Subject: [SciPol 605] Re: Following the Script: How Drug Reps Make Friends and Influence Doctors

From: john stampe <[email-masked]>
Date: Wed, 16 May 2007 03:45:55 -0700 (PDT)

Not being a physican, and not currently living in the US, two questions come to my mind.

What is the AMA's position considering it gets a large amount of money from "database product sales"?
How common is the practice outside of the United States?

John Stampe
johnsearth.blogspot.com

----- Original Message ----
From: MsRedSonya <[email-masked]>
To: Science and Politics <[email-masked]>
Sent: Saturday, May 12, 2007 12:21:08 PM
Subject: [SciPol 602] Following the Script: How Drug Reps Make Friends and Influence Doctors

Following the Script: How Drug Reps Make Friends and Influence Doctors
Adriane Fugh-Berman and Shahram Ahari
PLoS Medicine 4 (4), 150 (01 Apr 2007)
info:doi/10.1371/journal.pmed.0040150
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040150

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.

-James 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
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."

-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.)

Gifts create both expectation and obligation. "The importance of
developing loyalty through gifting cannot be overstated," writes
Michael 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&mldr;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
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.

-James 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&mldr;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 prescriptions" [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 gems": "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." 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, "&mldr; 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
"&mldr;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&mldr;." [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
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-grabbers").
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
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&mldr;

-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 accurate"; 72%
thought the information was "somewhat accurate"; and 14% said that it
was "not very" or "not at all" 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&mldr;Sales spending for specialty drugs that treat a narrowed
population segment average $25.3 million per product across the
industry." [25]

Conclusion
As one of us (SA) explained in testimony in the litigation over New
Hampshire's new ban on the commercial sale of prescription data, the
concept that reps provide necessary services to physicians and
patients is a fiction. Pharmaceutical companies spend billions of
dollars annually to ensure that physicians most susceptible to
marketing prescribe the most expensive, most promoted drugs to the
most people possible. The foundation of this influence is a sales
force of 100,000 drug reps that provides rationed doses of samples,
gifts, services, and flattery to a subset of physicians. If detailing
were an educational service, it would be provided to all physicians,
not just those who affect market share.

Physicians are susceptible to corporate influence because they are
overworked, overwhelmed with information and paperwork, and feel
underappreciated. Cheerful and charming, bearing food and gifts, drug
reps provide respite and sympathy; they appreciate how hard doctor's
lives are, and seem only to want to ease their burdens. But, as SA's
New Hampshire testimony reflects, every word, every courtesy, every
gift, and every piece of information provided is carefully crafted,
not to assist doctors or patients, but to increase market share for
targeted drugs (see Table 1). In the interests of patients, physicians
must reject the false friendship provided by reps. Physicians must
rely on information on drugs from unconflicted sources, and seek
friends among those who are not paid to be friends.

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