By Julie Appleby
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In the past few months, Dr. Joseph Gerstein could have enjoyed a Broadway show, a Texas Rangers baseball game, golf outings and a stay at an Austin, Texas, resort — all paid for by the prescription drug industry.
10 biggest drug pitches
These are the 10 drugs most commonly pitched by sales representatives to doctors in 2000
Product Treats Sales calls
Celebrex Arthritis 2.0 million
Vioxx Arthritis 1.6 million
Allegra Allergies 1.1 million
Claritin Allergies 1.1 million
Lipitor Cholesterol 1.0 million
Tequin Infections 972,000
Zoloft Depression 931,000
Augmentin Infections 894,000
Zyrtec Allergies 833,000
Prozac Depression 825,000
Gerstein refuses such offers. But such pitches — he says he gets one free travel offer a week — raise a growing concern about the role such marketing efforts play in what doctors prescribe for patients and how much the USA spends on drugs.
From simple pens and notepads to lavish dinners and trips out of town, doctors are increasingly being offered an array of goodies as incentives to listen to drug sales pitches or to offer their "opinions" to drug companies in focus groups.
The drugmakers hope that, in turn, the doctors will prescribe their products. And they do. A study published May 8 showed that of the drugs most responsible for the nearly 19% rise in spending on pharmaceuticals last year, the four top sellers were also among the top 10 drugs most heavily marketed to doctors.
"Physicians don't seem to be making the connection between the exorbitant prices for drugs and what is spent to lure them into prescribing," says Gerstein, director of pharmacy services for Tufts Health Plan in Massachusetts.
That's nonsense, says the drug industry. Its trade association says the $14 billion spent annually on marketing efforts mainly serves to inform doctors and consumers of the risks and benefits of new and existing drugs, with half that cost being to provide samples for doctors to give their patients.
"The (sales reps) will provide detailed information about the medicine," says Jeff Trewhitt of the Pharmaceutical Research and Manufacturers of America. "At that point, it's up to these doctors, the vast majority of whom are fiercely independent, to make a judgment."
Marketing tactics aren't new, but they're escalating in value as well as frequency:
- Since 1996, the number of sales representatives hired by drug firms has doubled, from 41,800 to 83,000 last year, according to industry tracking firm Scott-Levin.
- The drug industry spent $5.3 billion last year on advertising in physicians journals and sending sales representatives on office visits, up 10% from 1999.
- The drug industry sponsored more than 314,000 physician "events" last year, ranging from catered lunches in hospital conference rooms to getaway weekends at resorts, nearly double the number held 4 years earlier, Scott-Levin reports. The tab? Nearly $2 billion.
Marketing vs. informing
Marketing does not necessarily improve patient care, observers say.
"As a patient, I don't want a doctor deciding what drug to put me on based on who paid for him to go to a basketball game," says Stephen Schondelmeyer, professor of pharmaceutical economics at the University of Minnesota.
"Newer drugs get promoted more heavily. That's the basic underlying principle in capitalism, but that's not good health care," Schondelmeyer says. "Sometimes the best drug for me might have been out for a few years and may not be marketed as much."
Drug reps say they don't think the freebies affect a doctor's prescribing efforts. The offers are simply a way to get in the door so they can present more detailed information on the drugs.
"Doctors are not prescribing any drugs because they got tickets to see The Lion King," says a sales manager from a New Jersey-based drug firm, who feared she would be fired if she was quoted by name. "You're just trying to get your message across," she says. "What we're saying to them is, 'If you've got 10 antibiotics to choose from, this study shows that this one works better on respiratory infections. When this type of patient comes in, think of us.' "
Many doctors agree. They say drug reps provide important information that they may not have the time or ability to get elsewhere. They are not swayed, they say, in picking medications for their patients by free pens, catered lunches or industry-funded educational seminars.
But a January article in the Journal of the American Medical Association says otherwise: After reviewing 538 studies, the researchers concluded that marketing does influence which drugs doctors prescribe and which they ask to be included on hospitals' lists of preferred drugs.
"There's a notion among doctors that we're not influence-able," says Dr. Sharon Levine, associate executive director of The Permanente Medical Group, which restricts sales rep access to its doctors in the Kaiser Permanente system. "But the manufacturers wouldn't do it if it didn't work."
Life as a sales rep
Bill Bly spends his days trying to get doctors to listen to him, even for 30 seconds. He's been a drug company sales rep for 19 years, but these days, he says the job is getting tougher.
