Following the script

In 2000, pharmaceutical companies spent more than $15.7 billion on promoting prescription drugs in the United States alone. More than $4.8 billion was spent on detailing, the one-on-one promotion of drugs to doctors by pharmaceutical sales representatives, commonly called drug reps. The average sales force expenditure for pharmaceutical companies is $875 million annually.

Unlike the door-to-door vendors of cosmetics and vacuum cleaners, drug reps do not sell their product directly to buyers. Consumers pay for prescription drugs, but physicians control access. Drug reps increase drug sales by influencing physicians, and they do so with finely titrated doses of friendship. This article, which grew out of conversations between a former drug rep (SA) and a physician who researches pharmaceutical marketing (AFB), reveals the strategies used by reps to manipulate physician prescribing.

The friend game

Reps may be genuinely friendly, but they are not genuine friends. Drug reps are selected for their presentability and outgoing natures, and are trained to be observant, personable, and helpful. They are also trained to assess physicians' personalities, practice styles, and preferences, and to relay this information back to the company. Personal information may be more important than prescribing preferences. Reps ask for and remember details about a physician's family life, professional interests, and recreational pursuits.

A photo on a desk presents an opportunity to inquire about family members and memorise whatever tidbits are offered (including names, birthdays, and interests); these are usually typed into a database after the encounter. Reps scour a doctor's office for objects-a tennis racquet, Russian novels, seventies rock music, fashion magazines, travel mementos, or cultural or religious symbols-that can be used to establish a personal connection with the doctor.

Good details are dynamic; the best reps tailor their messages constantly according to their client's reaction. A friendly physician makes the rep's job easy, because the rep can use the "friendship" to request favours, in the form of prescriptions. Physicians who view the relationship as a straightforward goods-for-prescriptions exchange are dealt with in a businesslike manner. Skeptical doctors who favour evidence over charm are approached respectfully, supplied with reprints from the medical literature, and wooed as teachers. Physicians who refuse to see reps are detailed by proxy; their staff is dined and flattered in hopes that they will act as emissaries for a rep's messages.

Gifts create both expectation and obligation. "The importance of developing loyalty through gifting cannot be overstated," writes Michael Oldani, an anthropologist and former drug rep.²⁶ Pharmaceutical gifting, however, involves carefully calibrated generosity. Many prescribers receive pens, notepads, and coffee mugs, all items kept close at hand, ensuring that a targeted drug's name stays uppermost in a physician's subconscious mind. High prescribers receive higher-end presents, for example, silk ties or golf bags. As Oldani states, "The essence of pharmaceutical gifting; is ‘bribes that aren't considered bribes'".¹

Reps also recruit and audition "thought leaders" (physicians respected by their peers) to groom for the speaking circuit. Physicians invited and paid by a rep to speak to their peers may express their gratitude in increased prescriptions. Anything that improves the relationship between the rep and the client usually leads to improved market share.

Script tracking

Pharmaceutical companies monitor the return on investment of detailing-and all promotional efforts-by prescription tracking. Information distribution companies, also called health information organisations (including IMS Health, Dendrite, Verispan, and Wolters Kluwer), purchase prescription records from pharmacies. The majority of pharmacies sell these records; IMS Health, the largest information distribution company, procures records on about 70% of prescriptions filled in community pharmacies.

Patient names are not included, and physicians may be identified only by state license number, Drug Enforcement Administration number, or a pharmacy-specific identifier.⁵ Data that identify physicians only by numbers are linked to physician names through licensing agreements with the American Medical Association (AMA), which maintains the Physician Masterfile, a database containing demographic information on all US physicians (living or dead, member or non-member, licensed or non-licensed). In 2005, database product sales, including an unknown amount from licensing Masterfile information, provided more than $44 million to the AMA. ⁵

Pharmaceutical companies are the primary customers for prescribing data, which are used both to identify "high-prescribers" and to track the effects of promotion. Physicians are ranked on a scale from one to ten based on how many prescriptions they write. Reps lavish high-prescribers with attention, gifts, and unrestricted "educational" grants. Cardiologists and other specialists write relatively few prescriptions, but are targeted because specialist prescriptions are perpetuated for years by primary care physicians, thus affecting market share.

Reps use prescribing data to see how many of a physician's patients receive specific drugs, how many prescriptions the physician writes for targeted and competing drugs, and how a physician's prescribing habits change over time. One training guide states that an "individual market share report for each physician pinpoints a prescriber's current habits" and is "used to identify which products are currently in favor with the physician in order to develop a strategy to change those prescriptions into Merck prescriptions". ⁶

A Pharmaceutical Executive article states, "A physician's prescribing value is a function of the opportunity to prescribe, plus his or her attitude toward prescribing, along with outside influences. By building these multiple dimensions into physicians' profiles, it is possible to understand the ‘why' behind the ‘what' and ‘how' of their behaviour." ⁷

To this end, some companies combine data sources. For example, Medical Marketing Service "enhances the AMA Masterfile with non-AMA data from a variety of sources to not only include demographic selections, but also behavioural and psychographic selections that help you to better target your perfect prospects".⁸

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