UO > Feature > A Relationship in Flux

A Relationship in Flux

Pharmaceutical reps and physicians have always had a symbiotic,
if cautious, relationship. With production demands on doctors and
new ethical guidelines affecting how reps detail drugs, the old
face-to-face may be a thing of the past.

By William Atkinson Published March/April 2005

Up until a couple of decades ago, when life was simpler, pharmaceutical representatives dropped by physicians’ offices, chatted a few minutes about new drugs, dropped off some samples, and left. Things have changed. In the past couple of years, time constraints have caused many physicians to reevaluate how (and even if) they see reps. Even greater changes have occurred in areas related to ethics, such as gift-giving and “shadowing,” where reps actually sit in during patient consultations. As a result, many physicians are looking for new direction in how to create and manage functional and ethical relationships with reps.

“We believe that, in the vast majority of cases, relationships between sales representatives and doctors are very constructive,” says Jeff Trewhitt, a spokesperson for the Washington, DC-based Pharmaceutical Research and Manufacturers of America (PhRMA), which represents about 90 pharmaceutical companies.

In addition, the industry can provide value above and beyond educational information from reps. “Pharmaceutical companies fund research, and not all of it is focused specifically on their own drugs,” says Munsey Wheby, MD, the president of the American College of Physicians and a professor of medicine at the University of Virginia School of Medicine in Charlottesville. “For example, they fund medical education in certain hospitals through unrestricted gifts.”

However, he continues: “The proper relationship between the individual physicians and medical organizations and the pharmaceutical industry has always been a difficult area for physicians.” One reason, according to Wheby, is that there is a variety of opinions about what constitutes a “proper” relationship between physicians and the industry in general, and between physicians and reps specifically.

Scott-Levin, a pharmaceutical research firm, reported in 1999 that, while the industry spent less than $2 billion in direct-to-consumer advertising, it spent more than $11 billion in direct marketing and promotion activities to physicians, an average of around $10,000 per physician per year. The same firm also reported that pharmaceutical industry-sponsored events increased from 80,000 in 1993 to 280,000 in 1999, many of them expensive “junkets” for physicians that included cruises and resort vacations.

By 2002, according to the Kaiser Family Foundation, a non-profit health research organization, direct-to-physician spending had increased to more than $13 billion, and direct-to-consumer advertising was at $2.5 billion.

Recently, according to Wheby, the physician-rep relationships are being more closely examined, in large part due to concerns among the public as to whether physicians and the pharmaceutical industry are too close. For example, are physician prescribing practices influenced by pharmaceutical’s promotional practices? “The primary responsibility of a physician is to serve the patient’s best interest,” Wheby says. “The primary responsibility of industry is to promote profitability. This doesn’t mean industry is evil.

However, it does mean that the differing interests can cause some conflicts.”

Michael Goldrich, MD, a New Brunswick, New Jersey-based otolaryngologist and the chair of the AMA’s Council on Ethical and Judicial Affairs, adds: “The AMA has a long-standing policy on the relationship between physicians and the pharmaceutical industry. The policy emphasizes the ethical obligations of physicians to the patients.” Pharmaceutical reps are one avenue for physicians to gain new knowledge about new products on the market, he acknowledges. However, “Once this shifts over to the realm of marketing, which is where problems such as gift-giving and shadowing emerge, then the ethical concerns about compromising the physician’s objectivity really stand in the way of new knowledge and can potentially compromise patient care,” Goldrich says.

Wheby shares some specifics of how ethics can be compromised: “Detail people can become quite close to physicians. For example, they may develop friendships and have social relationships. This can lead to improper relationships,” he says.

Rodney Sorensen, DO, the chair of the neurology department at the Marshfield Clinic in Marshfield, Wisconsin, says, “I have always had an innate mistrust of whether drug reps are really in the business of doing things that are the best for patients. Getting objective data to us about medications is valuable, but so much of it is tainted by marketing.” In his experience, too many reps seem to be saying, “Prescribe this medication, because it will be good for me and my company.”

The potential friction and differing goals play out in at least four scenarios: rep visit frequency, the circumstances under which physicians see reps, gift-giving, and shadowing.

Timing of visits

Scott-Levin reported that, in 1999, 62,000 pharmaceutical reps called on physicians, twice as many as just six years earlier. By 2001, this number had increased to 88,000. Verispan, a health-care research firm, reported that the industry employed more than 90,000 reps in 2003. “There is a ‘sales force arms race’ in the pharmaceutical industry,” says Briscoe Rodgers, the CEO of Boston-based RepWire (formerly MedMeeting), a rep scheduling firm. “Companies don’t seem to see any choice other than increasing sales force size in order to maintain market presence and awareness.” However, the explosion has begun to overwhelm physicians, according to Rodgers.

