The amount of influence drug reps (aka pharmaceutical reps or drug pushers) have on doctors [1] [2] [3] [4]
Written by Diana Chan R.Ph, BCNSP (Pharmacist, Board Certified Nutrition Support Pharmacist)
When I was a pharmacy staff in the late 1970’s and a pharmacy director in the 1980’s, the pharmaceutical representatives (drug reps), also known as “detail men” I encountered were mostly male pharmacists. I still remember what my Eli Lily rep, an older gentleman, told me: “When I tell people I am a pharmacist from Eli Lily, doors always open for me”. Nowadays, as Carl Elliott puts it, the average drug rep looks like a supermodel, or maybe an A-list movie star. Drug reps today are mostly young women, well groomed, and strikingly good-looking. And they are always, hands down, the best-dressed people in the hospital.
The number of drug reps has escalated over the years
Between 1995 and 2005, the number of drug reps in the US increased from 38,000 to the height of 100,000, about 1 for every 6 physicians. The actual ratio is close to 1 drug rep per 2.5 targeted physicians, because not all physicians practice, and not all practicing physicians are detailed. Low-prescribers are ignored by drug reps. The number of reps in the U.S. market has dropped gradually to just 66,000 in 2012 and rebounded to 71,000 in 2016.
How much money is spent on drug reps to influence doctors’ prescribing habit?
According to an in-depth analysis published in JAMA in January, 2019, [5] of the nearly $30 billion that health companies now spend on medical marketing each year, around 68 percent (or about $20 billion) goes to drug reps for persuading doctors and other medical professionals—not consumers—of the benefits of prescription drugs. Meanwhile, US healthcare spending hit $3.3 trillion, or 17.8 percent of the GDP, in 2016.
The experience of some successful drug reps:
Carl Elliott, drawing from the experience of successful drug reps (Gene Carbona, Michael Oldani, Jordan Katz, Jamie Reidy, Shahram Ahari and others), who work for various big pharmaceutical companies, gave us an in-depth insight into how drug pushers influence doctors’ prescribing habit in an article published in The Atlantic on April 2006. Carl Elliott is a professor in the Center for Bioethics and the Departments of Pediatrics and Philosophy at the University of Minnesota. As a pharmacist who has worked for more than 3 decades in various settings including management, I can attest to most of what he is telling us in this article.
First and foremost, we must realize drug reps, are salespeople. They swear no oaths, take care of no patients, and profess no high-minded ethical duties. Their job is to persuade doctors to prescribe their drugs regardless whether drugs are marginally effective, exorbitantly expensive, difficult to administer, or even dangerously toxic. The devastating “opioid epidemic” epitomizes the extreme influence drug reps have on physicians. In the 1990s, Purdue Pharma, launched aggressive awareness campaigns and pain-education programs about opioid treatments for chronic, noncancer pain, which led to drug reps misleading medical professionals about the abuse potential of Oxycontin and promoted off-label use of the powerful pain-killer. Between 2000 and 2015, opioid prescriptions and overdose deaths quadrupled. The Centers for Disease Control and Prevention now estimates that about 46 people die each day from prescription opioid overdoses. [6] Reps that succeed are rewarded lavishly with bonuses or commissions. Reps that fail may find themselves unemployed. In other words, their ultimate goal is to increase the sale of the drugs they detail and thus their income, not to educate the doctors.
The power of lunch, goodies and drug samples on doctors’ prescribing habit.
The first duty of doctors, at least in theory, is to their patients. Doctors must make prescribing decisions based on medical evidence and their own clinical judgment. But after all, doctors are human. It is difficult to resist friendly, easygoing, fun to flirt with good-looking young reps. How can you demonize someone who brings you lunch and touches your arm and remembers your birthday and knows the names of all your children? After awhile even the most steel-willed doctors may look forward to visits by a rep. Besides lunch and other goodies for the staff and for the kids, drug samples is the most indispensable marketing tool. Doctors who accept samples of a drug are far more likely to prescribe that drug later on and pass them to their patients who are happy to try the new drugs with free samples.
