Healthy Skepticism Library item: 17970
Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.
Publication type: news
Ruttan S
Sugar-coated pills
The Edmonton Journal 2003 Sep 7
Full text:
This is a story about money — hundreds of millions of dollars and climbing.
It is also a story about doctors, patients and giant pharmaceutical firms, the ones that make prescription drugs for blood pressure, cholesterol, arthritis and more.
The equation here is simple: pharmaceutical companies want doctors to prescribe their drugs to patients instead of rival brands. When they find one who doesn’t, they try to induce him to switch with fancy dinners, weekends in the mountains, hockey and theatre tickets and gifts.
This courtship, largely unseen by the public, has been going on for years. But now there are signs of change. Doctors, including those in Alberta, have begun standing up to the drug companies, ignoring their representatives and pressuring the industry to institute reforms.
But just as the doctors are changing, so are the drug companies.
Increasingly, the firms are starting to go around the doctors and rally support for their drugs from the people who consume them.
Canada’s 60 research-based drug companies (excluding makers of generic drugs) are a multibillion-dollar industry employing 23,000 people. On research alone they spend $1.1 billion a year.
Among their employees are 9,600 people, roughly one for every six doctors, who do pharmaceutical marketing. In the larger Edmonton medical offices, rarely a day goes by without a visit from a pharmaceutical representative.
Toronto physician Dr. Joel Lexchin, a longtime critic of drug company mar-keting, estimates Canadian drug companies spend $1.7 billion a year marketing to Canada’s doctors. About half of that is spent on pharmaceutical representatives and their giant expense accounts, he says.
Industry spokesman Jacques Lefebvre questions Lexchin’s estimate, but offers none of his own. He said the industry spends $258,000 a year on promotional activities, not including salaries.
The office visit remains the pharmaceutical reps’ most basic contact.
The rep — called a “detailer” in the slang of the industry — may have an appointment to see a doctor, or more often, simply stops by in hope of grabbing a physician’s attention.
Don Price, an Ottawa-based medical office management consultant, said one tactic of drug reps is bringing a catered lunch into the physicians’ office — a practice that Edmonton catering firms are more than familiar with. Then, when doctors take a lunch break, the rep can have a few minutes with each one.
These sales people are paid by the number of actual contacts they have with doctors, he said.
The other tactic the companies use is organizing education sessions to which physicians are invited, to hear a lecturer talk about new treatments for some medical condition.
Continuing education is a requirement of most medical specialties, including family practice. Physicians are expected to keep up with new treatments.
What the pharmaceutical companies do is package that continuing education with a fancy dinner, a weekend in Banff, a round of golf, and other perks and gifts for doctors.
Spruce Grove physician Dr. Conrad Schulte wrote an article in The Medical Post two years ago outlining the barrage of invitations he receives from pharmaceutical companies.
In a one-year period starting in November 1999, he got 120 invitations, 90 of them to dinners.
“The best-attended pharmaceutically sponsored continuing medical education involved those with affiliated events, such as musicals or hockey games,” he wrote. “One five-star dinner I went to with an excellent talk had only the rep and myself show up. The next week, a rather poor talk with tickets for physicians and spouses to the play Jekyll and Hyde attracted more than 300 participants.”
Schulte refused to be interviewed by The Journal. In his Medical Post article, he estimated that if he’d accepted every invitation he got that year, the cost to the drug companies would have been $12,000.
DOCTOR RESISTANCE
Does all that doctor-drug industry interaction make a difference?
Studies suggest it does.
Drug industry contacts begin in medical school, according to Quebec psychiatrist Dr. Ashley Wagana, writing in the Journal of the American Medical Association in 2000. Medical residents, many of whom are short of money, are particularly apt to take the drug-sponsored meals, he wrote.
Wagana examined 29 individual studies on the doctor-drug industry relationship. He found that contacts with drug companies lead physicians to change their prescribing pattern, increase the number of drugs prescribed, and prescribe more new medications that have no demonstrated advantage over the older ones.
Whatever their initial susceptibility to the drug companies’ offerings over the years, doctors are showing an increasing resistance to them.
It was pressure from doctors, for example, that helped push the pharmaceutical industry to tighten its code of ethics, a move that may reduce some of the invitations described by Schulte.
As of Jan. 1, for instance, pharmaceutical companies were supposed to stop paying for the travel, hotel expenses and fun — golf or skiing, for instance — of doctors who attend education sessions in resorts like Banff.
