A former pharma rep explains how the industry pushes doctors to overprescribe

Originally published at: https://boingboing.net/2019/12/02/pills-pills-pills-2.html

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If I so much as accept a glass of water from a rep I’ll be fired. I’m apparently in the wrong line of work.

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Obligatory.

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The orthopedic department of the hospital I worked at during college had lunch delivered practically every Friday from pharma reps. It happened so often there was rarely a gap.

If anyone would like a more dramatic portrayal of this issue, Law & Order had an episode about it somewhere in season 13 or 14, I think. :wink:

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I don’t know if it’s still the case, but pharma sales reps used to be evaluated based on how much they expensed for entertainment. If it was too low, they could face disciplinary action or fired.

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You and I are going to have to start deuling L&O and Leverage episodes.

I see your “somewhere in s13 or s14” and raise you “The Double-Blind Job”.

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Related:

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I was a pharma rep. And this guy is using hyperbole, to a degree.

First of all, physicians are intelligent people. Way smarter than your average bear. And almost all of them are also highly ethical, which is why they spend way more years on their training than other professions all in the pursuit of directly helping other people.

You simply do not manipulate this sort of person to do anything not in a patient’s best interest. And you sure do not do that with a pen or a pad. You don’t do it with a dinner, or a vacation, or an honorarium. You just plain don’t.

And the fact of the matter is that doctors get all these goodies from ALL the pharma reps. Who represent ALL the various drugs - including the competitors to your own pharma company’s products. All of these dinners have an educational component - that’s the law now. You bring a bunch of docs to an evening meal/presentation and they get a lousy, uninformative, or clearly biased presentation? - you stop getting responses to your invitations.

Yes - some docs DO earn huge dollars on honoraria at those dinners. They also earn them at accredited conferences where continuing education credits are awarded through 3rd party medical education entities. Why? Because, let me tell you, not everyone can give a great presentation. You have to have a load of clinical experience. You have to be completely up-to-date on the latest research. Usually, you are publishing some of the latest research. You have to be able to give a dynamic information-filled, clinically-useful presentation to people who have seen hundreds of presentations. Very few people qualify. Many of the self-same docs are, in fact, used by the pharma reps who compete with one another!

I’m not going to give a huge defense of the pharma industry. I have a lot of gripes about it myself. But I will say this: There is a huge amount of animus about the industry, much of which is uninformed and misplaced. Because, let’s face it - nobody would give a flying **** about the pharma industry if the medical insurance providers paid all our pill bills.

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The problem would be so easy to fix–don’t let the drug companies find out what doctors prescribe their stuff.

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They’re also overworked, underappreciated, tired, lonely, hungry, horny, and human. You’re slinging some serious halo effect to jump from “was academically successful in human biology” to “is too clever to be manipulated.” Lots of electrical engineers and Olympic athletes are get into wacky stuff. And that’s setting aside Ahiri’s claims about targeting the docs they know are susceptible.

I just don’t see why they’d spend the money if it wasn’t working…

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And there are piles and piles of dead bodies that show that it worked too well for the opioid pushers. Hundreds of thousands of them.

NPR did a feature on the decline in life expectancy for people between 20 and 40, and the #1 contributor is the opioid epidemic.

Wow. That’s just oblivious. Physicians are human, and flawed. Many are wonderful people. A few (still too many) are scumbags.

https://www.justice.gov/usao-ndoh/pr/mansfield-physician-indicted-alleged-have-illegally-prescribed-tens-thousands-doses

https://oig.hhs.gov/fraud/enforcement/criminal/

…and so on.

Notice that nowhere is the point of view that some patients should not receive those drugs represented. What you get is Drug A is best for patients like this, Drug B is best for patients like that. What you’re missing is many of those patients should not be treated pharmacologically at all, or with a generic that no one profits from.

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Sorry, I am a physician, and most of that is just wrong. We are every bit as subject to human failings as anyone. There have been studies showing that even small tokens like pens and notepads can influence prescribing habits.

There are also many of us who assume we are not vulnerable to this kind of influence. Those tend to be the worst for it. In my office we do not allow gifts, marketing promo items, meals or visits by drug reps and I think are better for it. Now, I hasten to add that in pediatrics (my specialty) we do not get anywhere near the pressure that adult docs do, just for the fact that almost everything we prescribe is generic and kids are not as medicated as grown ups, so there is that.

