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Are Samples All that a Drug Rep has Left?

A while back, I linked to a story in which an opinion was offered that, after the new (updated) PhRMA code goes into effect in January ’09, about the only marketing tool a rep will have left is samples.

The link to this story is right here, and I suggest you read it for background. I forwarded it privately to a number of folks in my “inner circle.” There were some interesting reactions, including one very long written one, which I’ve gotten permission to reprint below (that’s why you want to scan the original article first – the context is important).

These are thoughts from Joe Elliott, Director of Marketing – Urology, Watson Pharmaceuticals:

Our company recently conducted some marketing training and review of what the updated PhRMA guidelines mean for acceptable marketing and promotional tactics Although there are a lot of rules, there’s still room for interpretation, and you will see variable application based on each pharma company’s interpretation of risk. In fact, most of the guidelines have to do with perception (and any lawyer can find a compliance problem if he/she wants to perceive one!) For example, if I held a meeting with MD’s at a Ritz Carlton (“resort” perception) with a sleeping or meeting room rate of $100 per person, that would NOT be acceptable compared to, say, a Marriott, even though I was paying >$250 per person.

However, some things, such as the giveaways mentioned in the article, will certainly disappear. It’s pretty amazing that states like Massachusetts and others want “gifts” to the MD of >$50 value reported. As one person in academia put it to me, the legislators certainly don’t think too highly of the MD’s in their own state if their ethics can be corrupted for $50!!

We’ll probably also see increased use of CME; bearing in mind, however, that the rules for involvement of the pharma company with the CME provider are now so draconian, that perhaps the opposite will happen. If you can’t provide input into the therapeutic content, or even suggest known MD experts, then how do you know that content relative to your product will be discussed or presented?  The concern about “programming” the content may or may not be legitimate, but in general historically these programs have been quite valuable to all involved, and honestly conducted. Rules on this have been in place for some time anyway.

As far as reps go, if their view of the world is that they must have samples to engage the MD, but do not actually do so, there probably is no need to employ those kinds of reps. Some reps may not realize it, but they still have promotional information, literature, and study data that they can deliver.  While it is clearly more difficult in general medicine and mass market therapies (e.g., hypertension) to have a dialogue with the physician, in fact the main responsibility of the rep is to exchange information of value to the MD in terms of optimizing patient treatment (see quote on p. 8 about the BEST way to see doctors). Doctors still see reps, especially specialty reps, because they are able to perform this function (see the quote in the article by Dr. Clark).

The best reps know the disease state, not just their drug, as well as the MD, and can therefore provide information about the most appropriate clinical situation that will fit their drug. If it doesn’t fit, the best reps acknowledge this, and are even willing to make alternative, competitive, suggestions. THAT behavior, focused on serving the interests of the patient, and the physician’s practice, is the basis of any credibility that the rep has, and why the MD will continue to see them. I can personally give you 5-6 stories of doctors calling reps into their offices to personally thank the rep for literally saving a patient’s life, through either the information they delivered, or the resources of the company that they provided access to.

The one area where reps will really have a difficult time under the 2009 guidelines is prohibition of meals outside the office or hospital. Typically a dinner (where the rules on what can be spent and what can be said- in-label info only- are already in place for every company), with a therapeutic discussion, are valuable and fuller interchanges, since there is no time pressure once out of the office, and no patients are waiting. However, now this can only be done with speakers present, which actually drives up the cost of these programs. I would not want to be a new pharma rep now, as it is much more difficult to build a personal relationship, which is the hallmark of all repetitive selling. A professional relationship based on established credibility and trust is not a bad thing, and is no more inappropriate in pharmaceuticals than in any other type of product.

As far as samples go, I don’t think you’ll see them disappear anytime soon, unlike the other giveaways. They’re simply too valuable to the patient and the doctors. Dr. Cutrona (see quote in the article) is inaccurate about safety issues, as any new prescribing information, including black box warnings, MUST be communicated by company representatives to the prescriber, whether they are treating children or not. Perhaps she doesn’t want to acknowledge that it is her responsibility to prescribe with knowledge of the full PI, and if she doesn’t know it, that’s exactly what the reps are for!!

If it was up to the drug companies though, and they felt every other company would behave similarly, they would eliminate samples tomorrow, simply based on the expense. The article makes a big point about how samples are used to generate prescriptions for brand drugs, which they surely are. But the physician has the option to prescribe whatever drug, including the generic version of the sample if it exists, that he wants. Few ever give drug companies credit for providing these samples for the right reason, which is to make sure the patient can tolerate the drug before a prescription is generated.

And while we’re talking about brands, and whether they have any incremental benefit vs. other older drugs, that also is the MD’s decision, and is the basis of FDA approval for the newer brand. It’s unfortunate that neither the provider community nor patients fully recognize that even incremental changes in drugs within the same class can be beneficial. If that was not the case, everyone would be on Mevacor, instead of Lipitor. One drug choice per drug class is not the right answer clinically for all patients. People simply respond and react differently. If it really is not any better, both provider and payer, as well as pharmacist, can implement decisions to force use of the older generic. In fact mandatory substitution by pharmacists already exists in most states.

I also don’t see too much credit being give to pharma for the free drugs (in the 10’s of millions of dollars per major company) being given away for indigent patients, or for the reimbursement support, co-pay assistance programs (which cannot legally be attached to any individual drug), rare disease programs, CME events, and medical society support (without which NO medical society would be solvent), etc.

Frankly, where the industry should spend more money is on compliance and persistence programs. MD’s assume that patients are taking the drugs as prescribed, but there is much documentation that 20-30% of the prescribed drug is never taken, for a variety of reasons. This leads to therapeutic failures that are often misunderstood or misinterpreted, as physicians do not always catch this. If patients increase this behavior for the economic reasons suggested on the last page of the article, not only drug profits would be affected, but so would patient outcomes!

(as with Chris in the original article, these thoughts are Joe’s and do not necessarily reflect those of his employer)

What are your thoughts? Feel free to give your two cents in the Comments!

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