"I was in a doctor's office the other day, and they'd had 10 reps visit already," says Bly, president of the Tulsa Pharmaceutical Representative Association.
Often the only way a sales rep can get a few minutes to pitch a company's prescription drugs to a doctor is to bring lunch to the office — for the entire staff — or invite a group of doctors to a free dinner at a local restaurant.
Bly defends such dinners and lunches as educational briefings to provide information to physicians on how to use the industry's products.
"Business is business," he says. "If companies were slipping money under the table to doctors, that would be one thing. These are legitimate programs. They're getting a nice meal. We're utilizing their time for a legitimate purpose."
Another rep, who allowed USA TODAY to accompany her on her rounds on the condition that she not be named, has 107 "target" doctors in her territory. Her mission: to meet with some weekly and others monthly — and to remind them of the three drugs she's pitching.
A good sales visit is one in which she can grab a minute of a doctor's time to give him a well-rehearsed 30-second pitch for her top drug. She's paid a salary, plus a bonus, which is based on getting doctors to write more prescriptions for her three drugs.
It's hard work. Most offices simply allow her to drop off samples, and doctors rarely take the time to chat. To get more time, she plays caterer. At her first stop one morning this month, she set up two lunch visits with the doctor and his staff. The receptionist reminded her: "No pizza. No salads."
On her second stop of the day, two other drug reps — identifiable by their suits and ties — were already sitting in the waiting room. At the third, she found the packages of her drugs at the back of the sample closet, behind a competitor's neatly stacked supplies. She restocked hers. One office wouldn't let her in at all.
The drug rep has few illusions about her role. She provides information, but many doctors already know what she has to say. They've been pitched many times before. She understands why few doctors give her more than a few seconds.
"Drug reps are lined up in their offices from the time they open till the time they close," she says, "so I can understand their annoyance."
Mostly, she's just there to remind them of her products. "Detailing is nothing more than a commercial, an in-front-of-your-face live commercial," she says.
She says her company has cut back on physician perks. Gone are the days when reps could hand out gift certificates to the local spa or meet a doctor at a nursery to fill his car with $100 in plants.
But some of her competitors have not scaled back on freebies.
"I had one doctor ask if I could get him front-row tickets to the Masters (golf tournament)," says the sales rep. "I said, 'No.' So he said, 'Well, your competitor can.' I said, 'I can do putt-putt golf for you and your kids.' " The doctor didn't see the humor.
"Some doctors have gotten greedy," she says. "It's trickled down to their staff. They even tell us what they want us to bring them for lunch."
Most of the freebies offered by sales reps are of minimal value, says Dr. Randolph Smoak, president of the American Medical Association (AMA), which has decade-old guidelines stating that doctors should not accept items of substantial value from drug or medical-device industry representatives.
The AMA is about to roll out an educational campaign reminding doctors of the guidelines but it, too, has run into controversy: The effort is being underwritten by drug companies.
Some drug firms also are taking a new look at sales practices.
In January, GlaxoSmithKline told sales reps that certain practices, such as "Dine 'n' Dash," are now banned. Dine 'n' Dash meant meeting doctors at restaurants and paying for take-out meals while giving a short drug sales pitch.
While some marketing efforts may be scaled back, the lure of free travel continues, says Gerstein, who shared with USA TODAY several recent letters from drug companies.
The drug companies wanted his opinion, the letters said, on topics ranging from Medicare to managed care. For his trouble, he would be paid honorariums of $500 to $3,000 and receive such things as tickets to sporting events, rounds of golf and a Broadway show. He refused.
Such events aren't really to seek doctors' opinions, says the New Jersey drug company's district manager.
The real reason, she says, is to get them to use her company's drugs. Yet, she says, no one is really sure if such events — or even sending the legions of sales reps to doctors' offices — really works: "Everyone's afraid to stop it, because they don't know what difference it's making."
Dr. William Hall, president of the American College of Physicians-American Society of Internal Medicine, acknowledges the importance of sales calls, but he agrees with marketing critics that some of the promotions are not appropriate.
Junkets to posh resorts are clearly inappropriate, Hall says. But lunch for the entire staff brought to a busy physician's office by a drug sales rep is probably OK, he says.
"We tell physicians to use their own judgment," Hall says.
"The litmus test is: 'Would I feel comfortable if my patients knew this interaction was taking place?'"