As a recent announcement by GlaxoSmithKline highlighted – the pharma giant will stop paying doctors to promote its products – the relationship between physicians and pharma reps is a complex and sometimes twisted one. At my first job in healthcare as a receptionist in the 1980s, I remember being puzzled when I was told one of the physicians was being “detailed”. Detailed? What the heck was that?
Detailing the Physician
I soon found out that the physician was meeting with a “detail rep”, which was slang for a pharmaceutical representative or drug rep who was providing the details of a specific drug to the physician. Detail reps were always sharp-suited, clean-cut and fit young men and women whose job was to visit the practice monthly and provide the physicians with in-depth information and study results proving the efficacy of their product. They also left samples for the physicians to hand out to patients to see how the medication performed, as well as branded objects such as pens, clipboards, sticky notes, mugs, clocks and magnets. Later I found out that some physicians also received other gifts from the reps including event tickets, dinners, gift baskets and trips. I didn’t find out until later that the reps made their money by the amount of drugs that were prescribed by the physicians they detailed. What a revelation!
As physician schedules got tighter with the advent of managed care in the 1990s, doctors became unable to meet with reps one-on-one. Physicians only had time to meet with reps over lunch, then it expanded to lunches for the whole office, which physicians saw as a perk for the employees. Pharmaceutical companies added to their arsenal by providing physicians with more than just the details – they developed patient education products, starter packages, patient assessment tools and patient call-in telephone lines to help patients continue their medication therapy.
In a case study document called “Making the Case for Drug Company Independence”, UMass Medical School/Meyers Primary Care Institute tells physicians:
In summary, it is important that prescribers recognize that pharmaceutical representative visits are part of a highly structured marketing campaign with the goal of increasing market share and product sales. This marketing takes many forms – prescriber detailing, CME programs, professional society support, conference and academic medical center restricted and unrestricted grant support, direct to consumer advertising, and patient support programs. Furthermore, industry monitors the behavior and beliefs of providers and patients alike, to maximize their marketing impact.”
The 1990s did bring new information on physicians’ prescribing habits, and drug reps were able to buy information as well as research physicians online. In 1997 the FDA dropped restrictions on direct-to-consumer advertising of prescription drugs, and we were introduced to ads for drugs that we were to ask our doctors about. Now physicians were getting pressured by both drug reps and patients to write prescriptions.
As more new drugs were manufactured and business boomed, pharmaceutical companies added legions of new drug reps. From 1996 to 2001 the pharmaceutical salesforce in America doubled to a total of 90,000 reps. There were so many reps trying to see the physicians that practices had to schedule special appointments for reps and had to make new rules, as some reps would try to sneak in back and side doors and would sometimes roam the clinic halls. Web-based drug rep scheduling programs were developed and offered at no charge to practices to help manage the chaos.
In my experience, physicians are either very hot or very cold about having pharmaceutical reps in their practice. Either they refuse to see them (reps call these docs “no-sees”), or think they perform a valid service. Many physicians agree that they could self-educate on the benefits of different drugs, but they hesitate to stop the drug reps coming to the practice as that would also stop the flow of samples into their practice. They like the opportunity for their patients to be able to try a drug before they invest in a whole month’s worth of it, and some patients would not take medications at all if they did not get samples.
But would emptying the sample closet hurt the patients?
An original research paper published in 2011 by the Journal of Family Practice tells the story of a practice in Oregon that stopping inviting drug reps into their practice. Interviews were conducted using questions related to 4 areas of policy perception: verification of policy decision, impact on clinic operations, influence of pharmaceutical industry, and lessons to share. The practice determined that not seeing drug reps improved the patient flow and they had little pushback from patients about not having samples available.
The First Wave of Change
In 2002, the pharmaceutical industry decided to police itself before somebody else did. The Pharmaceutical Research and Manufacturers of America (PhRMA) issued a voluntary code of ethics for pharmaceutical companies. Revised in 2008, the code restricted the gifting of most items and services unless they were educationally related.
As a practice manager at the time, I saw a noticeable shift in the way reps were treated in the practice, as well as a cooling of the perception of reps as part of the practice family. Drug reps seemed to get much sneakier and colleagues in many offices started applying very strict rules to drug rep visits.
You may have seen “Love and Other Drugs”, a 2010 movie based on Jamie Reidy’s book “Hard Sell” about his experiences as a Pfizer drug rep. Mr. Reidy says in his book:
An official job description for a pharmaceutical salesperson 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.”
According to a Prescription Project survey in 2008, “a majority of Americans (64%) say that it is important to know their physician’s financial ties to pharmaceutical companies and 68% would support legislation requiring pharmaceutical companies to disclose gifts to doctors. The survey showed that most Americans disapprove of even small gifts to physicians and believe that the pharmaceutical industry has a large influence over prescribing decisions.”
The Second Wave of Change
In early 2013, the Centers For Medicare and Medicaid Services (CMS) released their final regulations on the Physician Payment Sunshine Act that was passed in 2010 as a part of healthcare reform. The PPSA or “Sunshine Act” mandates that any manufacturer of medical supplies, medical equipment or pharmaceuticals will disclose to the Department of Health and Human Services (DHHS) any payments, gifts, or “transfers of value” over $10. The resulting disclosures will be publicly available in a database of transactions so that there will be “sunshine” on any financial relationships, direct or indirect, between providers and manufacturers.
The Third Wave of Change
In a sign that times are again changing for the pharmaceutical industry, British giant GlaxoSmithKline just announced that they will no longer pay doctors to promote their products at medical conferences and continuing education events. Glaxo also announced that they would suspend the practice of tying their salesforce’s commissions to prescription targets – a practice they had stopped in the United States in 2011, but will now be ended worldwide. Healthcare transparency advocates have long argued that these practices can lead to over-prescribing and unapproved, off-label uses.
While the unprecedented step by GlaxoSmithKline was seen as a welcome move by reformers, it is not happening in a vacuum. Glaxo and other pharmaceutical companies have come under scrutiny recently for their role in the explosion in US healthcare costs as well as how they market their drugs to doctors and patients. Last year Glaxo settled charges of mislabeling and misrepresenting their products in the US for a record $3 billion dollar fine. They are also currently under investigation in China for allegedly funneling half a billion dollars into the country to bribe officials. With a big scandal behind them, another one brewing, and a new regulatory and publicity hurdle on the horizon, it’s easy to read this announcement as a preemptive strike as opposed to an effort at improving their standards. Either way, it is a big shift in the way pharmaceutical companies do business, and providers, practices and systems need to understand how it will affect them.
This article was originally posted by Mary Pat Whaley on LinkedIn. Manage My Practice has a LinkedIn Group by the same name that you are invited to join.