. The

average cost of recruiting, hiring, and training a new rep is estimated to be

$89,000 [24]. When expenses are added to income and training, pharmaceutical

companies spend $150,000 annually per primary care sales representative and

$330,000 per specialty sales representative [25]. An industry article states,

“The pharmaceutical industry averages $31.9 million in annual sales spending

per primary-care drug…Sales spending for specialty drugs that treat a narrowed

population segment average $25.3 million per product across the industry.â€

[25]

More at link...

Sent via BlackBerry by AT & T