Drug Reps Use Sophisticated Bribes

St. Petersburg Times
To move more prescription drugs, sales reps sling swag
By Kris Hundley  
Sunday, April 5, 2009

  clip_image0021
Ben Schaefer, a cardiologist in Maine, rid his practice of pharma-freebies last summer,
before drug companies voluntarily banned them.
 
 
The transformation of a Jacksonville psychiatrist from a skeptic on Seroquel into a super-prescriber was marked by months of gentle pestering, generous $1,500 speaking engagements and giveaways of everything from a plastic brain to gourmet chocolates.

A neurologist in Tampa joked with Seroquel sales reps that she doled out so much of the powerful antipsychotic drug for migraines that they probably thought she was psychiatrist. She was rewarded with free trips to Scotland and Spain. “I want to go too ! =)” her Seroquel rep wrote.

A busy Panama City physician had no problem leaving patients to stew in the waiting room while he listened to a pitch about Seroquel from a persistent saleswoman.

“Dr had 3 pat (patients) waiting and did sit down w (with) me,” the rep wrote after a series of snubs at the front desk. “You never know what you will get w/dr b.”

Every day, legions of drug reps troop into doctors’ offices, then scoot back to their cars and enter notes about their encounters onto laptops or handheld devices. They include reminders about everything from medical questions to the doctor’s new Nissan 350Z or his kid’s Eagle Scout badge.

The notes are uploaded to a secure database at company headquarters and used by the drug rep, her partners and managers as the company refines its sales spiel.

Thanks to thousands of lawsuits pending against Seroquel, AstraZeneca’s best-selling antipsychotic, hundreds of pages of call notes concerning several Florida doctors recently were made public. Though specific to Seroquel, the salespeople’s notes reflect industry-wide practices. They give insights into what happens behind closed doors while patients cool their heels.

It’s not a pretty picture, with sales reps laying on the swag and doctors complaining about late honoraria and angling to get on the AstraZeneca’s “advisory board.”

Company spokesman Tony Jewell said the drug maker’s philosophy is that “any interaction with health care providers should be about providing information that helps them decide on the right medicines, for the right patients, at the right time.”

But notes from pharma’s emissaries reflect two different goals: Get the doctor to prescribe the drug. Then push him to boost the dosage.

A sales rep in Jacksonville was ecstatic when a nurse practitioner prescribed Seroquel at twice the dosage used by the psychiatrist in the same practice.

“Gave him goodies,” the rep wrote. “Biggest user of Seroquel in the office!”

• • •

AstraZeneca’s sales reps have worked wonders. Though approved only for schizophrenia and bipolar disorder, relatively rare mental illnesses, Seroquel has been one of the world’s best sellers. Last year sales reached $4.5 billion.

But Seroquel’s widespread use for everything from insomnia to anxiety has also triggered lawsuits alleging the drug caused weight gain, diabetes and other health problems. AstraZeneca, a U.K.-based company, denies the charges, noting that the FDA has repeatedly upheld the safety of Seroquel.

It also has denied that its salespeople illegally promoted unapproved, or off-label, uses of the drugs to doctors. Reps “are trained to ensure that every product promotion discussion with (a) health care provider conforms to the FDA-approved prescribing information,” Jewell said.

Company lawyers vigorously opposed unsealing sales reps’ notes, saying they contained confidential, proprietary information. But at a recent hearing in Orlando’s federal court, AstraZeneca agreed to release call notes from before January 2004, when Seroquel received FDA approval for bipolar mania.

Heavily redacted, the notes comprise what the company’s commercial brand leader, Alfred Paulson, described as sales reps’ “continuous conversation” with a half-dozen Florida health care providers who prescribed Seroquel to plaintiffs in pending lawsuits.

Depicting sales pitches, on which millions of dollars of revenue hinge, as simple “conversations” is an apt description for what, in the end, comes down to the chemistry between two people. Shahram Ahari, a drug rep for competitor Eli Lilly & Co. in 1999 and 2000, now lectures physicians on how to avoid being manipulated by well-trained marketing reps.

