My daily rant on pharmaceutical reps

1) Agree that drug reps are not evil. I have qualms about “marketing strategies can be evil” because that implies a moral equivalence to blowing up innocent civilians, but let’s save that conversation for another time/blog.

2) I see this point as a combination of two issues: there is no such thing as a perfect drug (which we have discussed before), and the growing tendency of big pharma to equate drug marketing to general consumer goods marketing. Few people object to “New and Improved!” on some shampoo or ads that imply your love life will improve because of some skin cream as long as there is no outright fabrication. And I think most people believe drugs should be held to a higher standard. The problem is where to draw the line in that vast grey area.

3) I believe there is less to thank big pharma for than they claim. One of the reasons big pharma spends so much competing with marketing is because so many of their drugs don’t differ much more than laundry soaps. The prevailing big pharma model is to focus on multi-billion dollar markets, tweak the active ingredient just enough to get a patent, copy the clinical trials that worked to get previous drugs on the market, and then pound away with reps and ads. Small patient groups, new indications for off-patent chemicals, highly innovative approaches, etc., get little research because the risk is higher and/or the payoff is lower. I don’t necessarily blame big pharma alone–they are making rational economic decisions in the health care environment established by the FDA, Medicare, insurance companies, etc.

Ultimately, higher economic risk requires a higher payoff. Raising safety and efficacy requirements raises economic risk, so the focus on blockbusters and marketing is a natural result from the push for ‘perfect’ drugs. Society has to figure out where to balance the risk from imperfect drugs with the loss of drug innovation. I don’t have the solution, but it seems the pendulum has swung too far in the pursuit of perfection.

4) Agree. The problem is how much is society willing to pay for this research and how will it be funded? Trying to force drug companies to do it seems like a free lunch, but as you note, they will twist and spin to satisfy their natural economic interests. Having a government agency fund it is more objective but clearly demonstrates the expense…

5) I am not sure what you mean by “the straw man argument” but this seems defensive. Almost every physician markets himself/herself. Buying a yellow pages listing is advertising. Wearing a white coat while seeing patients is promoting an authoritative image. Having your staff be pleasant and ‘working in’ a patient is customer relations. There is nothing wrong per se with marketing, since at its core it is learning about your customers and informing them how your services meet their needs. BTW, good marketing techniques include word of mouth.

6) This comment seems all over the place. You have a philosophic concern that someone is trying to influence you? People have been trying to influence other people ever since language was invented (and probably before). How can society possibly prevent attempts at influence? If anything, the current system is better than most because the attempts at influence are aimed mostly at an agent (the doctor) who is trained and paid to be more knowlegable, and hopefully more objective, than the end user/patient. Is it attacking physicians to say that they have a fiduciary responsibility to understand drugs and prescribe appropriately? Is it attacking physicians to say that if they don’t have the will/ability to cut through drug company BS they should get out of the profession? How can physicians claim on the one hand to be educated and skilled enough to deserve high pay for services, but then whine that those big bad drug companies just take advantage when they send in those donuts and cute little reps?

7) see #6

As a former drug rep, I want ot make one comment, based on 30 years of observation. The system of drug reps is subject to abuse, and always has been. Physicians can, and do, chose not to see reps, and always have. Where the wheels started to come off was when the industry started direct to consumer selling, especially on TV. Instead of the drug rep to physician demand creation, you have a patient to physician demand creation. This is a very different model.

“As well, I think there should be stricter control of the content of pharm rep pitches.”

The advertising fraud and FDA laws ARE remarkably strict. Enforce the laws we already have. Doctors, when a drug rep tries to scam you, turn ‘em in–just like you would if you caught an equipment seller trying to scam Medicare.

Since someone mentions DTC marketing – there’s a new twist to this. It’s drug sales reps coming to patient support group meetings.

A friend of mine, who has ulcerative colitis, told me that at his last support group meeting, a drug sales rep and a doctor came to talk to the group. It wasn’t clear if the doctor brought the rep, or the rep brought the doctor. To everyone’s delight, each patient got a coupon for a free 7-day trial of the drug the rep was pushing (oh, sorry, I meant educating everyone about).