Drug reps often do not have cap on how much they can earn other than their base pay. As a result, drug reps would schmooze with the receptionists, make friends with the nurses, and chat up the pharmacists in order to learn which drugs the local doctors were prescribing, using the right incentives to coax what they needed from these informants. Gene Carbona spent 12 years working for Merck and then Astra Merck. In his heyday, he claimed he had access to so much money for doctors that he had trouble spending it all. “The more money I spent,” Carbona says, “the more money I made.”
How script-tracking created a marketing frenzy.
In the 1990s, new information technology made it much simpler to track prescriptions. Market-research firms began purchasing script-related data from pharmacies and hospitals and selling it to pharmaceutical companies. With that technology, reps could find out exactly how many prescriptions any doctor was writing and exactly which drugs those prescriptions were for by just downloading the data with their laptops. Script-tracking reports[7]reveal that a lot of doctors were lying to the reps. Doctors might tell a rep that they were writing certain prescriptions, when in fact they weren’t just to get the rep off their backs. Now reps could detect the deception immediately. Script-tracking helped reps identify the “high prescribers” or “high writers” who will become the rep’s main target. Physicians are ranked on a scale from 1 to 10 based on how many prescriptions they write and their prescribing habit classified by names such as: “Hidden gems” who are 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. “The spreader” who uses a little bit of everybody’s product. “Loyalists” are very loyal to one particular product and uses it for most patient types. “Niche” physician is one who reserves certain product only for a very narrowly defined patient type. Another category is “sample-grabbers” referring to physicians who refuse to see drug reps but usually accept samples. Some physicians go as far as using samples for an entire course of treatment, which is an anathema to pharmaceutical companies because this “cannibalizes” sales. And the idea in physician segmentation would be to have a different messaging strategy for each of those physician segments. [8]
Since script-tracking reports are available to every rep from every company, the result created an arms race of pharmaceutical gift-giving, especially among reps who are marketing drugs in the same family, for example statins. We now have 7 statin drugs, which are cash cows for drug makers because they can be prescribed for almost anyone in the name of “preventive medicine”. Reps are forced to devise ever-new ways to exert influence on the doctors. Sandwiches for lunchcan upgrade to high-end restaurant foods and one-week vacation on cruise ship or to exotic destination can be camouflaged as continued medical education retreat. A Pfizer rep in the 1990s, recorded in his memoir that a doctor demanded a swimming pool in his back yard. So an “unrestricted educational grant” was set up for him during the Viagra era.
The problem of drug sampling.
Around 2007, the practice of sampling began to be criticized because it could interfere with prescribing habits. The drugs that reps most often brought in were the newer, more expensive drugs. This put the doctors in the awkward position of prescribing a drug even if it was not the most economical or the best fit for the patient. Many practices now limit or completely restrict sampling.
Further complicating the practice are guidelines from the Food and Drug Administration (FDA) that make sure drug manufacturers keep tight controls on how many samples they give out, the number that was actually dispensed and the identity of the recipients.
But that does not mean drug reps are showing up empty-handed. Reps now can offer rebate or discount cards, especially for biologicals that need refrigeration or stored in a specific way and can’t be carried around in a business briefcase. While discount cards are not as exciting as free samples, they are still an incentive for the doctor to give the new drug a try and can be just as helpful to patients in a world of rising costs. [9]
Should the use of physician’s prescription drug records be banned for marketing purposes?
Should it be illegal for drug reps to use doctors’ prescription drug records to influence their prescribing habit?
In 2006, New Hampshire passed an ACT to ban the commercial sale of prescription data, citing that 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 can boost the bottom line of the pharmaceutical companies. 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.
AMA’s position regarding drug reps using prescribers’ data to influence their prescribing habit.