“As much as doctors want to think the relationship with a sales person is about the transfer of knowledge, it’s the affinity between two people that’s the big money-maker for the drug company,” said Ahari, who is part of Pharmedout.org, a physician-education group in Washington, D.C. “That’s why drug companies hire former cheerleaders and athletes as drug reps instead of scientists. It’s a question of how gregarious and engaging you can be.”

While AstraZeneca declined to comment on its employees’ compensation, industry data shows drug reps earn an average of nearly $100,000 a year, including bonuses based on sales.

They learn sales techniques more often associated with door-to-door soliciting than medical offices. Doc too busy to see you? Send in several sales people, daily if necessary, until you get a sit-down. Show up on rainy days when patients cancel. And even highly paid physicians find it hard to resist a free lunch.

In 1999, Seroquel reps tried to waylay Dr. Maria Carmen Wilson, the Tampa neurologist, four times before hitting gold.

“We were able to speak to her at lunch that we brought for the office,” a rep wrote.

Wilson moved from free food to free trips to medical meetings in Spain and Scotland. By early 2002, a drug rep noted that Wilson was using a “ton of Seroquel” for patients with migraines.

Wilson, who says she was surprised to learn that drug reps recorded their interactions with her, denies that she was ever a big Seroquel prescriber. Despite her initial hopes, she says the drug did not turn out to be effective against chronic headaches.

“I still use it in low doses for people with intractable insomnia,” said Wilson, an associate professor at the University of South Florida. “But I make sure patients are acutely aware of the potential for weight gain, especially if they have a predisposition to diabetes.”

Wilson says the industry-funded jaunts to Europe did not unduly influence her.

“I went because I want to be up-to-date and learn,” she said of the seminars, which she did not report, as required, to USF officials. “But frankly, I’d prefer they were in Orlando.”

• • •

The call notes show that massaging doctors’ egos consumed an inordinate amount of a drug rep’s time.

Saleswomen in Miami quickly honed in on psychiatrist Dr. Heriberto Cabada’s need for extra schmoozing. “Would not pay attention, all about him,” wrote one frustrated sales rep in 2001. So the line worker pulled in a “customer solutions” specialist who offered to redo the doc’s patient history forms with a personalized logo.

She agreed to Cabada’s demands for multiple revisions, “one side only and … marbled type paper.” More attention was funneled his way through a “preceptorship,” in which a sales rep shadows the doctor for the day and pays for the honor.

In a few months, Cabada went from prescribing what he called “chicken dosages” of Seroquel to higher doses. Soon after his conversion, however, Cabada closed his practice and moved to Spain, where he now lives. He did not respond to an e-mail seeking comment.

Drug reps are taught to use free samples as a strategic weapon: Parcel them out sparingly, even if there are box loads in the trunk.

“It makes the doctor even more grateful,” said former Lilly rep Ahari. “And when he gives a freebie to the patient, the doctor feels like a hero.”

Dribbling samples out in small caches, and requiring the doctor’s signature each time, also gives the rep another chance at valuable face time.

“Samples are key to access,” wrote a sales rep who was routinely brushed off by Dr. John Roy Billingsley in Panama City.

AstraZeneca said it has voluntarily banned many of its “reminder” giveaways to docs — free pens, pads and hand wash emblazoned with drug names. But the company declined to say how such changes have affected its spending on physicians.

Ahari said he doubts drug companies have pared back their marketing budgets. “The money going to influence physicians is exactly the same,” he said.

“There’s absolutely no enforcement of these voluntary guidelines. All the incentives are still in place to wine and dine doctors at Hooters if he needs to.”

The reason: it works.

Case in point: Dr. Mohamed O. Saleh, a Jacksonville psychiatrist who was involved in early clinical studies of Seroquel. In 1998, he was telling AstraZeneca reps that their product wasn’t effective and two years later he was still dodging salesmen.

