Drug reps know what doctors are prescribing

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An excerpt from White Coat, Black Hat.

by Carl Elliott

[Michael] Oldani worked as a rep in the late 1980s and the 1990s, a period when the drug industry was undergoing key transformations. Its ethos was changing from that of the country-club establishment to the aggressive, new-money entrepreneur.

Impressed by the success of AIDS activists in pushing for faster drug approvals, the drug industry increased pressure on the FDA to let companies bring drugs to the market more quickly. As a result, in 1992 Congress passed the Prescription Drug User Fee Act, under which drug companies pay a variety of fees to the FDA with the aim of speeding up drug approval (thereby making the drug industry a major funder of the agency set up to regulate it). In 1997 the FDA dropped most restrictions on direct-to-consumer advertising of prescription drugs, opening the gate for the eventual Levitra ads on Super Bowl Sunday and Zoloft cartoons during daytime television shows. 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.

Many companies started hitting for the fences, concentrating on potential blockbuster drugs for chronic illnesses in huge populations: Claritin for allergies, Viagra for impotence, Vioxx for arthritis, Prozac for depression. Successful drugs were followed by a flurry of competing me-too drugs. For most of the 1990s and the early part of the following decade, the pharmaceutical industry was easily the most profitable business sector in America. In 2002, according to Public Citizen, a nonprofit watchdog group, the combined profits of the top ten pharmaceutical companies in the Fortune 500 exceeded the combined profits of the other 490 companies.

During this period, reps began to feel the influence of a new generation of executives intent on bringing market values to an industry that had been slow to embrace them. Anthony Wild, who was hired to lead Parke-Davis in the mid-1990s, told the journalist Greg Critser, the author of Generation Rx, that one of his first moves upon his appointment was to increase the incentive pay given to successful reps. Wild saw no reason to cap reps’ incentives. As he said to the company’s older executives, “Why not let them get rich?” Wild told the reps about the change at a meeting in San Francisco. “We announced that we were taking off the caps,” he told Critser, “and the sales force went nuts!”

It was not just the industry’s ethos that was changing; the technology was changing too. According to Oldani, one of the most critical changes came in the way that information was gathered. In the days before computers, reps had to do a lot of legwork to figure out whom they could influence. They had to 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. “Pharmacists are like pigeons,” Jamie Reidy, a former rep for Pfizer and Eli Lilly, told me. “Only instead of bread crumbs, you toss them pizzas and sticky notes.”

But in the 1990s, new information technology made it much simpler to track prescriptions. Market-research firms began collecting script-related data from pharmacies and hospitals and selling it to pharmaceutical companies. The American Medical Association collaborated by licensing them information about doctors (including doctors who do not belong to the AMA), which it collects in its Physician Masterfile. Soon reps could find out exactly how many prescriptions any doctor was writing and exactly which drugs those prescriptions were for. All they had to do was turn on their laptops and download the data.

What they discovered was revelatory. For one thing, they found that a lot of doctors were lying to them. Doctors might tell a rep that they were writing prescriptions for, say, Lipitor, when they weren’t. They were just being polite, or saying whatever they thought would get the rep off their backs. Now reps could detect the deception immediately. (Even today many doctors do not realize that reps have access to script-tracking reports.)

More important, prescription tracking helped reps figure out which doctors to target. They no longer had to waste time and money on doctors with conservative prescribing habits; they could head straight to the high prescribers, or high writers. The script-tracking report might even be accompanied by a profile of a physician put together by reps. (Oldani says, “A profile would be:  ‘Husband, three kids, loves needlepoint, off on Wednesdays. Amiable/expressive, brought up suicidality four times. High writer of Prozac. Won’t accept tickets. Nurse says loves red wine, only French.’”) Reps could get direct feedback on which tactics were working. If a gift or a dinner presentation did not result in more scripts, they knew to try another approach.

But there was the rub: the data was available to every rep from every company. The result was an arms race of pharmaceutical gift-giving, in which reps were forced to devise ever-new ways to exert influence. If the Eli Lilly rep was bringing sandwiches to the office staff, you brought Thai food. If GSK flew doctors to Palm Springs for a conference, you flew them to Paris. Oldani used to take residents to Major League Baseball games. “We did beer bongs, shots, and really partied,” he told me. “Some of the guys were incredibly drunk on numerous occasions. I used to buy half barrels for their parties, almost on a retainer-like basis. I never talked product once to any of these residents, and they took care of me in their day-to-day practice. I never missed quota at their hospital.”

Carl Elliott is a writer for The New Yorker and The Atlantic Monthly and author of White Coat, Black Hat.

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