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Even from other pressure sources. The chief orthopedic surgeon at the hospital I mentioned above would practically mainline caffeine by chewing on coffee beans to keep going. I’m not sure I’d want to be under his knife.

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Simply having been pitched a drug by a sales rep can cause a doctor to prescribe that particular brand due to the recency effect. There are SO MANY varieties of pharmaceuticals that its often recommended to ask your pharmacist if there are interactions with other meds you take, if it contains something you’re allergic to, or potentially severe side effects.

That is how doctors categorize meds all by themselves. And generics are prescribed the vast majority of the time anyway, are automatically substituted by Rx’s and Rx plans, and often (unfortunately now) generate higher profits than branded drugs.

I just went through selections for Medicare. All my drugs are generic, and some “plans” would have cost me $14,000 a year (!). I can purchase those same drugs for about 1/50th of the price by paying cash at the RX or online.

The whole prescription drug mess is a shell game where everyone (the doc, the pharma company, the medical insurer, the Rx, the hospital, the patient) is a player. It is often less expensive for a patient to be prescribed a prescription drug rather than buy it OTC, and sometimes less expensive for the patient to get a brand name than a generic.

And again - nobody would care if there were zero copays for drugs. An easy fix: mandate that all drugs be paid 100% by the insurer. (No copays, no minimums, no caps). Then let the insurers negotiate for the lowest prices.

Some issues I see with that study:

  1. The targeted docs are the ones who generate the most scrips. The difference was stark. This is why they were likely targeted in the first place, and does not necessarily mean that they have been co-opted into writing unnecessary scrips. (When I was a rep, the 80/20 rule was hammered all the time - spend your time on the 20% of docs who write 80% of the scrips)

  2. Both groups are writing generics most of the time.

  3. Is it possible that these offices are writing slightly more branded scrips because they are better at saving their patients money be “gaming” the RX plan? Depending on the plan/drug, sometimes a branded drug can cost less to the patient.

  4. My experience (which lasted for 20+ years, but ended 15 years ago) was that younger docs were more likely not to see reps/accept gifts and the opposite true for older docs. Older docs also seemed more likely to go directly to Go - that is, go directly to more modern drugs. I asked some about that, and they said they had too many years of experience - and much less stomach for - prescribing older drugs that would fail and require the patient to come back and/or would then be in worse shape or more difficult to deal with. They wanted simple and effective. One stop shopping.

I posted that one as it was recent. There have been many others. I have been practicing for 30+ years, and therefore certainly qualify as a “younger doc,” whatever that means. I prefer to think of it as ethical rather than old. Again, my practice is peds, and we live in a different world than most docs. YMMV.

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Well, US pharma has a LOT of money to spend! And my impression after being in the industry for two decades, was that the nature of Pharma marketing changed dramatically. When I started, there were very few reps and we were there to give solid information. I would go to the medical library every month to look at the latest clinical trials, copy them, and share them with docs. They sometimes found that very useful.

And then, all of the Pharma marketing departments changed. It appeared that they were taken over by MBA marketing grads who felt it was more effective to sell drugs to physicians the exact same way as Tide sold detergent to housewives. The emphasis on science information distribution gave way to what they called “share voice”. IOW, the more times a doctor heard the drug name or message the more likely they would prescribe it. The number of Pharma reps increased ten-fold. It was a nightmare.

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Only if the game is called “Everybody Kick the Patient!”

That completely ignores how they came to write so many scripts that they reached “targeted” status. Pharma companies have figured out how to reach physicians earlier and earlier in their career. Some now start marketing to physicians on their first day of med school. Another completely legal but problematic tactic is to fund fellowships. The sooner you build that loyalty, the longer it pays off.

The other big change was the switch from what I would call “skilled reps” who often had a pharmacy or nursing background to junior MBA-types. This coincided with a change to scripted sales calls, often using a tablet that not only presented the sales pitch but recorded which pitch was used, for how long, even down to how much time was spent on each slide. Reps who don’t follow the script or the right order of the sales process got in trouble, even if they were making sales.

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