By 2003, however, the rep was crowing that Saleh “really loves seroquel for elderly… said that he would — dose of 800 (mg) and even higher if necessary!”

Saleh and his nurse practitioner, Richard Daniel Malcolm, were wooed with everything from holiday treats (“Left pumpkin candy baskets … put seroquel labels on them”) to a video of Saleh for his use during a visit to Africa in 2002.

AstraZeneca also furnished Saleh with freebies for the trip. The payoff: the doctor told the drug rep he would put a picture on his Web site showing “African healthcare workers holding the Seroquel bags filled with (a text book) and pens/etc. Appreciated our support.”

Saleh, who said in July that he is still receiving $10,000 to $15,000 a year as a speaker for Seroquel, seemed aware of the persuasive power of drug company payola. In October 2003, he told AstraZeneca reps that he was concerned about his nurse practitioner, who had taken a fishing trip with the Seroquel rep and was pushing for his own speaking gigs.

“Concerned about payments to Dan (Malcolm) and can be inducement for scripts b/c paying so much,” wrote one of the two reps assigned to Saleh’s office.

Malcolm joined Saleh’s office in June 2001, four months after he was disciplined by the Florida Board of Medicine for pleading guilty to charges of domestic battery, driving with a suspended license and fraud in obtaining a medicinal drug.

Neither Saleh nor Malcolm returned calls or e-mails seeking comment.

• • •

When doctors complained that patients were ballooning up on Seroquel, sales reps often handed them a study by Chicago psychiatrist Dr. Michael J. Reinstein. Its startling message: “Use of S (Seroquel) to reduce weight and reduce risk,” according to a salesman who visited Panama City’s Billingsley.

Back at headquarters, however, company executives had serious questions about the validity of Reinstein’s findings. “Our clinical colleagues have significant and numerous issues in the past with the quality of research that this group has produced,” a note from Seroquel’s brand manager said in 2001.

While sales reps were not allowed to explicitly promote Seroquel for anything other than schizophrenia prior to 2004, the notes reflect a not-so-subtle, broad-based push.

In early 2000, Billingsley’s sales rep wrote, “S best in new Schizo’s, kids, adolescents, bi-pols, blacks and asians.”

Dr. Guido Nodal, Jr., a psychiatrist in Hialeah, at first was cautious about Seroquel, fearing potential links to cataracts. In late 2001, he told a male sales rep he would keep the drug in mind only for “smoking sciz pts.”

Two months later, however, a female rep wrote that Nodal “LOVES SER. FOR ELDERLY.” By year’s end he had 15 nursing home patients on the drug. (Later the FDA made all anti­psychotics warn that use in elderly with dementia could cause death.)

“Claims that he is switching patients from Risperdal to Seroquel at the nursing homes,” a sales rep wrote in 2003. “Writing as much as he can to all patients.”

Notes show that in the interim, Nodal received a textbook, mug, penlights (“Using lots”), payment for a preceptorship and dinner at Ruth’s Chris Steak House. He denies the giveaways influenced his prescribing.

“If drug companies stopped marketing, I think prescribing (patterns) would be more or less the same as they are now,” said Nodal, who said he tried to become a Seroquel speaker but was not accepted. “It didn’t affect me at all.”

Nodal closed his private practice last year and now works for the state’s Department of Corrections in Florida City. The agency does not allow drug reps to lobby its physicians.

Times researcher Carolyn Edds contributed to this report. Kris Hundley can be reached at hundley@sptimes.com or (727) 892-2996.


By the numbers

$7 billion

Amount drug industry spent on marketing directly to doctors (2004)

$2 billion

FDA budget (FY 2008)

1/3

Drug industry’s research & development budget compared to marketing budget

1 to 2.5

Ratio of drug reps to doctors in the United States

$96,700

Median annual total cash compensation for a drug rep (2008)

16 percent

Favorable change in a doctor’s prescribing habits after less than 1 minute with a sales rep

52 percent

Prescribing change seen after 3 minutes with a sales rep

Source: Pharmedout.org’s “Why Lunch Matters” 

One response to this post.