LIMITS TO FREE STUFF
Further changes to the ethical code of Rx&D, the organization representing Canada’s research-based pharmaceutical companies, are in the works, said spokesman Jacques Lefebvre.
The code still has plenty of wiggle room. Free entertainment can be provided to doctors provided it isn’t attached to an educational session. The only guideline is that the entertainment be “appropriate and reasonable.”
Would that allow a company to treat doctors to a cruise? Lefebvre would only say that anything that would create a flap if the media or public found out wouldn’t be considered reasonable.
As Lexchin points out, the top Rx&D fine for companies that break the code is just $15,000, “which is sort of lunch money for the drug companies.”
Nonetheless, said Lefebvre, the industry is very concerned about its public image, and companies do police each other. Violators’ offences are published in an industry newsletter.
DODGING THE DRUG REPS
Doctors’ behaviour toward the pharmaceutical firms is also changing because of the demands on their time. Price, the Ottawa-based medical consultant, said that with doctors’ workloads increasing in recent years, their time to meet drug reps often gets squeezed out.
Increasingly, he said, a doctor will duck out the back way to dodge a drug rep sitting in the waiting room.
“I’m not sure how the pharmaceutical companies are going to handle that,” Price said.
In other cases, doctors are acting on principle. Dr. Mary Hurlburt, a general practitioner who is president of the Capital Region Medical Staff Association, refuses to meet with drug sales reps.
“They try to catch my eye as I walk in,” she said, but she keeps walking.
Hurlburt doesn’t judge physicians who see the reps, but she feels there are better sources of information about which drugs to prescribe.
(While she won’t meet them, Hurlburt is happy to use the drug samples they leave behind, which can provide a short-course treatment for low-income patients.)
Similarly, Alberta doctors have taken a stand against the commercial use of their private prescribing habits. Pharmacists are now allowed to sell this information to a company called IMS Health Canada. IMS then sells the data to the pharmaceutical companies, which use them to lobby doctors.
The practice has infuriated Alberta doctors in particular, especially when the company began refusing to honour a doctor’s specific request that his data not be collected.
U.S. RESISTANCE GROWING
The case is now before the Alberta Court of Appeal.
Overall, physician resistance to drug reps is not well-documented in Canada. But that’s not the case in the United States, where getting access to physicians has become a major issue for pharmaceutical companies.
The number of sales reps in the U.S. doubled between 1995 and 2001, leaving doctors feeling under constant assault, according to a report by the U.S. consulting firm McKinsey and Company. Doctors are starting to resist the onslaught of drug reps.
Only eight per cent of sales reps’ visits to a doctor’s office now result in a meeting that the physician remembers later, according to McKinsey. Most reps who do see a doctor get less than two minutes, the company found.
In response to all this, the pharmaceutical industry has begun rethinking its tactics and is now targeting its message at others besides physicians.
“Ask me how many breakfasts I could have had at the Macdonald Hotel,” said Wendy Armstrong, Alberta’s best-known consumer advocate, in a recent interview.
“They’re always trying to win me over. And I always look them straight in the eye and say, ‘If you really want to help the cause, make the prices of the drugs lower.’ “
Armstrong said pharmaceutical companies these days are as eager to market to consumers as they are to doctors.
Canadian law prevents them from direct advertising to consumers (although we see ads for Nexium, Lipitor and others on American TV channels), but doesn’t prevent companies from giving financial assistance to disease groups of various kinds, she said.
EAGER TO SELL CONSUMERS
Armstrong, a longtime member of the Consumers Association of Canada, is now part of a nationwide group launching an organization called PharmaWatch, which will take a critical look at the pharmaceutical industry from a consumer point of view.
She says the industry tries to work through seniors’ groups or advocacy groups for particular diseases to promote a new drug. Key to the success of a drug is getting it on the provincial formulary — the list of drugs that the Alberta government decides to subsidize for seniors and the poor, she said. Pharmaceutical reps will coach citizens how to lobby to get the new drug on the formulary, said Armstrong.
“The pharmaceutical companies figured out who the real decision-makers are — the public.”
Lexchin says government officials themselves are targeted as companies try to get products on the formulary.
“You could lose 70, 80 per cent of your market if you’re not on a formulary, especially if it’s an expensive product,” Lexchin said.
“Doctors won’t prescribe it.”
sruttan@thejournal.canwest.com
DRUG BILLS
What the Alberta government has spent to subsidize prescription drugs
for seniors and others:
1997-98 — $185 million
1998-99 — $207 million
1999-00 — $251 million
2000-01 — $291 million
2001-02 — $349 million
