Healthy Skepticism Library item: 8149

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Publication type: news

Zaneski CT.
Medical sales reps arrive bearing gifts
Baltimore Sun 2004 Jun 17
http://pqasb.pqarchiver.com/baltsun/access/652026571.html?dids=652026571:652026571&FMT=ABS&FMTS=ABS:FT&date=Jun+17%2C+2004&author=Cyril+T.+Zaneski&pub=The+Sun&desc=Medical+sales+reps+arrive+bearing+gifts+

Full text:

Pharmaceuticals: The medical profession is taking a closer look at inducements for doctors to prescribe certain drugs.

By Cyril T. Zaneski
Baltimore Sun,
Originally published June 17, 2004

Dr. Lisa Pichney’s office is a popular stop for drug sales representatives.

As a gastroenterologist, Pichney writes a lot of prescriptions to help patients with heartburn, ulcers and excess stomach acid – common ailments that are the focus of a multibillion-dollar marketing competition among pharmaceutical giants. So more than 10 sales reps a week call on Pichney at St. Joseph Medical Center in Towson.

Reps, who typically get only a few minutes with Pichney, bring gifts: boxes of sample medications and forget-me-not pens, mugs, clocks and stuffed toys – all plastered with advertising. And Pichney, who has a sense of humor, displays every knickknack, giving her office the look of college dorm room with drug ads instead of beer promos.

Pichney insists the promos and pitches have no impact on the drugs she prescribes.

“What my drug reps are for is to educate me about new products, new studies or pending FDA warnings on old products. And, most important, they provide samples that are a great help for patients who have problems affording their medication,” she said. “To ask me to write prescriptions for their products is a ridiculous request.”

Few doctors would admit that drug company sales pitches influence their prescribing.

But pharmaceutical companies behave as though the reps and their handouts matter very much indeed.

In fact, for all the billions of dollars spent to reach consumers through drug ads on television and in publications, the pharmaceutical industry spends seven times as much to reach doctors and other professionals who prescribe the medicines.

AMA looks at issue

Just this week, the American Medical Association rejected a proposal that would have softened its stance against drug industry “freebies.” But AMA delegates deferred action on another proposal aimed at discouraging doctors from allowing drug reps to sit in on patients’ visits to the examining room.

Companies can pay several hundred dollars a day to physicians who allow reps into the examining room to learn first-hand about patients’ reactions with medications. AMA guidelines and federal privacy rules require that doctors allow the practice, known as “shadowing,” only if patients give their “informed consent.”

The medical professional is riven by a philosophical divide over drug industry practices.

The number of pharmaceutical sales reps who call on doctors and other health care professionals has doubled during the past decade to more than 90,000 – or a rep for every nine physicians. Industry consultant IMS Health suggests the true ratio of reps to doctors is even greater, with the sales force bearing down on 175,000 physicians who write 80 percent of the prescriptions – a rep for every two docs.

“The correlation between sales calls and the numbers of prescriptions is strong,” said

Harold Glass, director of the pharmaceutical business administration program at the University of the Sciences in Philadelphia. “Since making more sales calls is associated with increased prescribing, there’s been a sort of mutual escalation by pharmaceutical companies in the last few years, with up to five sales reps that call on behalf of the same company.”

The industry’s wooing of doctors with lavish expenses-paid ski trips, golf outings and fancy dinners has drawn harsh criticism from consumer advocates and the scrutiny of government investigators.

Last month, Pfizer Inc., the world’s largest drug manufacturer, agreed to pay fines of more than $430 million to halt government investigations into its marketing of the epilepsy drug Neurontin in 1994-2000.

The U.S. Justice Department says Pfizer provided doctors with weekends at Florida and Hawaiian resorts and trips to the 1996 Olympics in Atlanta with little or no medical education provided on the junkets.

Under pressure from its critics, the drug makers’ trade group, the Pharmaceutical Research and Manufacturers of America, or PhRMA, adopted in July 2002 a strict, voluntary code to guide the industry’s marketing conduct with doctors and other health-care professionals.

The PhRMA code allows companies to provide meals and gifts of less than $100 in connection with presentations and sales visits. The gifts must be something that can be used in a medical office. A stapler with a drug logo is OK under the code. A box of golf balls or a ticket to a sporting event is not.

The code’s impact was felt recently at a continuing medical education course for internists sponsored by the University of Maryland School of Medicine at the Sheraton Inner Harbor Hotel. About 115 physicians attended, helping them achieve the 50 hours of continuing education credit that they need for licensing every two years.

The drug industry used to spend heavily on such events. The companies sponsored cocktail parties, boat trips and dinners – and made the course a money-maker for the medical school, said Dr. Robert Vogel, a UM medical professor and the course director.

But in the wake of the code’s imposition, the weeklong course lost about $30,000 last year and this year it will lose about $10,000, he said. Just seven drug companies sponsored this year’s course, with five others setting up modest booths outside the meeting rooms.

“In the past, there were probably excesses,” Vogel said. “But now, this is a no-frills experience.”

Cost of influence

Even without the big-ticket perks, efforts to influence doctors are far from cheap. A face-to-face meeting with a doctor costs a drug-maker $2,250 to $3,000 an hour, when the costs of travel, samples, and other materials are counted, according to the
management consulting firm Cap Gemini Ernst & Young.