  1. Posted by Dan on August 2, 2009 at 5:33 am

    I’m an ex-big pharmaceutical whistleblower who filed a federal lawsuit in Boston 3 years ago because my big pharma employer was harming patients:

    You Have Now Been Sampled

    While the pharmaceutical industry’s image and reputation has and appears to continue to suffer, added damage has expressed itself with costly patent expirations.

    Yet the big pharma task forces still insist that reps provide incredible value, and the more the better.

    The pharmaceutical company’s drug representatives are the giver of gifts.

    This happens to ensure reciprocity will occur in the form of prescriptions from the gifted prescriber.

    The samples reps dispense are around 20 billion a year, along with the reps themselves costing about 5 billion a year by the pharmaceutical industry.

    It is possible for prescribers to order samples on the internet to be delivered to their practice, but this remains rare presently.

    As a big pharma ex drug rep for over a decade, which during that period the number of drug reps actually tripled, the drug rep’s vocation has become more ridiculous.

    Ridiculous, and possibly void of any true sense of accomplishment due to their customers preventing them from interaction with them. Some doctors refuse the rep’s presence in their clinic.

    The job has become nothing more than doing lunches and leaving samples at offices, for the most part.

    My perception formed from my own analysis of how drug reps operate in today’s environment in the medical community has led me to draw such conclusions, which I believe to be accurate.

    So they may be named at times in different ways, these promoters will be referred to now only as drug reps, which number close to 100,000 in the U.S. presently.

    Their job is to influence close to 1 million prescribers in this country, it is believed.

    Yet the number of drug reps is probably less now due to big pharma cutting thousands of reps recently.

    The cost to the pharmaceutical industry of these drug reps is around 5 billion dollars a year.

    Income for each rep grosses close to or above 100,000 grand a year on average, along with great benefits and a company car.

    Also, drug reps often get stock options as they gladly work from their homes and set their own hours, which I understand is much less than 8 hours a day.

    The main function these days of drug reps, I believe, is primarily to offer doctors various types of inducements of a certain value that are not gifts, but bribes, by definition.

    And these prescribers visited by drug reps are known as targets.

    Targets are determined by what is known as ‘data mining’.

    The American Medical Association releases identifying information on doctors that allows pharmaceutical companies to track their prescribing habits.

    If a doctor, for example, is a high prescriber of prescriptions for particular disease states, or a doctor has an affinity for a product promoted by a drug company, they become a target.

    The drug sampling of doctors may be considered an inducement, and a rather valuable one for the drug rep.

    These drug samples are what ultimately influence the doctor’s prescribing habits over anything else, including invalid clinical statements from drug reps.

    Perhaps this may be why the drug industry spends around 20 billion every year on samples.

    Yet I want to be clear on what I am saying: drug reps are some of the smartest people you will meet that do in fact have great paying jobs with great benefits.

    Most importantly and my opinion, I believe most reps really WANT to do well for their employers, yet are prohibited from doing so now.

    This is because of how their employers are now viewed in their medical community.

    Many years ago, drug reps have used their persuasive, yet ethical, abilities to influence the prescribing habits of doctors in an honest and ethical manner.

    Drug reps. focused on the benefits for the doctor’s patients with a particular drug that the detailer may promote to such a doctor.

    However presently, most health care providers now simply prevent drug reps to speak with them- now this is especially true when they are in clinic treating and assessing patients.

    More and more medical establishments are completely banning drug reps from their locations, and I speculate that this is occurring for many reasons, which may include the following:

    The doctors lose money. Doctors are normally busy, so their time is valuable.

    As a drug rep, you are an incredible waste of their time.

    Yet they will accept your samples still as a drug rep.