It is causing problems for reps, too. “As the number of reps has increased, productivity levels have plummeted,” says Rodgers. The reason: Physicians are still only seeing the same number of reps they did in the past, or, in many cases, even fewer.

Jeff McGeary, the president of the Philadelphia Area Pharmaceutical Representative Association, says, “Being a drug rep is definitely more challenging these days than it was when I started. For example, I have definitely seen some changes related to stricter access. Physicians tend to run busier schedules these days. They want to keep their hours as full as possible with patients.”

Time is a big issue for physicians, agrees Shannon Ostby, the president of the Metro Detroit Pharmaceutical Representatives Association. “Unfortunately, some reps don’t respect this time,” she admits.

While a rep’s individual approach can be important, some reps have more success seeing physicians than others simply by virtue of what they’re selling. Cambridge, Massachusetts-based Biogen IDEC, for example, is involved in oncology, neurology, and dermatology. “Given that we are in these specialty areas, physicians tend to want to see our reps,” says Irene Hunt, the marketing director for the neurology group. In addition, she says, reps focus exclusively on providing information, services, and other support to physicians and their patients. “Physicians tend to view all of this as value-added.”

Despite the value that reps can provide in terms of education and samples, some reps can “step over the line,” shifting from objective education to questionable marketing practices. “Some detail people can be very aggressive,” says Wheby. “As a result, more and more physicians and hospitals have found it necessary to create rules or guidelines for when and how detail people are seen.”

For example, physicians at Cardiovascular Specialists in Memphis, Tennessee meet with drug reps only on a pre-scheduled basis. “As new drugs are released, there is a need for the physicians to be informed,” says David Jones, the chief operating officer. “However, we have an individual who schedules these visits.”

Other facilities have tighter policies. “One of these is Columbus Oncology Associates in Ohio. “Most of the information our physicians need from drug reps can be handled via e-mail or an occasional phone call,” says Ruth Lander, the practice’s administrator. As such, physicians only see reps if they have brand new drugs, and then only for a few minutes at the end of administrative meetings twice a month.

In sum, more reps are jumping through more “hoops” just to get time with physicians. Further, the time the reps have is shorter. Result: Rep effectiveness is suffering. A study by McKinsey and Company found that for every 100 reps who visit physicians’ offices, only 20 get to meet with physicians, and the physicians themselves remember only eight of these encounters.

The price of admittance

Some medical practices have taken limiting rep access one step further—requiring pharmaceutical companies to pay to have their reps meet with physicians. While one result was the opportunity to increase clinic and physician incomes a bit, the main reason was to reduce the number of reps seeking time with physicians. “A few medical practices have tried this—not as a way to make money, but to discourage detail people from visiting,” says Wheby.

One medical practice that experimented with this concept for awhile was Seattle-based Polyclinic, an 80-physician multi-specialty practice. At the time, the group concluded that drug reps were too disruptive to the clinic’s workflow and patient flow. “At first, we tried to limit access,” says Lloyd David, the executive director. “We then had an interim program where we charged drug reps for visits with our physicians.” As of 2003, though, the clinic banned reps altogether. “We don’t even allow them into our building,” David says. He says the change in policy allows staff to focus on patients and removes a lot of interruptions for physicians.

Biogen IDEC’s Hunt is familiar with the concept of reps being charged for their time with physicians. “The physicians explain that it should be no different than charging their patients for time,” she says.

However, the practice has come under fire in the last year or so. The AMA’s Goldrich says, “The council’s view is that this is no different than any other kind of gift or payment to a physician.” The rationale: “Pharmaceutical reps should be providing useful information and knowledge to physicians. If this is true, then physicians should value the opportunity to communicate with reps, and there should be no charge.” However, according to Goldrich, if the physician is charging the rep, the implication is that what is valuable is the physician’s time, not the rep’s information.

RepWire’s Rodgers shares another concern. “Pharmaceutical companies giving money to medical groups is considered a conflict of interest,” he says. “For example, for Medicare and Medicaid purposes, the federal government considers it a kickback.”

So how can physicians reduce the number of reps they see without getting into the ethical issues of charging them directly? One option is a third-party service which charges reps to schedule appointments with physicians and clinics that are clients of the third-party firm. Two of the most well-known services are RepConnect and RepWire.

Under RepWire’s program, the medical practice faxes RepWire a sign-up sheet, where, for example, the first five reps who sign up each day can get in. The medical practice provides RepWire with instructions on what days are appropriate, when the time slots should be during those days, and how often a specific rep and pharmaceutical company can schedule appointments during a month. The reps can then sign up via the company’s Web site. “This not only helps the medical practice, but it is more convenient for the reps, because they have specific times when they are expected,” Rodgers says. “As a result, they don’t have to sit in the lobby and wait for an hour or more.” The scheduling service is free to medical practices. Reps that use the service pay a flat fee of $25 a month.

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