Few reps get an hour; the average visit to a doctor’s office lasts two to four minutes, with 43 percent of all sales calls ending at the receptionist, according to the firm’s report.

“Very few doctors do handstands when they see a drug rep coming through the door,” Glass said.

In all, the drug industry spent more than $18.5 billion wooing doctors and other health-care professionals in 2002. That’s up from $16.4 billion the year before and $8.4 billion in 1996, IMS Health reports.

With 2003 data still incomplete, spending on office and hospital promotions, medical journal ads and drug samples was on a pace to top $20 million.

The industry spends considerably less on the promotions aimed at patients.

Drug makers spent $2.6 billion on television and print ads in 2002 and was on track to spend a little more than $3 billion last year – mostly for a relatively limited number of drugs, IMS Health reports.

The intense promotion pressure is spurring a backlash from some in medicine.

Dr. Bob Goodman, a New York City internist and a faculty member at Columbia University’s College of Physicians and Surgeons, for one, refuses to meet with drug reps. He maintains that doctors can get better, unbiased information about drugs from the Internet and from journals and newsletters.

Goodman is leading a campaign to get doctors to swear off all drug company handouts and office sales calls. He calls his organization No Free Lunch, a reference to food that drug reps bring during lunchtime visits to medical offices.

About 300 doctors have signed Goodman’s pledge to shun the handouts. They have also sent Goodman hundreds of the drug industry’s handout pens, for which he sends them a “No Free Lunch” pen.

He said he got the idea for the exchange from a “guns for toys” program that New York police ran during a crack epidemic.

Medical schools and hospitals have also established policies in recent years in an attempt to keep tabs on the growing numbers of visiting sales reps.

St. Joseph in Towson, for example, gets visits from about 20 reps a day, said Barbara Ertel, the hospital’s director of pharmacy and rehabilitation. The reps are required to register with Ertel and stay out of areas where doctors treat patients – or eat lunch.

“If the doctor doesn’t want to see you in his office, he doesn’t want to be accosted when he’s trying to get a hamburger,” Ertel said. “Doctors don’t really have time to get bombarded by all these drug reps.”

Dr. William Henrich, professor and chairman of the Department of Medicine at the University of Maryland School of Medicine, said the school’s policies on drug reps have been the subject of recent intense debate.

“We elected to control access and not prohibit it,” Henrich said. “Part of our life here in medicine and in the country is in free access to commerce. And while this has certain unpleasant aspects like spam e-mail and sales calls at dinner, I think shielding residents from how the drug industry works is being a bit overprotective. These are trainees that are in their mid-20s, after all.”

The school also stopped short of banning drug company promotional paraphernalia.

“I didn’t think we could start policing what pens people use,” Henrich said. “My life is complicated enough.”

Industry responds

With spending on prescription drugs rising faster than on other health care over the past decade and millions of uninsured Americans struggling to pay for medicine, the drug industry is defensive about its spending on marketing and advertising.

Glass maintains that the industry’s promotional spending, while large, actually represents roughly the same percentage of its total revenue as it did a decade ago. The promotions, he said, are needed to enable drug companies to maximize profits on a
few blockbuster drugs – medications with more than $1 billion in annual sales – to cover the $800 million it takes to bring a medicine to market before patent protections expire. It can take 12 to 14 years of the drug’s 25-year patent life to get a medication to market, he said.

“Once the patent is gone, a drug falls to generics and its sales collapse,” Glass said. “It’s a very risky business.”

To measure a company’s marketing efforts to lure customers to its medication, consider Nexium, the heavily advertised “Purple Pill.”

Nexium is a proton pump inhibitor. It prevents the release of acid in the stomach and intestines to relieve acid reflux disease, which is also known as gastroesophageal reflux disease, or GERD. Patients with the disease experience persistent heartburn two or more times a week – a problem for more than 40 million Americans.

Sales of $3.3 billion

AstraZeneca spent $411 million promoting the Purple Pill last year. That helped make it a $3.3 billion blockbuster, the seventh-biggest-selling brand name drug last year, according to the trade publication Pharmaceutical Executive.

The drug maker paired a heavy direct-to-consumer campaign with a doubling of its sales force to 6,000 reps the past two years, company spokeswoman Rachel Bloom-Baglin said.

“If the medication wasn’t effective in the first place, all the marketing in the world wouldn’t help sell it,” Bloom-Baglin said. “The bottom line is the marketing works because the pill is effective.”

But the advertising apparently gives Nexium a leg up on two competitors, Wyeth’s Protonix ($1.49 billion in sales last year) and Eisai’s Aciphex ($1 billion), which market to doctors but not directly to consumers.

Pichney, who writes prescriptions for all three, displays Nexium’s purple tape dispenser, stapler, note holder, and clock and gives windowsill space to a stuffed dragon named Gerdee from Protonix, and a couple of model cars promoting Aciphex.

Patients, who see Nexium ads on television, overwhelmingly ask for the Purple Pill, Pichney said.

“It was very smart that they made the pill purple, because nothing else is purple,” Pichney said. “It definitely works. People come in the door and say, ‘I want that purple pill I saw on television last night.’”