    The credibility you possibly have thought you had and were perceived as such by doctors as a drug rep is no longer viewed to exist to any noticeable degree by the prescriber.

    For example and this is based on my experience and my colleagues, doctors view any information you may provide to them as biased and embellished.

    In my opinion, based on information and belief, their view regarding their assessment of you as a drug rep is accurate due to the statistical gymnastics the employers of drug reps engage in.

    This effectively and ultimately is permitting and encouraging the drug reps to lie to the doctor and likely are unaware of the statements stated by them are misleading.

    Doctors by their very nature seek answers objectively.

    And doctors do in fact find out about drugs through other methods besides the representative of the drug’s maker.

    Such methods include the internet and experience with certain medications.

    Most drug reps in this country in particular mostly hire drug reps based on such qualities as the candidate’s looks as well as their personality, overall.

    Furthermore, it is possible that pharmaceutical companies desire their drug reps to be obedient and to not question what is asked of them.

    Upon speculation, this can be possibly determined by the background of the candidate, which may indicate they seek popularity as well as are money driven.

    In addition, most drug reps do not have degrees remotely related to any aspect of anything of a scientific or clinical nature.

    During my decade as a drug rep, I would encounter on very rare occasion another rep that may have been a nurse or researcher.

    This is quite concerning that others do not have similar backgrounds because the type of training necessary is rare for a drug rep.

    In fact, based on my opinion, many do not particularly care to acquire education related to such medical or clinical topics.

    They learn the basics in order to sell their promoted products.

    Yet anyone who has ever worked with doctors in a clinical setting, or in a hospital working in a clinical nature, likely they would agree that a drug rep should want to and seek all related to the complexities involved in the restoration of another’s health.

    Many drug reps, it is believed, are void of any complete interest in medicine completely, and I believe this to be necessary.

    In addition, ethical considerations due to their possible deliberate ignorance created by the necessity of what they are required to say or do by their employers may be viewed as a disturbing fallacy as well.

    This allows them with the encouragement and coercion of their employer to embellish the benefits of their promoted products at times in addition to offering inducements to doctors in various ways.

    These inducements, or remuneration are always tacit and selective.

    These gifts are issued to select prescribers upon instruction of their employer.

    Examples may be creating a check from your company to a certain supporting doctor and handing this check to thank a doctor for supporting your company’s products for doing little if anything for your employer to justify this check.

    Or tangible items are given to such prescribers, such as TVs or DVDs which may or may not be utilized in a particular doctor’s office. It happens often, such activities.

    From the drug rep’s perspective, it is unlikely they will even consider the possibility to question their pharmaceutical employer due to the great risk of losing income and benefits that they are unlikely to acquire at another place of employment.

    Because of their consistent and conscious effort to keep their high-paying jobs, the drug reps always appear overtly anxious to please their superiors- regardless of any ethics or legalities regarding any activity they may be required to perform.

    With big pharma in particular, each drug rep is given a variety of budgets, such as a chunk of cash for doctor office lunches that they are required to spend in a certain period of time.

    Another chunk of cash may be assigned to a rep to pay assigned or registered speakers of their employer to speak to other prescribers about a disease state related to the drug rep’s promoted product.

    These activities, in my time with big pharma, were never monitored or questioned by managers or superiors.

    What I did notice is that my annual raises were greater than others according to the amount I spent for that particular year.

    This tactic, according to a big pharma company, was a very objective and noticeable variable with securing and keeping your employment in big pharma.

    While legally risky, the drug companies continue to dispense to their reps these large budgets their drug reps are in effect coerced to dispense with complete autonomy.

    This spending of this budget can be fabricated, which is too complicated to fully explain.

    This design perhaps is why there are now various state and federal disclosure laws that are presently being considered to mandate the release of all funds dispensed from pharmaceutical companies.

    This would include why a company’s funds were spent and for what reason or method.