June 23, 2011, The US Supreme Court overturned a Vermont law that banned the use of physician prescription drug records for marketing purposes, ruling for free-speech rights over medical privacy concerns. [10] [11]
While the American Medical Association (AMA) supports the appropriate disclosure of prescriber data, the AMA firmly believes that every physician has the unequivocal right to decide whether his or her individual prescribing data is shielded from pharmaceutical detailers. The AMA created the Physician Data Restriction Program, which enables physicians to “opt out” of such disclosure while still allowing their data to be available for academic and governmental research. Physicians overwhelmingly oppose data mining and consider it a violation of their privacy, according to a recent poll of 740 physicians by MDLinx.
Drug reps’ point of view regarding to marketing to doctors.
One successful rep revealed that successful marketing to doctors is to give doctors gifts without making them feel that they are being bought. “Bribes that aren’t considered bribes”[12] is the essence of pharmaceutical gifting, which do not come with an explicit quid pro quo. Whatever obligation doctors feel to write scripts for a rep’s products usually comes from the general sense of reciprocity implied by the ritual of gift-giving. The reality is– reps would not give doctors free stuff if they did not expect more scripts from them.
The medical industry began hiring more and more reps, with backgrounds in sales rather than in pharmacy, nursing, or medical science related fields. These reps have the nickname of “Pharma Barbie” and “Pharma Ken”, whose medical knowledge was exceeded by their looks and catering skills. Most doctors continued to see reps in order to learn about new drugs or keep the supply of free samples flowing. Some doctors feel they rightfully deserve all the gifts and perks because reps take up their precious time which should be devoted to their patients.
The following is a direct quote from Carl Elliott’sarticle: “When an encounter between a doctor and a rep goes well, it is a delicate ritual of pretense and self-deception. Drug reps pretend that they are giving doctors impartial information. Doctors pretend that they take it seriously. Drug reps must try their best to influence doctors, while doctors must tell themselves that they are not being influenced. Drug reps must act as if they are not salespeople, while doctors must act as if they are not customers. And if, by accident, the real purpose of the exchange is revealed, the result is like an elaborate theatrical dance in which the masks and costumes suddenly drop off and the actors come face to face with one another as they really are. Nobody wants to see that happen.” As an insider I can attest to this description of the intricate relationship between doctors and drug reps.
Are doctors becoming the new drug reps?
The industry as a whole is hiring more and more doctors as speakers. The audience are medical students and or other doctors. Thecontent of the speech and the slideswere usually supplied by the pharmaceutical companies. The return on investment for doctor-led events was nearly twice that of rep-led events, even after subtracting the generous speaking fees. This raises the question: Are doctors becoming the new drug reps?
These speakers and consultants are considered “thought leaders,” or “key opinion leaders”. Some “thought leaders” consult and speak on behalf of many different companies in order to generate a substantial supplemental income. Reps refer to these doctors as “drug whores.” The opinion of one “thought leader” is that “Better a whore than a concubine.”
“Thought leaders” serve an indispensable function in a very lucrative marketing niche by promoting off-label uses (uses other than those approved by the FDA)—something reps are strictly forbidden to do. “Thought leaders” who were willing to talk about off-label uses usually receive hefty speaking fees. Other doctors were paid just to listen. Some “key opinion leaders” are ghostwriters for journal articles in favor of the pharmaceutical company. In other words, they got paid for just signing the article written by somebody else. The influence of these “experts” on other doctors’ prescribing habits cannot be underestimated.
Example: Neurontin was approved for the treatment of epilepsy, but according to the lawsuit brought about by a whistle-blower in 1996, Parke-Davis was promoting it for other conditions—including bipolar disorder, migraines, and restless legs syndrome—for which there was little or no scientific evidence that it worked. Get this: The litigation over Neurontin cost Pfizer $430 million in criminal fines and civil damages from 1994 to 2002. In spite of the adverse publicity and fine, the drug’s popularity and profitability soared. Neurontin generated more than $2.7 billion in revenues in 2003, more than 90 percent of which came from off-label prescriptions and the fine was only about 16% of 2003 revenue.
Why are drug reps the last to know about potential problems with their drugs?