Talk about targeting your audience. It’s ready made, and you get to pitch to the very people who will be taking your drug. What’s more, they’re all too open to your suggestions, and won’t have any nasty medical/scientific backgrounds that could gum up the works with pointed questions.

My friend was unaware that the sales rep wasn’t a licensed health professional, and that the rep didn’t have to have a science or medical background to get their job.

How does the current reimbursement system in any way remove healthcare providers from the strains of marketing?

Back to reality, the over commercialization of healthcare and hospital and physician advertising efforts are amongst some of the largest concerns in healthcare policy.

http://jme.bmjjournals.com/cgi/content/extract/32/1/26

The growing competition, as reimbursements fails to keep up with inflation, is actually probably increasing the pressure to market oneself as a physician.

Any comparative depression in physician marketing (versus the rampant use of it by pharm companies) is due solely to ethical concerns and not economic forces.

CJD, I have no idea how you came to the conclusion in your post above…

Incidentally, I’m not saying that having a third party reimbursement system is easy. It’s not. It has its own unique drawbacks. But having to market your skills to the public is not one of them.

You’re putting words in my mouth I did not say. I never said you had it great, nor did I refuse to recognize the downside. In fact, I specifically acknowledged that a downside existed. My only point was that you don’t have to market. Every system has its upside and downside.

As for the rest of your points, I agree wholeheartedly. Although I bet firefighters and police officers would take a reimbursement system like that if it reimbursed at the levels you get. Their average income is likely 1/5 or less of a physician’s. And, never forget, you CAN opt out of that system if you so choose. It is not mandatory.

My biggest frustration with you guys is that you SEE the problem with your system, as you clearly point out. Yet the majority of your time and lobbying money is spent on malpractice issues. I don’t really get it.

db wrote:

Nexium is a good PPI. It is not significantly better than other PPIs for the great majority of patients. It does cost significantly more than other PPIs.

In a similar vein, SteveSC wrote:

One of the reasons big pharma spends so much competing with marketing is because so many of their drugs don’t differ much more than laundry soaps. The prevailing big pharma model is to focus on multi-billion dollar markets, tweak the active ingredient just enough to get a patent, copy the clinical trials that worked to get previous drugs on the market, and then pound away with reps and ads.

I’ve always been puzzled by the bad rap that me-too drugs get. On the one hand, some people complain that Rx drugs are too expensive. At the same time, they will often complain that there are too many me-toos. (Note that I mean some people in the abstract, not that db or SteveSC were making these complaints.)

What puzzles me is this: if two or more drugs are really me-toos — that is, they’re essentially interchangeable for a given patient group — then I’d expect there to be some price competition between them, even if each is proprietary. Such competition may well be imperfect, and may be skewed by marketing (as in the case of Nexium?). Still, it seems this should result in lower prices than if there was only one drug of that class. This should be a net benefit to the patient.

Of course, another possibility is that nominal me-toos aren’t really perfect substitutes. One drug in a class may be better for some subsets of patients, while another may be beter for other subsets. Perhaps a single drug would provide at least some benefit to all patients, but having several options to choose from may provide marginally better outcomes for the group as a whole. Here again, me-toos should be a net benefit for the patient.

I’d like to ask db: is this consistent with your experience in using me-toos? If you judge that two or more drugs are therapeutically equivalent for a given patient, do you consider price in selecting what to prescribe? How often do you find that supposed me-toos aren’t really equivalent, and that it’s useful to you and your patients to have several variations to choose from? More generally, what’s your feeling about the intrinsic benefits of having multiple me-toos in a class?

I realize this is something of a tangent to the original post. Maybe it’s worth discussing as a separate topic?

(Note: I realize one can also argue that me-toos are an inefficient use of resources that would be better allocated to developing drugs for greater unmet needs. I think that’s essentially what SteveSC is saying in point 3. I readily acknowledge that’s a legitimate concern, but that’s beyond what I’m trying to get at above.)