    Because, according to the lobbyists of pharma companies, they consistently insist that whatever they spend always is for the benefit of public health.

    As mentioned earlier, presently such activities are quite covert.

    Yet if such laws are mandated, it is likely the accounting of pharma companies will become rather creative and incomplete.

    In summary, as a big pharma drug rep, my budgets were unlimited, and I typically spent more than I made though the activities I have mentioned so far.

    And this is not an isolated case.

    Historically, pharma lavished doctors with expensive gifts and trips. Now it is about funding for them, such as financial grants.

    Basically, the two remain synonymous and ethically conflicting.

    Then there is the issue is what again is referred to as data mining.

    The American Medical Association sells this prescribing data on individual doctors to pharmaceutical companies or pharmacies, by providing others identifying numbers of a particular doctor, such as a state license number or DEA number.

    This allows big pharma to track and analyze prescriptions a doctor writes for patients not far from real time availability.

    This data shows the volume of scripts of a particular doctor and what the doctor has been prescribing for the doctor’s patient for their disease state.

    And this data reveals competitor products to the drug rep as well.

    Aside from being deceiving and dishonest, the data allows a pharma company to ‘reward’ those doctors who support their products.

    And this data conversely allows a drug company to treat other doctors with ‘neglect’, which means the non-supporters of a pharma company will not receive any inducement or remuneration from a particular pharma company.

    The data, by the way, only reflects numbers linked with particular products, and fortunately is free of patient names- this data that is provided to all drug reps.

    What has been described is the method typical with all big pharma companies, in my opinion, and I worked for three of them.

    It appears to be manipulative in a psychological paradigm- a combination of Pavlovian responses combined with positive and negative reinforcement.

    So such methods create a toxic culture required to be absorbed by those members of such a pharma company.

    Furthermore, the tactics implemented by pharma companies vacuum the judgment of prescribers, which may prevent patients from receiving objective treatment.

    Yet on the most basic level, it is the samples left with prescribers that ultimately determine their prescribing habits- with various inducements to some doctors running close in second place.

    Yet remarkably, prescribers are prescribing more and more generics, which typically are not sampled to prescribers.

    I find this comforting that the manipulation efforts of the pharma industry are not as effective as they believe they are in a rather delusional way.

    Yet what is happening now in regards of branded meds vs. generic meds, insurance companies are flat out paying doctors to switch patients to a generic if one is available.

    I speculate they are paying doctors for this as a response of what pharma has been doing for quite a long time.

    From a clinical paradigm, if a medication is providing desired treatment and good tolerability for a particular patient, one could argue it would be unethical to switch treatment for financial gain.

    This is further complicated by the fact that most patients are aware that insurance company payments to doctors for this even occur.

    It is likely and I believe that most drug reps are good and intelligent people who unfortunately are coerced to do things that may be considered corruptive to others in order to maintain their employment.

    In other words, the drug reps have compromised their integrity, ultimately.

    It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps that exists presently.

    This atonomy and coercion to have big pharma’s drug reps. do the wrong things for the medical community often.

    Because it is obvious that internal controls, if any, within pharmaceutical companies are ineffective and not enforced.

    It is possible that these pharma companies falsely believe that being an ethical company would make them a company without excess profit. One can only speculate on their true motives.

    Yet it appears that overt greed has replaced ethics with this element of the health care system, which is the pharmaceutical industry, as illustrated with what occurs within these companies.

    However, reversing this misguided focus of drug companies is not impossible if the right action is taken for the benefit of public health.

    Likely, if there are no drug reps, there is no one to employ such tactics mentioned earlier.

    Because authentically educating doctors does not appear to be the reason for their vocation.

    This is far from being the responsibility of a pharmaceutical sales representative.

    Perhaps most frightening is that most drug reps fail to dig deep enough to realize that what they do at times may damage public health.

    “Fear ensures loyalty.” — Author unknown

    Dan Abshear (what has been written is based upon information and belief)

    Reply

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