Reps are the last to know about potential problems with their drugs in order for them to be detailing a drug enthusiastically right up to the day it is withdrawn from the market. Otherwise it is likely to erode that rep’s credibility with doctors.
In 2002, the Office of the Inspector General in the Department of Health and Human Services announced its intention to crack down on drug companies’ more notorious promotional practices. As a result, the Pharmaceutical Research and Manufacturers of America (PhRMA), which represents the country’s leading innovative biopharmaceutical research companies, issued a set of voluntary marketing guidelines (PhRMA code). [13] This code put many restrictions on gift giving and fees to healthcare professionals including, for example, the value of promotional items, meals, and the fees paid to speakers. The locations for CME or speaker training programs are not allowed to be held outside of doctors’ office or medical facilities and cannot not be combined with entertainment activities such as sport events or golfing paid for by the company. [14] However, as long as reps feel pressure to meet quota, they will find ways to get around the rules. Not all drug companies belong to PhRMA, and those that don’t are not bound by PhRMA’s code. The companies that tried to follow the guidelines lost a ton of market share, and the ones who didn’t gained it. As one former rep pointed out: “The bottom line is that if you don’t pay off the doctors, you will not succeed in pharmaceuticals. Period.”
Do all physicians favor the gift-giving marketing strategy?
To be fair, there are pockets of physicians, especially among younger physicians and medical students who resist the gift-giving marketing strategy. The American Medical Student Association may be the only mainstream medical organization with a principled position against taking industry gifts. They adopt the policy of “No Free Lunch” and “Just say no to drug reps.”
CONCLUSION:
Both doctors and reps are organization men/women. In their daily work, they are responding to the pressures and incentives of a market-driven health-care bureaucracy that Americans have designed. The drug industry also became a big political player in Washington: by 2005, according to the Center for Public Integrity, its lobbying organization had become the largest in the country.
Until we can reform our fee-for-service system to remove the incentive of doing more without clear benefits for healthcare consumers, the idealism of being a conscientious healer will forever be challenged and drug reps will continue to hustle and flourish in the new medical marketplace.
The best approach is highlighted by the top-ranked Cleveland Clinic. There, doctors are paid a flat salary instead of by a price-for-service model. This shift has led to a hospital where costs are visible and under control. Redundant tests are at a minimum, and physician turnover is much lower than at comparable hospitals.
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REFERENCES:
[1] https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876413/
[3] https://arstechnica.com/science/2019/01/healthcare-industry-spends-30b-on-marketing-most-of-it-goes-to-doctors/
[4] Olsen, Gwen (2009-04-24). Confessions of an Rx Drug Pusher.
[5] https://jamanetwork.com/journals/jama/fullarticle/2720029
[6] https://arstechnica.com/science/2019/01/healthcare-industry-spends-30b-on-marketing-most-of-it-goes-to-doctors/
[7] Reidy J. Hard sell: The evolution of a Viagra salesman. Kansas City: Andrews McMeel Publishing; 2005. p. 210
[8] Brand R, Kumar P. Detailing gets personal: Integrated segmentation may be pharma’s key to “repersonalizing” the selling process. Pharmaceutical Executive. 2003. Available: http://www.pharmexec.com/pharmexec/article/articleDetail.jsp?id=64071)
[9] https://www.biopharmadive.com/news/spotlight-trends-pharma-sales-force-digital-marketing/504949/
[10] https://www.medscape.com/viewarticle/745191
[11] https://www.cga.ct.gov/2006/rpt/2006-R-0461.htm
[12] Michael Oldani, – an anthropologist and former drug rep Oldani MJ. Thick prescriptions: Toward an interpretation of pharmaceutical sales practices. Med Anthropol Q. 2004;18:328–356. [PubMed]
[13] https://www.phrma.org/codes-and-guidelines/code-on-interactions-with-health-care-professionals
[14] https://www.phrma.org/-/media/Project/PhRMA/PhRMA-Org/PhRMA-Org/PDF/Code-of-Interaction_FINAL21.pdf
